key: cord-1001449-uh5gce0r
authors: Rankin, Danielle A.; Yanis, Ahmad; Haddadin, Zaid; Talj, Rana; Fernandez, Kailee N.; Bloos, Sean M.; Stahl, Anna; Gu, Wenying; Nicotera, Janet; Howe, Harrison L.; Salib, Seifein; Chappell, James; Howard, Leigh M.; Khankari, Nikhil K.; Halasa, Natasha B.
title: The impact of community closures among nonessential and essential workers, Nashville, Tennessee: A cross‐sectional study
date: 2022-05-24
journal: Health Sci Rep
DOI: 10.1002/hsr2.658
sha: 6c9dd57ea37ef98e4af39c7f7abf94f156bf9512
doc_id: 1001449
cord_uid: uh5gce0r

BACKGROUND AND AIMS: The effects of community closures and relaxing social distancing restrictions on severe acute respiratory syndrome coronavirus‐2 (SARS‐CoV‐2) by occupational risk remain unclear. Therefore, we evaluated the impact of community closures and reopening phases with the prevalence of testing SARS‐CoV‐2‐positive among nonessential and essential workers. METHODS: We constructed a cross‐sectional cohort from March 20 to July 31, 2020, of 344 adults from Metropolitan Nashville, Tennessee. We performed an unconditional logistic regression model to evaluate the impact of community closures and phase implementation on testing SARS‐CoV‐2 positive by occupation to estimate adjusted prevalence odds ratios (aPORs) and 95% confidence intervals (CIs). RESULTS: During a stay‐at‐home/Phase I order, those with non‐essential occupations had 59% decreased prevalence odds (aPOR:0.41; 95% CI: 0.20–0.84) of testing SARS‐CoV‐2‐positive compared to when no restrictions were in place. Persons with essential occupations had four times the prevalence odds of testing SARS‐CoV‐2‐positive (aPOR:4.19; 95% CI:1.57–11.18) compared with nonessential occupations when no community restrictions were established. CONCLUSION: Stay‐at‐home restrictions were associated with a lower risk of SARS‐CoV‐2 infection in the community for nonessential workers. Essential employees remained at increased risk for SARS‐CoV‐2, including when no community restrictions were in place and vaccines were not available. This study supports targeting prevention measures for these high‐risk occupations.

To control the transmission of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) before vaccine availability, US public health officials implemented several community interventions. These measures specified mandatory mask-wearing, emphasis on hand hygiene, limiting patron densities at social venues (e.g., restaurants and bars), restricting mass gatherings, nonessential business closures, and stay-at-home orders. 1 On March 23, 2020, the Metro Public Health Department in Nashville, Tennessee issued a stay-at-home order for non-essential workers in Davidson County 2 ; and by March 31, 2020, the Tennessee governor issued a state-wide mandate. 3 Despite these pandemic-related interventions, individuals in professions essential to continue infrastructural operations were still required to attend work, regardless of the phase of restrictions. 4, 5 Essential occupations included individuals in healthcare (i.e., emergency responders, nurses, physicians, environmental services, and nursing assistants), correctional facilities, transportation, agricultural, food production (meat and poultry factories), construction, grocery stores, pharmacies, and energy sectors. 4, 5 Empiric evidence examining the effects of community closures and phase reopening on the risk of coronavirus disease 2019 (COVID-19) among the essential workforce is limited. The goal of our study was to assess the impact of community closures and reopening phases on testing positive for SARS-CoV-2 in Metropolitan Nashville, Tennessee, with a focus on examining differences by occupation, before the introduction of the SARS-CoV-2 vaccine.

We conducted a cross-sectional study from our main longitudinal community-based SARS-CoV-2 surveillance study, COPE (COVID-19, Outbreak, Pandemic, Exploration). Adults (≥18 years) who resided in Metropolitan Nashville, Tennessee between March 20 and July 31, 2020, were eligible if one member within a household had SARS-CoV-2-infection confirmed by molecular testing for SARS-CoV-2 from a Vanderbilt University Medical Center affiliated testing location (i.e., emergency room, hospital, testing site, and outpatient clinic) or another testing site (e.g., health department, local pharmacy, etc.).

Participants were recruited and enrolled if they opted into providing their contact information for research after verbal Informed consent was obtained. This study was approved by the Institutional Review Board at Vanderbilt University and followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines for cross-sectional studies ( Figure S1 ). 

Type of occupation was dichotomized as nonessential (i.e., unemployed or persons working from home [referent]) and essential (i.e., work in professions with contact to people [e.g., frontline, healthcare, grocery, transit, factory, construction, and retail employees, etc.]). 9 Persons holding essential occupations, but reported working from home during enrollment, were assigned to the nonessential group.

The outcome of our study was defined as laboratory-confirmed SARS-CoV-2-positive. Evidence of SARS-CoV-2 infection was defined by detection of nasal viral genomic RNA using reverse-transcriptase quantitative polymerase chain reaction (RT-qPCR) and/or by detection of serum IgG to SARS-CoV-2 using a chemiluminescent microparticle immunoassay. Those with negative RT-qPCR results but positive SARS-CoV-2 serology within 6 weeks of symptom onset were classified as SARS-CoV-2-positive.

Potential confounders were identified using directed acyclic graphs and evaluated using a 10% change in estimate criterion ( Figure S2 ).

Missing data was assessed and a total of 344 adults (100%) had complete data for all variables. Interactions between dichotomized occupational exposure (i.e., nonessential, essential) and phase implementation (i.e., no restrictions, stay-at-home/Phase I, and Phase II/III) with SARS-CoV-2 prevalence were assessed on the additive and multiplicative scales. Additive interactions were evaluated using the relative excess prevalence odds due to interaction (REPI), with 95% confidence intervals (CIs). 10 Multiplicative interactions were evaluated using the likelihood ratio test (LRT) for nested models comparing model fit of two models with and without the inclusion of the multiplicative interaction term (p < 0.20). Unconditional logistic regression was used to evaluate phase implementation and its impact on SARS-CoV-2 prevalence for phase and occupational exposure adjusted for sex (male/female) and ethnicity (Hispanic/non-Hispanic) to estimate adjusted prevalence odds ratios (aPORs) and 95% CIs.

Statistical significance was based on two-tailed tests with α = 5%.

A sensitivity analysis excluding persons in healthcare professions was performed. All analyses were conducted using statistical software Stata 16.0 (StataCorp LLC).

Of the 344 adults, 256 (74%) were SARS-CoV-2-positive (RTq-PCR = 235; serology = 22). The mean age was 42 years (SD = 14), 51% were female, 88% were White, and 45% were in essential occupations ( Table 1) Age, years-mean (SD) 42 (14) 43 (14) 40 (13) were more likely to be male and of Hispanic ethnicity than nonessential workers ( Table 1 ). The majority of essential employees were healthcare personnel, in other essential occupations, or factory workers (26%, 21%, and 15%, respectively; Figure 2 ).

Persons in nonessential occupations during the stay-at-home/Phase I order had 59% reduced prevalence odds (aPOR: 0.41; 95% CI: 0.20-0.84) of SARS-CoV-2 compared with when no restrictions were in effect (Table 2 ). In contrast, persons in essential occupations had approximately four times the prevalence odds (aPOR: 4.19; 95% CI:

1.57-11.18) of SARS-CoV-2 compared with nonessential occupations when no restrictions were in effect. We observed an interaction between occupation and phase implementation, which was statistically significant on the multiplicative scale and was 13.6 times more than multiplicative (expected aPOR under complete multiplicativity = 0.31, p < 0.001) during the stay-at-home/Phase I order ( (Table S1 ). 

Stay-at-home/Phase I: What we observed for the essential workers during a Stay-at-Home/Phase I order is 13.59 times more than multiplicative.

Phase II/Phase III: What we observed for the essential workers during a Phase II/Phase III is 1.73 times more than multiplicative.

been recognized. 16 Individuals in these professions are inherently at risk for exposure to SARS-CoV-2 through prolonged direct contact to patients 17 and/or other employees, 5 crowded working conditions, 16 lack of the availability of personal protective equipment (PPE), and poor ventilation. 9 Although we observed an increased prevalence odds for all essential occupations, the majority (74%) of essential employees in our study were in nonhealthcare professions. In the United States, federal regulations require healthcare professionals to receive annual PPE training focused on the prevention of transmissible diseases. 18 

Study limitations include the potential for a lack of generalizability as we used a single-center cohort of convenience sampling. In addition, SARS-CoV-2 prevalence and mitigation strategies vary by jurisdiction. 21 Thus, our findings may not be applicable to other regions outside of Metropolitan Nashville, Tennessee. Our analysis was restricted to assessing the prevalence of effects within phases and does not reflect the incidence of SARS-CoV-2 within phase implementation in Nashville, Tennessee. We were unable to measure exposure intensity nor time incurred by persons of essential occupations and their adherence to mitigation strategies. Personto-person interactions were not measured or assessed in this study.

Additionally, self-selection bias may have occurred if persons with a higher risk for severe COVID-19 sought clinical testing or healthconscious individuals were more likely to participate in our study.

We did not find a persisting association as restrictions were relaxed in Phase II/III for essential occupations compared to nonessential occupations during the pre-COVID-era. We posit this may be attributed to lower incidence within our community, less testing being performed, or small sample sizes.

Our findings suggest that community closures for non-essential occupations can be an effective mitigation strategy to reduce SARS- data; review and approval of the manuscript; or decision to submit the manuscript for publication.

Natasha Halasa, MD, MPH receives grant support from Sanofi, Quidel, and speaker compensation from an education grant supported by Genentech. Sanofi also donated vaccines and influenza antibody testing for influenza vaccine trial. Sanofi, Quidel, nor

Genetech had a role in the design or conduct of the study, collection, management, analysis, and interpretation of the data; review and approval of the manuscript; or decision to submit the manuscript for publication. All other authors declare no conflicts of interest.

Danielle Rankin affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained.

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Danielle A. Rankin http://orcid.org/0000-0003-3018-3373

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