Journal Pre-proof COVID-19 risk factors among health workers: A rapid review Malizgani Mhango, Mathias Dzobo, Itai Chitungo, Tafadzwa Dzinamarira PII: S2093-7911(20)30296-1 DOI: https://doi.org/10.1016/j.shaw.2020.06.001 Reference: SHAW 424 To appear in: Safety and Health at Work Received Date: 4 May 2020 Revised Date: 1 June 2020 Accepted Date: 1 June 2020 Please cite this article as: Mhango M, Dzobo M, Chitungo I, Dzinamarira T, COVID-19 risk factors among health workers: A rapid review, Safety and Health at Work, https://doi.org/10.1016/ j.shaw.2020.06.001. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Occupational Safety and Health Research Institute, Published by Elsevier Korea LLC. COVID-19 risk factors among health workers: A rapid review Malizgani Mhango 1, Mathias Dzobo 2, Itai Chitungo 2 and Tafadzwa Dzinamarira 3 1 2 3 School of Public Health, University of Western Cape, 7535, Cape Town, South Africa Department of Medical Laboratory Sciences, University of Zimbabwe, Harare, Zimbabwe Department of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, 4001, South Africa Corresponding author: Tafadzwa Dzinamarira; Department of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, 4001, South Africa; anthonydzina@gmail.com Acknowledgements We acknowledge librarians Dzingayi Shangwa and Nontobeko Sikhosana for assistance with search criteria for multiple databases. COVID-19 risk factors among health workers: A rapid review Abstract Coronavirus disease 2019 (Covid-19) poses an important occupational health risk to health workers (HWs) that has attracted global scrutiny. To date, several thousand HWs globally have been reported as infected with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) virus that causes the disease. It is therefore a public health priority for policy makers to understand risk factors for this vulnerable group to avert occupational transmission. A rapid review was carried out on 20 April 2020 on Covid-19 risk factors among HWs in PubMed, Google Scholar and EBSCOHost Web (Academic Search Complete, CINAHL Complete, MEDLINE with Full Text, CINAHL with Full Text, APA PsycInfo, Health Source - Consumer Edition, Health Source: Nursing/Academic Edition) and WHO Global Database. We also searched for pre-prints on the medRxiv database. We searched for reports, reviews and primary observational studies (case control, case cross-over, cross- sectional and cohort). The review included studies conducted among HWs with Covid-19 that reported risk factors irrespective of their sample size. 11 studies met the inclusion criteria. Lack of personal protective equipment, exposure to infected patients, work overload, poor infection control and pre-existing medical conditions were identified as risk factors for Covid-19 among HWs. In the context of Covid-19, HCW face an unprecedented occupational risk of morbidity and mortality. There is need for rapid development of sustainable measures that protect HWs from the pandemic. Introduction The Coronavirus disease (Covid-19) pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus has challenged the health systems of countries it has affected. As of 30 April 2020, the pandemic has infected more than 3,2 million individuals with over 230,000 fatal cases in 187 countries 1. The person-to-person transmission routes of Covid19 include direct transmissions, such as cough, sneeze, droplet inhalation transmission, and contact transmission, such as the contact with oral, nasal, and eye mucous membranes 2. Health workers (HWs) are at the forefront of the Covid-19 outbreak response and as such are exposed to hazards that put them at risk of infection 3. As early as February 2020, scholars had established that transmission of the disease among HWs is associated with overcrowding, absence of isolation room facilities, and environmental contamination 4. However, in the context of the rapidly evolving Covid-19 pandemic, occupational health and safety policy-makers need timely access to updated health information on the risk HWs face. This evidence is best obtained through a systematic review, however, this review method requires vast resources, including time, to complete that do not suit the needs 5-7. In this study, we aimed to map available evidence on Covid-19 risk factors among HW to guide future research and policy. Methods Information sources and literature search We searched PubMed, Google Scholar and EBSCOHost Web (Academic Search Complete, CINAHL Complete, MEDLINE with Full Text, CINAHL with Full Text, APA PsycInfo, Health Source - Consumer Edition, Health Source: Nursing/Academic Edition) and WHO Global Database for relevant studies. We also searched for pre-prints on the medRxiv database. The search terms will include “Coronavirus,” “Covid-19,” “2019-nCoV,” “SARS-CoV-2”, “risk”, “risk factor”, “infection”, “illness”, “disease”, “health care worker”, “health care professional”, and “occupational health” were used. Boolean terms, AND and OR, were used to separate the keywords. The reference lists of all full-text articles screened were searched for relevant studies. Inclusion criteria We searched for reports, reviews and primary observational studies (case-control, case-crossover, cross-sectional and cohort). The review included studies conducted among HW that reported COVID-19 risk factors irrespective of their sample size. Screening process We developed a screening criterion a priori for each of the three stages, title and abstract and full text. Two researchers screened the articles independently. Differences in screen results at fulltext stage were resolved by discussion. Data abstraction and analysis process A data abstraction form was developed, discussed and revised a priori. The form extracted information on first author, title, sample size, reported risk factors and other relevant findings. Only one reviewer (TD) abstracted data from the included studies. For collating, summarizing and reporting of the findings; first, the reviewers familiarized themselves with the content of the articles. Secondly; findings reported in the articles were grouped into categories based on the reported factors and a narrative was provided. Results Our initial keyword database search found 1,698 potentially eligible articles. Results from each database search are presented in Supplementary File 1. Following title screening, 82 articles were eligible for inclusion in abstract screening. These articles were imported into EndNote X9, eight duplicates removed leaving 74 articles to be included in abstract screening. Following abstract screening, 38 studies were excluded leaving 36 articles for full-text screening. 25 articles were excluded after full articles screening and 11 articles were included in data extraction. Characteristics of included studies Table 1 shows characteristics of included articles. All included studies reported Covid-19 risk factors among HW. Of these, one was a short communication 8, two were reports 9,10, four were reviews 11-14, one retrospective cohort 15, one retrospective data analysis 16, one prospective cohort 17 and one case-control 18. All included studies were published in 2020. The total number of HW reported in the studies was 1,619, however, five studies did not specify a sample size. One study was a preprint article pending peer review 16. Study Findings 11 articles were included for data extraction and narrative summary. The reported Covid-19 risk factors among HW were grouped into five; lack of personal protective equipment (PPE), exposure to infected patients, work overload, poor infection control and pre-existing medical conditions. Insufficient PPE 9,10,14,16 or lack thereof 8 was reported as an important risk factor for Covid-19. Exposure to infected patients mainly through work in high-risk departments and contaminated fluid/ aerosols were reported as another important Covid-19 risk factor among HCW. Work overload resulted in lack of rest, long-time exposure to infected patients 8,9 and working under pressure16. Longer duty hours were reported as Covid-19 risk factor in a retrospective cohort conducted at a hospital in Wuhan, China 15. A review conducted by Yu et al. revealed limited or absence of knowledge on infection control as a risk factor for Covid-19 among HCW in the radiology department 13. Similarly, a retrospective analysis by Bai et al. 16 and a rapid review by Viswanath et al. 11 revealed lack of established practices of infection control poor infection control and direct contact with contaminated surfaces as important risk factors. Surprisingly, sub-optimal hand hygiene was reported as a Covid-19 risk factor among HCW 15. A review conducted by Ing et al. 14 on physician deaths from Covid-19 reported older age (physicians 57 years of age or older accounted for three-quarters of COVID-related deaths), male gender (90% of deaths were male physicians) and pre-existing conditions (hypertension, diabetes mellitus, cardiovascular disease, chronic lung disease and immunocompromised individuals) as risk factors. Discussion This review has revealed that research on Covid-19 risk factors for HW is still in its infancy. While this is to be expected given the pandemic only broke out in December of 2019, the available evidence shows active research interest on the subject. The review revealed lack of personal protective equipment, exposure to infected patients, work overload, poor infection control and pre-existing medical conditions as Covid-19 risk factors among HW. The WHO released interim guidance on HW risk assessment and management in the context of Covid-19 3. The guidance is offered for both the HW and their facilities. While this blanket guidance is available, occupational health policymakers would need to contextualize the procedures based on available resources and information. Our review revealed exposure to infected patients and work overload as two important Covid-19 risk factors among HW. This corroborates a recent Centers for Disease Control and Prevention (CDC) report that estimated that of the 9282 cases of Covid-19 cases among HW in the United States of America, 55% had exposure in the healthcare setting 19. Further, a mathematical modelling study by Temime et al, found that R0 for Covid-19 was higher for HW as compared to that of the general public as they have prolonged contact with infected individuals 20. HW at greatest risk are those who are exposed to the airways and the oral cavity of patients for prolonged periods such as dentists. Our review found contact with contaminated fluid as a Covid-19 risk factor. Similarly, according to Meng et al., dentists accounted for 5% of the fatalities among physicians exposed to Covid-19 21. Concerns on contamination through suction have also been reported elsewhere 2. Covid-19 has overwhelmed health systems globally resulting in longer working hours and increased workload for HW. Italian physicians have suggested a community-centred or home care system for Covid-19; not only lessen the workload on HW but also decrease the transmission of disease and HW exposure 22. Further, there is a need for social support services to help HW who are struggling emotionally and allow for periodic breaks from work. The protection of HWs is essential despite the increased demand and global shortage of PPE. To ensure the availability of adequate PPE for all HWs, governments need to expedite the procurement and devise strategic use of the available PPE. For example, in developing countries, the strategic use of PPE may include extended wear and reuse of certain PPE like gowns, especially in low-risk hospital departments. With the Covid-19 pandemic, there is also the potential for panic amongst HWs that may result in the irrational use of PPE. A balance will need to be struck between HWs safety and strategic use of available resources. Finally, HWs should be trained on proper ways of wearing and taking off PPE to prevent contamination The Covid-19 pandemic has put a strain on the health system workforce due to the overwhelming infection in some countries. This has meant that older HWs mostly doctors and nurses have had to join as frontline workers and some to come out of retirement to offer experience, expertise, leadership, and boost the morale of younger professionals. Old age alongside pre-existing health conditions such as hypertension, diabetes mellitus, cardiovascular disease, chronic lung disease, and immunosuppression were important Covid-19 risk factors identified in this review. These have been touted as major risk factors for severe Covid-19 disease elsewhere 23,24. Health facilities ought to assign duties for high Covid-19 risk departments based on age and underlying conditions. This paper has a number of strengths and weaknesses. While there are many existing papers dealing with occupational health issues related with the Covid-19, identifying the risk factors for infection is an important first step to guide appropriate measures to reduce these risks. This paper provided a concise review of available evidence on the subject as at 20 April 2020, a period when there was an upward trajectory in the number of cases among HWs globally. Rapid reviews by nature have multiple limitations 25. In this study, important omissions were made on steps for a full systematic review. These include publication language restriction and risk of bias/quality appraisal. However, this review will serve as a precursor to a larger, thorough and systematic review and meta-analysis the authors of this paper are working on. Secondly, the evidence on risk factors are likely to be under-reported given the rapid evolution of the pandemic and lack of readily available data from other parts of the world like Africa at the time of the review. Third, due to the heterogeneity among included articles, our review findings can not be generalized or clinically implicated. However, we believe the review yielded important findings to inform occupational health policymakers on Covid-19 risk factors among HWs and researchers on gaps in scientific evidence. Conclusion In the context of Covid-19, HWs face an unprecedented occupational risk of morbidity and mortality. Lack of and/or inadequate PPE, exposure to infected patients, work overload, poor infection control and pre-existing medical conditions put HWs at risk for nosocomial Covid-19 infection. Further studies are needed to inform the development of efficacious infection control measures. There is a need for rapid development of sustainable measures that protect HWs from the pandemic Funding No funding was received for this study. Competing interests None declared. Supplementary Files Supplementary File 1: Results from keywords search. Available online at DOI: 10.5281/zenodo.3769186 References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. WHO. Coronavirus disease 2019 (COVID-19) Situation Report – 101. 30 April 2020. https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200430-sitrep101-covid-19.pdf?sfvrsn=2ba4e093_2. Published 2020. Accessed 1 May 2020. Peng X, Xu X, Li Y, Cheng L, Zhou X, Ren B. 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Number First author 1 Country Liu M China 2 Wang J China 3 Ran Li China 4 Viswanath A Singapore 5 Bai Y China 6 Romano MR Italy Title Clinical characteristics of 30 medical workers infected with new coronavirus pneumonia Reasons for healthcare workers becoming infected with novel coronavirus disease 2019 (COVID-19) in China Risk Factors of Healthcare Workers with Corona Virus Disease 2019: A Retrospective Cohort Study in a Designated Hospital of Wuhan in China Working through the COVID-19 outbreak: Rapid review and recommendations for MSK and allied heath personnel SARS-CoV-2 infection in health care workers: a retrospective analysis and a model study Facing COVID-19 in Ophthalmology Department Study design/Article Type Case control Sample size Reported risk factors 30 Exposure to infected patients Short communication Not Lack of PPE, specified exposure to infected patients, work overload, poor infection control 72 Exposure to infected patients, work overload, poor infection control Retrospective cohort Rapid review Exposure to infected Not specified patients, poor infection control Retrospective analysis 171 Review Lack of PPE, exposure to infected patients, work overload, poor infection control Not Exposure to infected specified patients, work overload 7 Grimm CA USA 8 Yu J China 9 Schwartz L Taiwan 10 Barrett E United States of America 11 Ing EB (This study was a review of studies in various countries) PPE – Personal protective equipment Hospital Experiences Responding to the COVID19 Pandemic: Results of a National Pulse Survey March 23–27, 2020 Infection Control against COVID-19 in Departments of Radiology Report 323 Review Not Exposure to infected specified patients, work overload, poor infection control Lack of PPE, Not specified exposure to infected patients, work overload, poor infection control Protecting Healthcare Brief report Workers During the Coronavirus Disease 2019 (COVID-19) Outbreak: Lessons From Taiwan’s Severe Acute Respiratory Syndrome Response Prevalence of SARS-CoV-2 Prospective cohort 829 infection in previously undiagnosed health care workers at the onset of the U.S. COVID-19 epidemic Physician Deaths from Review 194 Corona Virus Disease (COVID-19) Lack of PPE Exposure to infected patients Lack of PPE, exposure to infected patients, pre-existing conditions Conflict of interest None declared