key: cord-0988764-froa5gn6 authors: Razzak, Junaid A; Bhatti, Junaid Ahmad; Tahir, Muhammad Ramzan; Pasha-Razzak, Omrana title: ESTIMATING COVID-19 INFECTIONS IN HOSPITAL WORKERS IN THE UNITED STATES date: 2020-04-11 journal: nan DOI: 10.1101/2020.04.06.20055988 sha: 9fb51f09a4454a8975a7842a5f1f31fd26749b83 doc_id: 988764 cord_uid: froa5gn6 Objective: We estimated that how many hospital workers in the United States (US) might get infected or die in the COVID-19 pandemic. We also estimated the impact of personal protective equipment (PPE) and age restrictions on these estimates. Methods: Our secondary analyses estimated hospital worker infections in the US based on health worker infection and death rates per 100 deaths from COVID-19 in Hubei and Italy. We used Monte Carlo simulations to compute point estimates with 95% confidence intervals for hospital worker infections in the US based on the two scenarios. We computed potential decrease in infections if the PPE were available only to those involved in direct care of COVID-19 patients (~ 30%) and if workers aged ≥ 60 years are restricted from patient care. Estimates were adjusted for hospital workers per bed in the US compared to China and Italy. Results: The hospital worker infections per 100 deaths were 108.2 in Hubei and 94.1 in Italy. Based on Hubei scenario, we estimated that about 53,640 US hospital workers (95% CI: 43,160 to 62,251) might get infected from COVID-19. The Italian scenario suggested 53,097 US hospital worker (95% CI: 37,133 to 69,003) might get infected during the pandemic. Availability of PPE to high-risk workers could reduce counts to 28,100 (95% CI: 23,048 to 33,242) considering Hubei and to 28,354 (95% CI: 19,829 to 36,848) considering Italy. Restricting hospital workers aged ≥ 60 years from direct patient care reduced counts to 1,985 (95% CI: 1,627 to 2,347) considering Hubei and to 2,002 (95% CI: 1,400 to 2,602) considering the Italian scenario. Conclusion: We estimated significant burden of illness due to COVID-19 if no strategies are adopted. Making PPE available to all hospital workers and reducing exposure of hospital workers above the age of 60 could have significant reductions in hospital worker infections. We estimated significant burden of illness due to COVID-19 if no strategies are adopted. Making PPE available to all hospital workers and reducing exposure of hospital workers above the age of 60 could have significant reductions in hospital worker infections. author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint (which was not peer-reviewed) is the . https://doi.org/10.1101/2020.04.06.20055988 doi: medRxiv preprint The COVID-19 pandemic has resulted in significant loss of life and major disruption of social and economic structures across the globe. 1 By March 27th, 2020, the total number of people infected exceeded 595,000 with over 27,000 deaths. 2 Even robust healthcare systems are challenged severely by the numbers of patients and the severity of the illness. 3 One of the major concerns in managing this outbreak is the safety of healthcare workers especially those working in the hospital settings. 4 The city of Wuhan in China has seen over 3,000 healthcare workers being infected while in Italy, where a major epidemic is ongoing has reported 7,145 healthcare worker infections including 51 physician deaths by March 27, 2020. 5 Ongoing shortages of personal protective equipment (PPE) have resulted in heightened anxiety and in some cases refusal of care by the healthcare providers. 6 In the face of restrictions to PPE availability and usage, as well as case reports of deaths of doctors and nurses, hospital workers are worried about their health, their ability to keep working and possible mortality, as well as the risk to their families. 7 These concerns are not unfounded as the risk of infection appears inordinately high, with 20% of responding hospital workers in Italy becoming infected. 3 While hospital workers without the requisite PPE continue to see patients in many settings, an increasing number of hospital worker infections or increasing reluctance to provide care remains one of the major risks to the global response. 4 There is currently no published evidence on the expected number of infected hospital workers in the US or projections for other countries around the world. 8 The available data show that the risk All rights reserved. No reuse allowed without permission. author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint (which was not peer-reviewed) is the . https://doi.org/10.1101/2020.04.06.20055988 doi: medRxiv preprint of COVID-19 infection amongst hospital-based workers is directly proportional to the number of patients in the healthcare system. 5, 9, 10 This relationship is modulated by other factors, including adequate supply and optimal usage of PPE. 4, 6, 8, 10 The shortage of PPE has created circumstances where its use is prioritized for hospital workers that are highly exposed to COVID-19 patients, such as intensive care or emergency care workers. 9, 11, 12 Illness outcomes, including mortality, are further influenced by the characteristics of the hospital worker population, including age structure and prevalence of other risk factors, such as occurrence of comorbid conditions, which could have a direct impact on risk of disease severity and number of deaths. 1, 5, [13] [14] [15] We estimated the number of hospital workers in the US at risk of contracting the infection or dying due to COVID-19. We estimated COVID-19-related counts for infections and deaths if perfect PPE conditions are available to high risk hospital workers. We also evaluated the impact of curtailing hospital-based direct patient care in workers above a certain age on estimated counts for infections and deaths. Our secondary analyses estimated hospital worker infections in the US based on health worker infections and deaths per 100 deaths from COVID-19 in Hubei and Italy normalized for hospital workers per beds in the US. All rights reserved. No reuse allowed without permission. author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint (which was not peer-reviewed) is the . https://doi.org/10.1101/2020.04.06.20055988 doi: medRxiv preprint We extracted data for COVID-19 infections from Hubei, China and Italy. We also extracted data from the two other jurisdictions, the Wuhan city (located in Hubei province) and the country of South Korea for initial comparisons. China's Hubei province, the initial site of the epidemic is a landlocked province with a population of more than fifty-eight million people, with the city of Wuhan home to almost eleven million of them. Wuhan is a transport hub and major rail interchange in China and was at the center of the initial outbreak, with the first case reported on (CSSE) at Johns Hopkins University 2 -Initially based on DXY, an online platform run by members of the Chinese medical community, which aggregates local media and government reports to provide COVID-19 cumulative case totals in near real-time at the province level in All rights reserved. No reuse allowed without permission. author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint (which was not peer-reviewed) is the Official government publications: We used the daily report published by the Italian Ministry of Health (English version) to obtain the overall number of COVID-19 infections, deaths amongst those patients as well as the number of health worker infections. 5 We also obtained the percentage of patients who were severely or critically ill from the report. For US data, we used the most up to date official press release from the city and state departments of New York, 21 Massachusetts, 22 and Florida. 23 We used the Organization of Economic Cooperation and Development data for 2017 for numbers of physicians, nurses, and hospital beds in China, Italy, and the United States. 24,25 All rights reserved. No reuse allowed without permission. author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint (which was not peer-reviewed) is the . https://doi.org/10.1101/2020.04.06.20055988 doi: medRxiv preprint From all three sites, we attempted to extract data regarding the total number of fatalities, the number of health workers found to be infected with COVID-19 and health worker mortality. Number of fatalities -defined as the number of cases reported as a case of suspected, probable or confirmed COVID-19 that died as a result of the disease or its complications. We then computed the expected deaths in the US based on COVID-19 deaths per million population in various jurisdictions. We computed the COVID-19-related hospitalizations in the US considering four scenarios: four times the deaths (e.g., Italy), eight times the deaths (e.g., Hubei), ten times the deaths (e.g., close to current NY city) and 15 times the deaths (e.g., similar All rights reserved. No reuse allowed without permission. author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint (which was not peer-reviewed) is the the high risk (exposed) workers received PPE, we assumed that 30% of total healthcare would work directly with patients (i.e., high-risk) whereas 70% would be managing other patients as observed in China. 26 For these estimations, we assumed the infection rate would be 55% in high risk (exposed) hospital workers and 26% in other hospital workers under inappropriate PPE conditions. 26 We used the following to compute infections if PPE is available only in high risk workers. Based on age distribution of infection risks in Italy and China, we also computed COVID-19 infections if hospital workers over the age of 60 or 50 years are restricted from working directly with the patients. 5, 27 For all computations, we estimated the death rate assuming it to be 3% of infections as observed globally for cases upto March 27, 2020. 28 All rights reserved. No reuse allowed without permission. author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint (which was not peer-reviewed) is the . https://doi.org/10.1101/2020.04.06.20055988 doi: medRxiv preprint As of 3/19/2020, the province of Hubei had 67,800 cases of which 48,557 were from Wuhan and South Korea had 8,799 cases. As of 3/27/2020, Italy saw 79,968 infections. The mortality rate per million showed high variability between the regions (Table 1) . author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint (which was not peer-reviewed) is the . https://doi.org/10.1101/2020.04.06.20055988 doi: medRxiv preprint Table 3 presents the unadjusted counts for hospital worker infections and deaths for scenarios if admissions were four, eight, ten or fifteen times the deaths. The highest number assumes a very high intensity epidemic with a large number of deaths and the health system is not prepared to handle the surge. author/funder, who has granted medRxiv a license to display the preprint in perpetuity. author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint (which was not peer-reviewed) is the . https://doi.org/10.1101/2020.04.06.20055988 doi: medRxiv preprint We present estimates for the burden of disease and deaths due to COVID amongst hospital workers in the US. We highlight the risks of limited access or use of PPEs amongst hospital workers in the US and estimate the impact of two interventions: infection control including the use of PPEs and age restriction of hospital-based healthcare workers. We also present a clear path to significantly reducing this burden through two strategies: continuous wide-spread and proper use of personal protection strategies and limiting the exposure to hospital workers over the age of 60 years. Unlike the community's risk of exposure, we based the risk of hospital worker infections on the magnitude of exposure defined as the number of patients with COVID-19 admitted to the hospitals across the US. We believe that hospital admissions and deaths, rather than total number All rights reserved. No reuse allowed without permission. author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint (which was not peer-reviewed) is the . https://doi.org/10.1101/2020.04.06.20055988 doi: medRxiv preprint of cases in the community, are more useful measures of the risks to hospital workers and are key metrics of the burden on the healthcare system. We based our estimates on several assumptions. Some of these assumptions are changing quite rapidly based on newer data. Our analysis assumes that the level of exposure of US hospital workers is similar to Italy and China. In both of these settings, especially in the earlier phase of the epidemic, there was a shortage of PPE which is also an issue in many US healthcare settings. Age is one of the key determinants of risk of infections and death in China and Italy. 14, 15, 29, 30 Our estimates of hospital admission are based on Italian and Chinese experience with different population distribution. In the US, earlier results show a relatively younger population group being affected. 29 Similarly, the number of healthcare workers per bed is quite different in China, Italy and the US and was controlled in our analysis. We also controlled for the age distribution of the healthcare workforce including the age distribution of nurses and physicians in the US. We did not find data on other healthcare workers and assumed that their age distribution would be similar to nurses and physicians. We also assumed that the mortality rate amongst hospital will be three percent though the estimates for population level mortality have varied between 1.9 per million in South Korea to 258 per million to 395 per million in Lombardi, Italy. We were not able to do a sub-analysis of the mortality risk based on the presence of prevalent comorbidities like diabetes, heart diseases, and hypertension. We did not include some other interventions such as the shift length and number of hours working in the clinical areas. Earlier studies have found them to be a significant determinant of COVID-19 infection. 26 Finally, we did not look at the mental health issues and the morbidity caused by them. All rights reserved. No reuse allowed without permission. author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint (which was not peer-reviewed) is the There is a significant worry about the shortages of PPEs worldwide. Our study shows the potential impact of PPEs and other aggressive infection control measures Importantly, our study also shows that aggressive infection control measures including the use PPEs by all healthcare workers and not just high-risk workers should be considered. Implementation of such strategies will have to be balanced against the potential shortages in the high risk patient care areas, increased cost of healthcare delivery, decrease in the efficiency of care delivery, and in some cases potential for increase in the risk of infection if proper donning and doffing procedures are not adopted. Age is the major determinant of death as in the general population including healthcare workers. 3, 14, 26 Based on the mortality data from Italy and China, we believe that reducing exposure of hospital workers over 60 could result in significant reduction in the overall morbidity and mortality amongst hospital workers. 14, 26 There is concern in the US that the age distribution is All rights reserved. No reuse allowed without permission. author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint (which was not peer-reviewed) is the . https://doi.org/10.1101/2020.04.06.20055988 doi: medRxiv preprint potentially different. 29 If the age distribution is in fact younger, then an earlier age cut-off point can be considered. Currently, in the US, almost 30% of licensed physicians and nurses are over the age of 60 years and the impact of removing that large a workforce could be immense. [33] [34] [35] Innovative solutions, such as the use of telemedicine, could limit the exposure of over 60 hospital workers while ensuring access to care to healthcare needs of the population. 36 We estimate a significant burden of illness and deaths due to COVID-19 if no strategies are adopted. We propose widespread availability and training on the use of PPEs to not only those working in highs risk areas of the hospital but to everyone providing direct patient care can significantly reduce the number of infected hospital workers. Similarly, reducing exposure of hospital workers above the age of 60 years, will reduce the death rates by over 90% amongst hospital workers but would require solutions that ensure service delivery to patients. The opinions and findings presented in this manuscript are of authors only. The views presented here do not represent the official position or policy of the authors' affiliate institutions. None. All rights reserved. No reuse allowed without permission. author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint (which was not peer-reviewed) is the . https://doi.org/10.1101/2020.04.06.20055988 doi: medRxiv preprint No specific funding was available for this study. JAR is partially supported by the grant funded by the Fogarty International Centre of the National Institute of Health. JAR and OPR conceived they study and wrote the first draft. JAR, MRT and JAB performed the analyses and supported the draft of the study. All authors read the final version of results and manuscript. The study uses the open source secondary anonymized data sources. The study meets the STROBE guidelines for reporting. All rights reserved. No reuse allowed without permission. author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint (which was not peer-reviewed) is the . https://doi.org/10.1101/2020.04.06.20055988 doi: medRxiv preprint Coronavirus disease 2019 (COVID-19) Situation Report -61 An interactive web-based dashboard to track COVID-19 in real time COVID-19 and Italy: what next? Lancet Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings Integrated surveillance of COVID-19 in Italy. 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