By Gary Evans, Medical Writer

On July 27, 2020, three sisters stood outside a hospital window, watching their father die of COVID-19. Two were nurses, and the third was Estefana Johnson, LMSW, a grief counselor in Phoenix.

“I can’t tell you how appreciative I was of the nurse who cared for my father when he was passing,” she says. “She was in the room when we couldn’t be. Her kindness — the love in her face, the compassion — overshadowed the loss. She became us; she was an extension of us. My goal now is to use my own skills to help these nurses and doctors who are suffering. If it is not a direct family member, the loss of colleagues is very traumatic to our healthcare workers.”

While healthcare workers literally bear witness to death, who tolls the bell for them? There is no official count for healthcare workers who have died of COVID-19. Ask how many of these heroes have put their lives on the line and lost them in the process, and one enters a maze of incomplete reports collected from limited jurisdictions, mixed with extrapolations and models confounded with variables.

“We don’t know how many healthcare workers have died as a result of COVID, let alone how many have died of it acquired at work,” says Matthew Wynia, MD, MPH, FACP, director of the Center for Bioethics and Humanities at the University of Colorado Anschutz Medical Campus. “We really are flying blind here a lot of the time because we don’t have standardized reporting systems where all of the states are using the same metrics.”

Wynia is the co-author of a recent report written at the request of the Department of Health and Human Services (HHS) as part of a rapid assessment of the healthcare mortality issue.

Where Is a National Reporting System?

“Other information that is often missing is pregnancy, race and ethnicity, what type of job were they doing, did they have adequate PPE [personal protective equipment], or was their hospital in the midst of a surge and they were overwhelmed and running out,” Wynia says. “All of those questions we really just can’t answer because we don’t have that information on any kind of national basis.”

HHS requested data on deaths related to COVID-19 due to occupational exposure as well as deaths that “could reasonably be attributed to conditions exacerbated by COVID-19,” such as suicides.

“The absence of a uniform national framework and inconsistent requirements across states for collecting, recording, and reporting healthcare worker (HCW) mortality and morbidity data associated with COVID-19 impairs anyone’s ability to make comparisons, do combined analyses, or draw conclusions about the scale of the problem,” the report authors concluded. “Promulgation of a robust national data reporting system, including collection of data on circumstances and interventions that may raise or lower risk, as well as data on where the infection occurred, would support the adoption of effective mitigation strategies and policies to reduce COVID-19 mortality and morbidity in HCWs.”1

As of March 3, the Centers for Disease Control and Prevention (CDC) reported 416,831 COVID-19 cases in healthcare workers and 1,373 deaths. These data represent a considerable undercount, as the CDC details the hamstrung database from which the information was drawn. COVID-19 status was collected from 21.6 million people, but healthcare occupational status was known for only 18%. Of the 416,831 cases of COVID-19 among healthcare personnel, death status was only available for 332,247.2

An investigative journalism project documented 2,900 HCW deaths from March through Dec. 23, 2020.3

“There are estimates that are really low and there are estimates that are really high — and that fact alone is really concerning” Wynia says. “It really means that the best studies on this are ones that are being done by newspapers right now looking through death notices and finding this woman was a nurse, this person was a respiratory therapist, and counting them up that way. If that is the best we can do, it is kind of pathetic.”

Indeed, of all the exhibits that could be presented to indict the nation’s pandemic response, the jury of history will note some unknown but significant portion of dead HCWs were uncounted casualties. It compounds the image of HCWs begging for PPE, the CDC dropping the longstanding recommendation that N95 respirators were designated single-use only, and the widely ridiculed suggestion that scarves and bandanas might partially protect healthcare workers if PPE supplies were exhausted.

“We have seen this repeatedly with PPE shortages and shifting guidelines around PPE as supply changed and new knowledge emerged,” says Sue Anne Bell, PhD, FNP-BC, co-author of the federal report. “If we can learn from some of these mistakes, we can have better systems to understand what is happening to our healthcare workers.”

As it stands, it is almost as if healthcare workers were seen in some sense as expendable, rather than essential. Whether that is true to any degree, it can never happen again. Epidemiologists and virus hunters agree: Another pandemic is coming.

The Fire Next Time

It is not as if there were no warning signs for COVID-19. Like flares from a sinking ship, alerts, warnings, and near misses have come one after the other in this young century. A series of epidemics and pandemics led to the deaths of many healthcare workers, including the original severe acute respiratory syndrome (SARS), 2002-2003, and the largest outbreak of Ebola virus in history (2014-2016). SARS disproportionately hit healthcare workers. In Liberia, 8% of the healthcare workforce died of Ebola.

Other outbreaks of novel viruses during this period include yet another coronavirus: Middle East respiratory syndrome (MERS), 2012-present. MERS still is circulating primarily in Saudi Arabia, originating in bats and now established an animal reservoir in dromedary camels ubiquitous in the country. MERS infections hold a 16% mortality rate in HCWs.4 There is reported work on a vaccine, but Saudi Arabia has thus far refused to cull their camels, an animal iconic to their culture.

“High seroprevalence and high genetic stability of MERS-CoV in camels indicate that camels pose a public health threat,” researchers reported. “The widespread MERS-CoV infections in camels might lead to a risk of future zoonotic transmission into people with direct contact with these infected camels.”5

Finally, a full-blown influenza pandemic occurred in 2009. It was not a devastatingly virulent strain of H1N1 influenza, but it was highly transmissible and there was no immediately available vaccine. As it circulated the globe, it infected a staggering 1 billion people, suggesting that some future antigenic drift of influenza could include the high-virulence code that virus was genetically lacking.

Nathan Wolfe, PhD, author of the 2011 book The Viral Storm, warned that rapid global travel and the continuing encroachment of animal habitats would lead to an age of pandemics. Exacerbated by climate change, the constant intermingling of microbes creates evolutionary pressure to mutate zoonotic pathogens until they transmit to susceptible humans.

“The way that we think about these things is that there is this constant process by which these viruses are ‘pinging’ at human populations from the animal reservoirs that they come from,” he wrote. “The events that we see are an incredibly small percentage of the events that are occurring.”6

While this past is prelude, the COVID-19 pandemic is the event that really exposed our surprisingly fragile, and meagerly funded, public health system. There are many other examples, but the haphazard production and storage of PPE is another broken link that must be addressed. The healthcare system itself came close to breaking as the virus surged in various locales. We now know that in a pandemic scenario, the vaunted United States healthcare system can barely protect its frontline workers, let alone keep track of the dead.

“We need to understand the scope of the problem without guessing,” Bell says. “On a good day, our healthcare system already is substantially stressed. The pandemic has stretched our system to the limit, exposing that we need better support for healthcare workers than is in place right now.”

Thus, the call for a national reporting system for HCWs.

“There is remarkable fragmentation of reporting systems nationally,” Wynia says. “There are mechanisms for nationwide reporting of occupational hazards, injuries, deaths. If you get killed by a crane at a construction site, that will be reported. But there is not a national reporting system — OSHA [Occupational Safety and Health Administration] has just never set one up — for occupationally acquired pandemic illness. There are actually models for this. In laboratory enforcement, there are occupationally acquired infections that are tracked, but not in the hospital itself. That’s a problem.”

OSHA May Be Unleashed

It is a problem that may partially be resolved by OSHA issuing an infectious disease standard to protect HCWs now that the political climate has changed. Rulemaking was proposed in 2016, but fell victim to an antiregulatory agenda at the federal level. To say the least, things have changed. It is harder to ignore the fact that thousands of HCWs have died of COVID-19, part of more than half a million people dead nationally. President Biden recently issued an executive order protecting HCWs from COVID-19, telling OSHA that “ensuring the health and safety of workers is a national priority and a moral imperative. Healthcare workers and other essential workers, many of whom are people of color and immigrants, have put their lives on the line during the COVID-19 pandemic.”7

“Notably, no OSHA category counts deaths specifically from occupationally acquired infection,” according to the federal report. “When a recognized incident, such as a needlestick, leads to illness and death in an HCW, the occupational source is clear. However, when an infectious disease is circulating in the community, it may not be possible to trace individual cases among HCWs to occupational rather than community exposure. Although this may leave any single case uncertain in origin, measures such as excess disease, hospitalization, and death among HCWs compared to the general public could indicate the added risk overall due to occupational exposure.”1

A national reporting system that accounts for such factors could help diffuse occupational vs. community acquired, which has become something of a suspicious, if not false, dichotomy. First, during a pandemic, it would seem the death of an HCW is worth reporting and recording whether they acquired COVID-19 at work or in the community. Even if they clearly acquired it in the community, colleagues and patients at their healthcare facilities may have been exposed and put at risk.

To be blunt, hospitals may see more potential liability and expense in occupational COVID-19 infections. The system may include a built-in disincentive to report occupational infections if there is overlapping disease transmission in the community.

“We had a good bit of discussion about this, and I know there are hospitals and health systems that are really interested in making sure that if someone catches COVID-19 that they are able to say, ‘We don’t know that they caught it at work,’” Wynia says. “They might have caught it at a picnic, or going out to a bar, or at home. [That said], it’s entirely possible. The best studies that we could find on this suggest that maybe even the majority of healthcare workers with COVID-19 caught it somewhere other than a hospital or a clinic.”

As more HCWs are vaccinated and PPE is more available and universally used at work, there may be more clearly defined risk between clinical settings in the community.

“I think most hospitals want to do the right thing,” Wynia says. “Most health system managers are good people who are honestly trying to figure out the best way to go here. But there is obviously the underlying incentive to not spend too much time looking at these things because sometimes you are going to get burned.”

Still, healthcare systems have multiple incentives to keep their workforce healthy and determine the source of infection, Bell says.

“I think the incentive is if we have data that track occupational-related deaths, we can understand and improve working conditions and [determine] where the infections are coming from,” she says. “We will have healthier employees, patients, and communities.”

HCWs have been the most valuable commodity throughout in the pandemic response. The shocking paradox is one could make a counterargument that HCWs were seen as somewhat expendable as the worst pandemic in a century brought the nation to its knees.

REFERENCES

  1. National Academies of Sciences, Engineering, and Medicine. 2020. Rapid Expert Consultation on Understanding Causes of Health Care Worker Deaths Due to the COVID-19 Pandemic (December 10, 2020). Washington, DC: The National Academies Press. https://www.nap.edu/catalog/26018/rapid-expert-consultation-on-understanding-causes-of-health-care-worker-deaths-due-to-the-covid-19-pandemic-december-10-2020
  2. Centers for Disease Control and Prevention. COVID Data Tracker. Cases and deaths among healthcare personnel. March 3, 2021. https://covid.cdc.gov/covid-data-tracker/#health-care-personnel
  3. Jewett C, Lewis R, Bailey M. More than 2,900 health care workers died this year — and the government barely kept track. Kaiser Health News. Dec. 23, 2020. https://khn.org/news/article/more-than-2900-health-care-workers-died-this-year-and-the-government-barely-kept-track/
  4. Al-Tawfiq, Memish ZA. Middle East respiratory syndrome coronavirus in the last two years: Health care workers still at risk. Am J Infect Control 2019;47:1167-1170.
  5. Aljasim TA, Almasoud A, Aljami, HA, et al. High rate of circulating MERS-CoV in dromedary camels at slaughterhouses in Riyadh, 2019. Viruses 2020;12:1215.
  6. Evans G. The fire next time: Hard work, luck may prevent pandemic. Hospital Infection Control & Prevention. July 1, 2013.
  7. The White House. Executive order on protecting worker health and safety. Jan. 21, 2021. https://www.whitehouse.gov/briefing-room/presidential-actions/2021/01/21/executive-order-protecting-worker-health-and-safety/