Compounding the tragic loss of so many healthcare workers (HCWs) during the pandemic, a new report concludes that, in the absence of a national reporting system, the true count of those who have died of COVID-19 is unknown.

“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.1 “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 caused by 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 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.”

As of March 13, 2021, the Centers for Disease Control and Prevention (CDC) reported 445,284 COVID-19 cases in HCWs and 1,458 deaths.2 These data likely represent a considerable undercount. COVID-19 status was collected from 21.6 million people, but healthcare occupational status was known for only 18%. For the 445,284 cases of COVID-19 among healthcare personnel, death status was only available for 355,681 (79.88%). 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.”

It makes all the more damning those earlier images of HCWs without adequate PPE facing an emerging pathogen with no existing immunity. The threat was underscored when the CDC dropped its longstanding recommendation that N95 respirators were designated single-use only.

“We need to understand the scope of the problem without guessing,” says Sue Anne Bell, PhD, FNP-BC, co-author of the federal report. “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 [HCWs] 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.”

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. Recently, President Biden issued an executive order, telling OSHA that “ensuring the health and safety of workers is a national priority and a moral imperative. [HCWs] 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.”4

“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 differentiate between occupational infections and those that are community acquired. The system may include a built-in disincentive to report occupational infections if there is overlapping disease transmission in the community. Hospitals may see more potential liability and expense in occupational COVID-19 infections.

“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, says Bell, a nurse scientist and professor at the University of Michigan School of Nursing.

“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.”

REFERENCES

  1. National Academies of Sciences, Engineering, and Medicine. Rapid Expert Consultation on Understanding Causes of Health Care Worker Deaths Due to the COVID-19 Pandemic (December 10, 2020). Washington, DC;2020.
  2. Centers for Disease Control and Prevention. COVID Data Tracker. Cases and deaths among healthcare personnel. Updated March 15, 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. The White House. Executive order on protecting worker health and safety. Published Jan. 21, 2021. https://www.whitehouse.gov/briefing-room/presidential-actions/2021/01/21/executive-order-protecting-worker-health-and-safety/