








key: cord-325778-y5miy24f
authors: Quigley, Ashley L.; Stone, Haley; Nguyen, Phi Yen; Chughtai, Abrar Ahmad; MacIntyre, C. Raina
title: Estimating the Burden of COVID-19 on the Australian Healthcare Workers and Health System
date: 2020-10-29
journal: Int J Nurs Stud
DOI: 10.1016/j.ijnurstu.2020.103811
sha: 
doc_id: 325778
cord_uid: y5miy24f

INTRODUCTION: There is no publicly available national data on healthcare worker infections in Australia. It has been documented in many countries that healthcare workers are at increased occupational risk of COVID-19. We aimed to estimate the burden of COVID-19 on Australia healthcare workers and the health system by obtaining and organizing data on HCW infections, analyzing national HCW cases in regards to occupational risk and analyzing healthcare outbreak. METHODS: We searched government reports and websites and media reports to create a comprehensive line listing of Australian healthcare worker infections and nosocomial outbreaks between January 25(th) and July 8(th), 2020. A line list of healthcare worker related COVID-19 reported cases was created and enhanced by matching data extracted from media reports of healthcare related COVID-19 relevant outbreaks and reports, using matching criteria. Rates of infections and odds ratios (ORs) for healthcare workers were calculated per state, by comparing overall cases to healthcare worker cases. To investigate the sources of infection amongst healthcare workers, transmission data were collated and graphed to show distribution of sources. RESULTS: We identified 36 hospital outbreaks or outbreaks between January 25(th) and July 8(th), 2020. According to our estimates, at least 536 healthcare workers in Australia have been infected with COVID-19, comprising 6.03% of all reported infections. The rate of healthcare worker infection was 72/100,000 and of community infection 34/100,000. healthcare workers were 2.76 times more likely to contract COVID-19 (95% CI 2.53 to 3.01; P<0.001). The timing of hospital outbreaks did not always correspond to community peaks. Where data were available, a total of 131 healthcare workers across 21 outbreaks, led to 1656 healthcare workers being furloughed for quarantine. One hospital was closed and had 1200 workers quarantined in one outbreak. CONCLUSION: The study shows that HCWs were at nearly 3 times the risk of infection. Of concern, this nearly tripling of risk occurred during a period of low community prevalence suggesting failures at multiple hazard levels including PPE policies within the work environment. Even in a country with relatively good control of COVID-19, healthcare workers are at greater risk of infection than the general community and nosocomial outbreaks can have substantial effects on workforce capacity by the quarantine of numerous workers during an outbreak. The occurrence of hospital outbreaks even when community incidence was low, highlights the high risk setting that hospitals present. Australia faces a resurgence of COVID-19 since late June 2020, with multiple hospital outbreaks. We recommend formal reporting of healthcare worker infections, testing protocols for nosocomial outbreaks, cohorting of workforce to minimize the impact, and improved PPE guidelines to provide precautionary and optimal protection for healthcare workers.

131 healthcare workers across 21 outbreaks, led to 1656 healthcare workers being furloughed for quarantine. One hospital was closed and had 1200 workers quarantined in one outbreak.

The study shows that HCWs were at nearly 3 times the risk of infection. Of concern, this nearly tripling of risk occurred during a period of low community prevalence suggesting failures at multiple hazard levels including PPE policies within the work environment. Even in a country with relatively good control of COVID-19, healthcare workers are at greater risk of infection than the general community and nosocomial outbreaks can have substantial effects on workforce capacity by the quarantine of numerous workers during an outbreak. The occurrence of hospital outbreaks even when community incidence was low, highlights the high risk setting that hospitals present. Australia faces a resurgence of COVID-19 since late June 2020, with multiple hospital outbreaks. We recommend formal reporting of healthcare worker infections, testing protocols for nosocomial outbreaks, cohorting of workforce to minimize the impact, and improved PPE guidelines to provide precautionary and optimal protection for healthcare workers.

What is already known about this topic:

 The absence of formal national reporting of HCW infections makes it difficult to inform work health and safety of HCW.

As of 11 th July, over 12 million cases of COVID-19 have been confirmed worldwide, causing more than 548,000 deaths 3 , with global COVID-19 healthcare worker (HCW) infections on the rise. By early March 2020, more than 3300 HCW had been infected in China alone, with reports of at least 22 HCW deaths 4 . In Italy, a country with a high burden of COVID-19, over 20% of responding HCW have been infected, with almost 200 HCW deaths 5, 6 . The International Council of Nurses (ICN) has reported that more than 600 nurses have died in the COVID-19 pandemic and estimate that over 450,000 HCW had been infected by June 3 rd , 2020 7 . The number of global HCW infections may be underreported due to many countries state health departments not tracking deaths and infections by occupation 8 .

The precise dynamics of transmission of COVID-19 is unknown, but likely through a combination of droplets, aerosols and contact 9, 10 . Frontline HCWs, such as those working in emergency wards are at increased risk as HCW are often exposed to patients with high viral loads whilst providing care 11 and accumulated respiratory aerosols in the work-place may pose a risk to occupational safety. Hospitals are highly contaminated environments 11 and hazard controls including PPE are often compromised.. In the UK, where testing was done in two National Health System (NHS) trusts, almost one in five HCW were infected 12, 13 . Therefore, given the hospital as a site of potential outbreaks, infected HCW may be asymptomatic or presymptomatic, and unknowingly infect others at work. A study of HCW infections in Wuhan, China, found that the case infection rate of HCW was 2.0%, significantly higher than non-HCW at 0.43% 14 .

An analysis of the COVID-19 HCW infections in China during the initial phase of the outbreak, found that a high number of HCW cases occurred through contact with asymptomatic patients or mildly symptomatic patients of COVID-19 and through direct contact between HCW 15 . A surgical patient in a Wuhan hospital infected 14 HCW before fever onset 16 . HCW may therefore unknowingly acquire and transmit infections to patients and other HCW around them. Many studies have also shown that hospitals not only present a high exposure setting for respiratory infections in HCW 17, 18 but that presenteeism is a key risk factor in disease transmission and extension of an outbreak 19 . An employee who attends work regardless of having a medical illness which prevents them from functioning optimally, demonstrates presenteesim 19 . Despite the serious public health risks of presenteeism 20 , HCW have been identified as a group that are very likely to continue to work when infected with diseases such as influenza and norovirus 21 . In addition, asymptomatic or pre-symptomatic infection can result in nosocomial outbreaks as HCW may work without realizing they are infected.

Shortages of personal protective equipment (PPE) have been described as a contributing risk factor for COVID-19 in HCW worldwide 5, 22, 23 . Initial recommendations from the Centres for Disease Control and Prevention (CDC) were to use respirators, but following a shortage in supply of these, guidelines changed to the use of medical masks, or even cloth masks 24, 25 27 . Further to this, there is always the concern of the risk that demand could outweigh supply of HCW in hotspots that emerge during peaks in the pandemic 28 .

Whilst COVID-19 HCW infections have been estimated at greater than over 19 000 cases in the United States of America and over 150 000 cases in Europe 1,2,12,13 , in the absence of national reporting of HCW infections, the impact of COVID-19 on HCW in Australia needs to be investigated 12, 13 . The aim of the study was to estimate the burden of COVID-19 on Australian HCW and the national health system using publicly available data.

Although there is no national reporting of HCW infections, daily press releases from government sources and media reports have reported on hospital outbreaks and HCW infections. We collected publicly available data on Australian COVID-19 patients reported by National and state/territory Governments and the media between January 25 th , 2020 and July 8 th , 2020. HCW For the line list of outbreaks where an outbreak is defined as 2 or more cases of COVID-19 in a one week period, outbreak information was matched using date, location (state/territory and city), the name of the clinical facility, number of cases, patient age, number of deaths and occupation as an HCW. Matching criteria were used to match information from the media to relevant outbreaks and reports. Matched outbreaks included in this report were detailed in state media releases and thus were recorded in the line list.

HCW cases from media reports were matched with HCW cases recorded in the line list based on the matching criteria matrix in Table 1 . A case is considered a high probability match if fulfilling at least one criterion from all groups (1, 2 and 3); a medium probability match if fulfilling at least one criterion from groups 2 and 3; and otherwise a low probability match. Only cases with high probability matching were included for the line list and analysis. For the purposes of this study, clinical facilities were deidentified in reporting the results. 

Rates of infections for HCW were calculated using reported cases and the remaining total cases as the numerator, and denominator data was obtained from the Australian Government 42 outbreak in Melbourne has also seen a rise in HCW infections since late June 2020. 

Out of 36 hospital outbreaks identified from the media, 2 (5.56%) started with a HCW that travelled interstate; 2 (5.56%) started with a HCW that returned from overseas; 4 (11.11%) started with a HCW that was a contact of a known case from a communityoutbreak; 5 (13.89%)

were traced to contact with a patient that tested positive for COVID-19, and 22 (61.11%) did not have information to determine the source of infection. Based on the setting in which the first HCW case was working on when they acquired COVID- Descriptive information for HCW outbreaks is outlined in Table 3 in the Appendix.

One way to measure the burden of COVID-19 infections on the health system is to measure the ratio of the number of HCW being quarantined because of contact with a known case, to the number of positive cases. facilities or wards were not shut down. The factors that might explain the disparity in the ratios include the type of acute care facilities such as emergency departments which may not be able to be shut down and availability of HCW to replace those in quarantine. In the absence of formally reported statistics on HCW infections, we estimated 536 HCW infections up to July 2020, and that HCW account for 6.03% of COVID-19 infections in Australia and have double the risk of contracting COVID-19 than the general community. The numbers we estimate are consistent with Federal government press releases that there were 481 HCW infections by April 2020, released well after national cases had significantly decreased 59 . The higher risk of infection is consistent with studies overseas which show a higher risk for HCW 12, 13 .

A potential limitation of the risk analyses conducted for this study were based on open-sourced data for HCW cases, which may vary depending on each state's individual data publishing policies. We also used media reports, which have not been verified. In most cases, however, there were multiple media reports about each outbreak, often with quotes from health officials.

There is also a potential effect of testing rates on the identification of COVID-19 cases. We accounted for this by representing the daily testing rates in conjunction with the daily HCW infections reported. The source of infection for 22 of the 36 outbreaks analyzed could not be identified. The occupational risk level for the 36 outbreaks is therefore uncertain. The study did not include a second wave of COVID-19 which occurred in the State of Victoria in June-July 2020, where over 3000 HCW were infected 60, 61 . Therefore, this study may not be generalizable to the period July-August 2020. It may not be generalizable to other countries or settings, with different COVID-19 epidemiology and health systems.

Nosocomial outbreaks of SARS and SARS-COV-2 have been described 62 , showing hospitals to be a high risk setting for outbreaks. HCW may become infected from COVID-19 patients, coworkers or from outside the hospital, and may act as vectors for onward transmission to coworkers, patients and community members including household contacts. There are some

HCWs who have continued to work while symptomatic and some may be asymptomatically infected and working. Our analysis shows that the source of hospital outbreaks can be from both COVID-19 patients and from infections imported into the hospital by HCW or others.

Undiagnosed COVID-19 patients 63 or undiagnosed HCW may both cause transmission in the hospital setting.

The largest COVID-19 HCW outbreak occurred during the first few weeks of the Australian pandemic when community transmission was low and testing of HCW was based on symptoms. 

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