More than 3,000 healthcare workers in China have suspected or confirmed novel coronavirus infections, raising the stakes considerably as employee health professionals brace for community spread to begin in the United States.

Chinese researchers compared the COVID-19 situation to two previous coronavirus outbreaks: severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS).

“Most secondary transmission of SARS and MERS occurred in the hospital setting,” they reported. “Transmission of COVID-19 is occurring in this context as well — 3,019 cases have been observed among health workers as of Feb. 11, 2020 (of whom there have been 1,716 confirmed cases and five deaths).”1

The authors of another published report from China described a COVID-19 outbreak in a hospital in Wuhan, which resulted in 40 infections in clinical staff caring for patients.2 In addition, about one-fourth of the healthcare workers contracted the coronavirus from a single patient. That transmission is reminiscent of the “super spreader” phenomenon seen with SARS and MERS.

“One patient in the current study presented with abdominal symptoms and was admitted to the surgical department,” reported researchers from Zhongnan Hospital of Wuhan University. “More than 10 healthcare workers in this department were presumed to have been infected by this patient.”

It is unclear whether the two papers are describing the same patient, but the authors of the aforementioned paper giving the total case count reported that a surgical patient in Wuhan infected “14 healthcare workers even before fever onset.”1 Other than the deaths, the clinical outcomes for the healthcare workers were not reported.

The infections raise “staggering” implications, including the availability and sustainability of personal protective equipment (PPE), training in proper use, and the “impact on the morale and family concerns for healthcare workers,” noted Daniel Lucey, MD, MPH, FIDSA, FACP, of the Infectious Diseases Society of America.3

A Complicating Variable

Potential factors cited include that some infections occurred earlier in the outbreak when the index of suspicion was lower, some were spread by asymptomatic cases, and others due to shortages and/or improper use of PPE. However, one overriding variable complicates analysis and undermines clear conclusions: The vast majority of worker infections occurred in Wuhan amid a large and expanding outbreak in the community.

“You have to separate out the possibility of acquisition in the community before you assume that every healthcare provider is getting it from their work place,” says David Weber, MD, hospital epidemiologist and associate chief medical officer at University of North Carolina Health Care in Chapel Hill. “There are more than 50,000 cases just in Wuhan and Hubei province.”

This points to a major challenge of COVID-19 that differs from influenza season, when healthcare workers are one of the first groups to be immunized. With no COVID-19 vaccine, healthcare workers face risks in the community, which certainly increase as they treat infected patients in the hospital.

“Another vulnerability — as we saw with the case of Ebola with the healthcare providers [infected] in Dallas [in 2014] — is the failure to appropriately identity and isolate cases in the healthcare facility as soon as they come in,” Weber says.

That is a major emphasis in U.S. hospitals, as many facilities are asking about travel history and have masks at the ready for suspected patients. At this stage of the outbreak, PPE is providing a thin line of protection that can be compromised by incorrect use. The Ebola outbreak revealed healthcare workers may contaminate themselves, particularly when removing PPE.

“Another possibility is that they were improperly wearing the PPE; for example, wearing it just over their mouth but not over their nose,” Weber says. “Were they properly fit-tested, as they are in the United States, for the respirators?”

There also are issues of diminishing PPE supplies, which may press workers to reuse disposable gear or treat patients without full protection. “We know there have been shortages in China, so did the [infected personnel] have an adequate number of gowns, gloves, masks, and face shields?” Weber says. “Or did they run out and were reusing masks? We know they are not really designed to be reused.”

It is possible that some of the healthcare workers could have done all these things correctly and still been infected, Weber concedes. “Maybe they did everything right and they didn’t get in the community,” he says. “They identified all of the patients, they had PPE, and they donned and doffed it perfectly, but what they were doing just failed. I don’t know that I can exclude that, but to me those other possibilities are probably more likely.”

The threat to healthcare workers will be revealed in clearer terms if occupational infections occur in other nations in the absence of large community outbreaks, he adds.

“I think we will have a much better sense of what the risks are to healthcare providers once we begin following all of these cases that have occurred outside of China,” Weber says.”

REFERENCES

  1. Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: Summary of a report of 72,314 cases from the Chinese Center for Disease Control and Prevention. JAMA 2020; Feb 24. doi: 10.1001/jama.2020.2648. [Epub ahead of print].
  2. Wang D, Hu Bo, Hu Chang, et al. Clinical characteristics of 138 hospitalized patients With 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA 2020; Feb 7. doi: 10.1001/jama.2020.1585.
  3. Lucey D. China discloses 1,716 healthcare workers with COVID-19, Feb. 14, 2020. Science Speaks: Global ID News. Available at: https://bit.ly/2PvhpRU.