Update Alert 7: Epidemiology of and Risk Factors for Coronavirus Infection in Health Care Workers
Authors: Roger Chou, Tracy Dana, Shelley Selph, Annette M. Totten, David I. Buckley, Rongwei Fu
Journal: Annals of Internal Medicine (2021)

Letters9 February 2021Update Alert 7: Epidemiology of and Risk Factors for Coronavirus Infection in Health Care WorkersFREERoger Chou, MD, Tracy Dana, MLS, Shelley Selph, MD, MPH, Annette M. Totten, PhD, David I. Buckley, MD, MPH, Rongwei Fu, PhDRoger Chou, MDPacific Northwest Evidence-based Practice Center and Oregon Health & Science University, Portland, OregonSearch for more papers by this author, Tracy Dana, MLSPacific Northwest Evidence-based Practice Center and Oregon Health & Science University, Portland, OregonSearch for more papers by this author, Shelley Selph, MD, MPHPacific Northwest Evidence-based Practice Center and Oregon Health & Science University, Portland, OregonSearch for more papers by this author, Annette M. Totten, PhDPacific Northwest Evidence-based Practice Center and Oregon Health & Science University, Portland, OregonSearch for more papers by this author, David I. Buckley, MD, MPHPacific Northwest Evidence-based Practice Center and School of Public Health, Oregon Health & Science University–Portland State University, Portland, OregonSearch for more papers by this author, Rongwei Fu, PhDPacific Northwest Evidence-based Practice Center and School of Public Health, Oregon Health & Science University–Portland State University, Portland, OregonSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/L21-0034 SectionsSupplemental MaterialAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail This is the seventh update alert for a living rapid review on the epidemiology of and risk factors for coronavirus infection in health care workers (1). Beginning with this update alert, we shifted from monthly to bimonthly updates and focused on risk factors for coronavirus infection. A key question on the epidemiology (incidence and prevalence) of coronavirus infection in health care workers was dropped because of lack of change in wide ranges in estimates, likely related to variability in health care settings, symptom status, exposure status, use of infection prevention and control measures, community prevalence, and other factors. Searches were updated from 25 October to 24 December 2020 using the same search strategies as the original review. The update searches identified 3869 citations. We applied the same inclusion criteria used for prior updates, with previously described protocol modifications (2) to focus on higher-quality evidence. Eighteen studies on risk factors for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection were added for this update (3–20).The original rapid review included 34 studies on risk factors for coronavirus infections (3 studies on SARS-CoV-2 infection, 29 studies on SARS-CoV-1 infection, and 2 studies on Middle East respiratory syndrome–CoV infection) (1); 46 studies (44 studies on SARS-CoV-2 infection, 0 studies on SARS-CoV-1 infection, and 2 studies on Middle East respiratory syndrome–CoV infection) were added in prior updates (2, 21–25). For this update, 12 cohort studies (3–9, 11, 14, 15, 18, 19) and 6 cross-sectional studies (10, 12, 13, 16, 17, 20) were added (Supplement Table 1). Four studies were done in the United States (4, 7, 18, 20), 10 in Europe (Spain [5, 11, 14], Italy [8, 9], the United Kingdom [12, 17], France [13], Sweden [15], and the Netherlands [15]), 2 in India (6, 10), and 1 each in China (19) and Egypt (3). As with studies included in prior updates, the studies had methodological limitations, including potential recall bias, low or unclear participation rates, small sample sizes, and potential collinearity. Some studies did not control for confounders, and those that reported adjusted estimates were limited in their ability to control for exposures and personal protective equipment (PPE) use.Similar to prior report updates, estimates did not indicate an association between sex (13 studies [3–6, 9, 11–13, 15, 17–20]) or age (12 studies [3–5, 9, 11–13, 15, 17–20]) and risk for SARS-CoV-2 infection or seropositivity. Fifteen new studies found no consistent association between health worker role (nurse vs. physician) and risk for SARS-CoV-2 infection (3–5, 7–12, 14–16, 18–20). In the only study that controlled for confounders, the adjusted odds ratio (OR) for risk for SARS-CoV-2 seropositivity for nurses versus physicians was 1.52 (95% CI, 1.18 to 1.95) (4). Five new studies found that Black race (4, 18), Black or Asian race or ethnic minority (12, 17), or Hispanic (20) race/ethnicity was associated with an increased risk for infection versus White race (Supplement Table 2). In 4 studies that controlled for confounders, adjusted ORs ranged from 1.92 to 2.79 (4, 12, 17, 20). Nine new studies reported inconsistent associations between direct patient contact or contact with patients with COVID-19 and risk for SARS-CoV-2 infection or seropositivity primarily based on unadjusted risk estimates (3–5, 7, 8, 10, 14, 18, 19). In 2 studies that controlled for potential confounders, direct contact with patients with COVID-19 was associated with increased risk for infection versus no contact (adjusted OR, 1.69 [CI, 1.28 to 2.24]) (14) and versus a nonclinical health care worker role (adjusted OR, 3.08 [CI, 1.09 to 8.78]) (13).Regarding mask use, 1 study found that always using an N95 or surgical mask was associated with decreased risk for SARS-CoV-2 infection versus less complete use (adjusted OR, 0.83 [CI, 0.72 to 0.95] for N95 mask and 0.86 [CI, 0.75 to 0.98] for surgical mask) (4). Another study found that N95 and surgical masks were each associated with decreased risk for SARS-CoV-2 infection versus no mask based on unadjusted estimates; an N95 mask was associated with decreased risk versus a surgical mask (OR, 0.76 [CI, 0.63 to 0.92]) (18). Use of PPE (not limited to masks) was associated with decreased risk for infection versus no PPE in 1 study (5) (adjusted OR, 0.45 [CI, 0.26 to 0.83]). Two other studies did not find an association between PPE use and risk for infection but reported an imprecise estimate (3) or did not control for confounders (20). There was no new evidence for infection control training and education (Supplement Table 3). Overall, new evidence indicates an association between Black, Hispanic, or Asian race/ethnicity in health workers in the United States or the United Kingdom and increased risk for infection; results regarding risk factors updated with the new studies were otherwise judged to be consistent with the original review and prior updates (Supplement Tables 2 to 6).References1. Chou R, Dana T, Buckley DI, et al. Epidemiology of and risk factors for coronavirus infection in health care workers: a living rapid review. Ann Intern Med. 2020;173:120-136. doi:10.7326/M20-1632 LinkGoogle Scholar2. Chou R, Dana T, Buckley DI, et al. Update alert 2: epidemiology of and risk factors for coronavirus infection in health care workers [Letter]. Ann Intern Med. 2020;173:W77. doi:10.7326/M20-4806 LinkGoogle Scholar3. Abdelmoniem R, Fouad R, Shawky S, et al. SARS-CoV-2 infection among asymptomatic healthcare workers of the emergency department in a tertiary care facility. J Clin Virol. 2021;134:104710. [PMID: 33276180] doi:10.1016/j.jcv.2020.104710 CrossrefMedlineGoogle Scholar4. Akinbami LJ, Vuong N, Petersen LR, et al. SARS-CoV-2 seroprevalence among healthcare, first response, and public safety personnel, Detroit metropolitan area, Michigan, USA, May-June 2020. Emerg Infect Dis. 2020;26:2863-2871. [PMID: 32956614] doi:10.3201/eid2612.203764 CrossrefMedlineGoogle Scholar5. Algado-Sellés N, Gras-Valentí P, Chico-Sánchez P, et al. Frequency, associated risk factors, and characteristics of COVID-19 among healthcare personnel in a Spanish health department. Am J Prev Med. 2020;59:e221-e229. [PMID: 33220760] doi:10.1016/j.amepre.2020.07.014 CrossrefMedlineGoogle Scholar6. Banerjee A, Mukherjee K, Bhattacharjee D, et al. Status of health-care workers in relation to COVID-19 infection: a retrospective study in a level 4 COVID hospital in eastern India. J Assoc Physicians India. 2020;68:55-57. [PMID: 33247643] MedlineGoogle Scholar7. Barrett ES, Horton DB, Roy J, et al. Prevalence of SARS-CoV-2 infection in previously undiagnosed health care workers in New Jersey, at the onset of the U.S. COVID-19 pandemic. BMC Infect Dis. 2020;20:853. [PMID: 33198725] doi:10.1186/s12879-020-05587-2 CrossrefMedlineGoogle Scholar8. Calcagno A, Ghisetti V, Emanuele T, et al. Risk for SARS-CoV-2 infection in healthcare workers, Turin, Italy. Emerg Infect Dis. 2021;27. [PMID: 33021927] doi:10.3201/eid2701.203027 CrossrefMedlineGoogle Scholar9. Colaneri M, Novelli V, Cutti S, et al. The experience of the health care workers of a severely hit SARS-CoV-2 referral hospital in Italy: incidence, clinical course and modifiable risk factors for COVID-19 infection. J Public Health (Oxf). 2020. [PMID: 33140084] doi:10.1093/pubmed/fdaa195 Google Scholar10. Goenka M, Afzalpurkar S, Goenka U, et al. Seroprevalence of COVID-19 amongst health care workers in a tertiary care hospital of a metropolitan city from India. J Assoc Physicians India. 2020;68:14-19. [PMID: 33187030] MedlineGoogle Scholar11. Gras-Valentí P, Chico-Sánchez P, Algado-Sellés N, et al; Grupo COVID-19 del Servicio de Medicina Preventiva. Sero-epidemiological study of SARS-CoV-2 infection among healthcare personnel in a healthcare department. Enferm Infecc Microbiol Clin. 2020. [PMID: 33162223] doi:10.1016/j.eimc.2020.09.015 Google Scholar12. Jones CR, Hamilton FW, Thompson A, et al. SARS-CoV-2 IgG seroprevalence in healthcare workers and other staff at North Bristol NHS Trust: a sociodemographic analysis [Letter]. J Infect. 2020. [PMID: 33271169] doi:10.1016/j.jinf.2020.11.036 Google Scholar13. Krastinova E, Garrait V, Lecam MT, et al. Household transmission and incidence of positive SARS-CoV-2 RT-PCR in symptomatic healthcare workers, clinical course and outcome: a French hospital experience. Occup Environ Med. 2020. [PMID: 33277384] doi:10.1136/oemed-2020-106866 CrossrefMedlineGoogle Scholar14. Pérez-García F, Pérez-Zapata A, Arcos N, et al. Severe acute respiratory coronavirus virus 2 (SARS-CoV-2) infection among hospital workers in a severely affected institution in Madrid, Spain: a surveillance cross-sectional study. Infect Control Hosp Epidemiol. 2020:1-7. [PMID: 33118904] doi:10.1017/ice.2020.1303 CrossrefMedlineGoogle Scholar15. Rashid-Abdi M, Krifors A, Sälléber A, et al. Low rate of COVID-19 seroconversion in health-care workers at a Department of Infectious Diseases in Sweden during the later phase of the first wave; a prospective longitudinal seroepidemiological study. Infect Dis (Lond). 2020:1-7. [PMID: 33232190] doi:10.1080/23744235.2020.1849787 Google Scholar16. Schmitz D, Vos M, Stolmeijer R, et al. Association between personal protective equipment and SARS-CoV-2 infection risk in emergency department healthcare workers. Eur J Emerg Med. 2020. [PMID: 33105329] doi:10.1097/MEJ.0000000000000766 CrossrefMedlineGoogle Scholar17. Shields A, Faustini SE, Perez-Toledo M, et al. SARS-CoV-2 seroprevalence and asymptomatic viral carriage in healthcare workers: a cross-sectional study. Thorax. 2020;75:1089-1094. [PMID: 32917840] doi:10.1136/thoraxjnl-2020-215414 CrossrefMedlineGoogle Scholar18. Sims MD, Maine GN, Childers KL, et al; BLAST COVID-19 Study Group. COVID-19 seropositivity and asymptomatic rates in healthcare workers are associated with job function and masking. Clin Infect Dis. 2020. [PMID: 33150375] doi:10.1093/cid/ciaa1684 Google Scholar19. Wang X, Jiang X, Huang Q, et al. Risk factors of SARS-CoV-2 infection in healthcare workers: a retrospective study of a nosocomial outbreak. Sleep Med X. 2020;2:100028. doi:10.1016/j.sleepx.2020.100028. Google Scholar20. Yogo N, Greenwood KL, Thompson L, et al. Point prevalence survey to evaluate the seropositivity for coronavirus disease 2019 (COVID-19) among high-risk healthcare workers. Infect Control Hosp Epidemiol. 2020:1-6. [PMID: 33317655] doi:10.1017/ice.2020.1370 CrossrefMedlineGoogle Scholar21. Chou R, Dana T, Buckley DI, et al. Update alert: epidemiology of and risk factors for coronavirus infection in health care workers [Letter]. Ann Intern Med. 2020;173:W46-W47. doi:10.7326/L20-0768 LinkGoogle Scholar22. Chou R, Dana T, Buckley DI, et al. Update alert 3: epidemiology of and risk factors for coronavirus infection in health care workers [Letter]. Ann Intern Med. 2020;173:W123-W124. doi:10.7326/L20-1005 LinkGoogle Scholar23. Chou R, Dana T, Buckley DI, et al. Update alert 4: epidemiology of and risk factors for coronavirus infection in health care workers [Letter]. Ann Intern Med. 2020;173:143-144. doi:10.7326/L20-1134 LinkGoogle Scholar24. Chou R, Dana T, Buckley DI, et al. Update alert 5: epidemiology of and risk factors for coronavirus infection in health care workers [Letter]. Ann Intern Med. 2020;173:W154-W55. doi:10.7326/L20-1227 LinkGoogle Scholar25. Chou R, Dana T, Selph S, et al. Update alert 6: epidemiology of and risk factors for coronavirus infection in health care workers [Letter]. Ann Intern Med. 2021;174:W18-W19. doi:10.7326/L20-1323 LinkGoogle Scholar Comments 0 Comments Sign In to Submit A Comment Author, Article, and Disclosure InformationAuthors: Roger Chou, MD; Tracy Dana, MLS; Shelley Selph, MD, MPH; Annette M. Totten, PhD; David I. Buckley, MD, MPH; Rongwei Fu, PhDAffiliations: Pacific Northwest Evidence-based Practice Center and Oregon Health & Science University, Portland, OregonPacific Northwest Evidence-based Practice Center and School of Public Health, Oregon Health & Science University–Portland State University, Portland, OregonDisclaimer: The original review was funded by the World Health Organization. The World Health Organization staff developed the key questions and scope for the original review but did not have any role in the selection, assessment, or synthesis of evidence for this update.Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=L21-0034.Corresponding Author: Roger Chou, MD, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail Code BICC, Portland, OR 97239; e-mail, chour@ohsu.edu.This article was published at Annals.org on 9 February 2021. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoKeeping Up With Emerging Evidence in (Almost) Real Time Christine Laine , Darren B. Taichman , Eliseo Guallar , and Cynthia D. Mulrow Update Alert: Epidemiology of and Risk Factors for Coronavirus Infection in Health Care Workers Roger Chou , Tracy Dana , David I. Buckley , Shelley Selph , Rongwei Fu , and Annette M. Totten Epidemiology of and Risk Factors for Coronavirus Infection in Health Care Workers Roger Chou , Tracy Dana , David I. Buckley , Shelley Selph , Rongwei Fu , and Annette M. Totten Update Alert 2: Epidemiology of and Risk Factors for Coronavirus Infection in Health Care Workers Roger Chou , Tracy Dana , David I. Buckley , Shelley Selph , Rongwei Fu , and Annette M. Totten Update Alert 3: Epidemiology of and Risk Factors for Coronavirus Infection in Health Care Workers Roger Chou , Tracy Dana , David I. Buckley , Shelley Selph , Rongwei Fu , and Annette M. Totten Update Alert 4: Epidemiology of and Risk Factors for Coronavirus Infection in Health Care Workers Roger Chou , Tracy Dana , David I. Buckley , Shelley Selph , Rongwei Fu , and Annette M. Totten Update Alert 5: Epidemiology of and Risk Factors for Coronavirus Infection in Health Care Workers Roger Chou , Tracy Dana , David I. Buckley , Shelley Selph , Rongwei Fu , and Annette M. Totten Update Alert 6: Epidemiology of and Risk Factors for Coronavirus Infection in Health Care Workers Roger Chou , Tracy Dana , Shelley Selph , Annette M. Totten , David I. Buckley , Rongwei Fu Update Alert 8: Epidemiology of and Risk Factors for Coronavirus Infection in Health Care Workers Roger Chou , Tracy Dana , David I. Buckley , Shelley Selph , Rongwei Fu , and Annette M. Totten Update Alert 9: Epidemiology of and Risk Factors for Coronavirus Infection in Health Care Workers Roger Chou , Tracy Dana , Shelley Selph , Annette M. Totten , David I. Buckley , Rongwei Fu Update Alert 10: Epidemiology of and Risk Factors for Coronavirus Infection in Health Care Workers Roger Chou , Tracy Dana , David I. Buckley , Shelley Selph , Rongwei Fu , Annette M. Totten Update Alert 11: Epidemiology of and Risk Factors for Coronavirus Infection in Health Care Workers Roger Chou , Tracy Dana , David I. Buckley , Shelley Selph , Rongwei Fu , Annette M. Totten Metrics Cited byPortrait of Montréal healthcare workers infected with SARS-CoV-2 during the first wave of the pandemic: a cross-sectional studyIncidence and Prevalence of Coronavirus Disease 2019 Within a Healthcare Worker Cohort During the First Year of the Severe Acute Respiratory Syndrome Coronavirus 2 PandemicSevere Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Dose, Infection, and Disease Outcomes for Coronavirus Disease 2019 (COVID-19): A ReviewUpdate Alert 11: Epidemiology of and Risk Factors for Coronavirus Infection in Health Care WorkersRoger Chou, MD, Tracy Dana, MLS, David I. Buckley, MD, MPH, Shelley Selph, MD, MPH, Rongwei Fu, PhD, Annette M. Totten, PhDUpdate Alert 10: Epidemiology of and Risk Factors for Coronavirus Infection in Health Care WorkersRoger Chou, MD, Tracy Dana, MLS, David I. Buckley, MD, MPH, Shelley Selph, MD, MPH, Rongwei Fu, PhD, Annette M. Totten, PhDUpdate Alert 9: Epidemiology of and Risk Factors for Coronavirus Infection in Health Care WorkersRoger Chou, MD, Tracy Dana, MLS, Shelley Selph, MD, MPH, Annette M. Totten, PhD, David I. Buckley, MD, MPH, Rongwei Fu, PhDSARS-CoV-2 Ig G among Healthcare Workers and the General Population April 2021Volume 174, Issue 4 Page: W45-W46 Keywords COVID-19 Epidemiology Health care providers Medical risk factors Nurses Odds ratio Personal protective equipment Racial and ethnic issues Risk management Upper respiratory tract infections ePublished: 9 February 2021 Issue Published: April 2021 Copyright & PermissionsCopyright © 2021 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...