COVID-19 infections among healthcare workers and other people working in healthcare settings

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Organization: Public Health Agency of Canada

Date published: 2021-03-03

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Box 1. Key findings

  1. Overall, twenty percent of COVID-19 cases are People Working in Healthcare Settings (PWHS), this proportion has been declining since a peak in May, 2020.
  2. Additional data is required to assess COVID-19 exposure among PWHS.
  3. Infected PWHS tend to be female and are younger than those infected in the general population.
  4. PWHS have been affected by COVID-19 in all provinces.
  5. PWHS have fewer severe outcomes from infection, as represented by hospitalization and death, compared with those not working in healthcare settings.

People working in healthcare settings (PWHS) are on the frontline of the COVID-19 pandemic, and may face numerous vulnerabilities including risk of COVID-19 exposure, stressful work environments, long hours and fatigue, burnout, and in some instances, stigma and discrimination Footnote 1, in addition to diversity factors that may compound vulnerabilities such as ethnicity/culture, ability, and other socioeconomic and demographic factors. It is important to understand the impact of the COVID-19 pandemic on PWHS given their critical role in response efforts Footnote 2. PWHS represent a wide range of individuals, including healthcare professionals (nurses, dentists, and pharmacists) and support workers (food service workers, housekeeping staff and office administrator). PWHS is a self-reported designation and the interpretation may vary among individuals and jurisdictions.

This report summarizes current information on COVID-19 infection among PWHS in Canada using the national COVID-19 surveillance system. The report discusses the limitations of these data sets (Box 2) and describes work being done to address the remaining data gaps (Box 3), to better understand the impact of COVID-19 on PWHS. The national COVID-19 surveillance system initially characterized the clinical and epidemiologic features of COVID-19 and was not intended to collect information about specific occupations and exposures among PWHS Footnote 3. As knowledge of COVID-19 increases, national surveillance system objectives are expanding. Additional strategies are in development to capture information specifically about COVID-19 among PWHS (Box 3), which can inform interventions for this important category of worker.

COVID-19 disease is caused by the SARS-CoV-2 virus. In this report, the term COVID-19 will be used to refer to both the virus and the disease.

20% of COVID-19 cases are PWHS, but not necessarily acquired in healthcare settings

In 2019, Statistics Canada estimated that health and social services workers made up approximately 13% of the workforce, and approximately 7% of all Canadians Footnote 4. Among the 117 820 COVID-19 cases reported in Canada as of September 14, 2020 (for whom occupation data were available), 20% (n=23 087) considered themselves as PWHS. This suggests that PWHS test positive for COVID-19 more often than the general Canadian population and may be due to a variety of reasons. Although PWHS may have more exposures to COVID-19 as frontline workers, they may also be more likely to seek testing given more knowledge of COVID-19, greater access to testing at worksites, or have workplace requirements for regular testing as part of infection prevention and control guidelines.

The proportion of all COVID-19 cases that are PWHS has changed over time

The proportion of reported COVID-19 cases that are PWHS has declined steadily since a peak in May, 2020, of approximately 23% of all positive cases. From January, 2020 to July, 2020 the proportion of all cases occurring in PWHS was much higher than their representation in the population. After the May, 2020 peak, this proportion declined significantly to 6.5%, suggesting that more recently PWHS are no more likely to become infected with COVID-19 than the general population (Table 1). It should be noted that the proportions are based on the subset of cases for which occupation is known. Reporting on occupation has declined steadily since June, 2020.

Table 1. Number and percent of COVID-19 cases in general population, by month, Canada 2020 Footnote a
Month Cases in PWHS Total COVID-19 cases (where occupation is known)

% of

total cases

January to February 28 293 9.6%
March 506 2 619 19.3%
April 3 663 19 052 19.2%
May 14 436 62 253 23.2%
June 2 949 16 419 18.0%
July 843 9 019 9.3%
August 435 4 666 9.3%
September 1 to September 14 227 3 499 6.5%
Table 1 Footnote a

Source: PHAC database as of September 14, 2020.

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Additional data is required to assess COVID-19 exposure on PWHS

Like all Canadians, PWHS may be exposed to COVID-19 through their interactions in the community, travel or work (Figure 1). Given their role as front-line workers and likelihood of contact with an infected person, understanding occupational exposure for PWHS is important. Of the cases of COVID-19 who identified as healthcare workers and who had exposure information available (n=23 087):

Figure 1. Number of COVID-19 cases of people working in healthcare settings by date of onset Footnote a and exposure category (n=23 087 Footnote b), Canada 2020 Footnote c
Figure 1 - Footnotes
Figure 1 Footnote a

If date of illness onset was not available, the earliest of the following dates were used as an estimate: specimen collection date and laboratory testing date.

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Figure 1 Footnote b

37 cases have been excluded from this table due to missing dates, for a total of 23 050 included.

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Figure 1 Footnote c

Source: PHAC database as of September 14, 2020.

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Table 2. Number of COVID-19 cases in PWHS, by month of illness onset Footnote a and exposure category (n=23 087 Footnote b), Canada 2020 Footnote c
Month of onset International travel Domestic acquisition - contact with traveler Domestic acquisition - contact of COVID-19 case Domestic acquisition - unknown source Pending information
February 6 0 19 2 0
March 332 33 1 525 649 13
April 72 48 8 509 2 502 12
May 7 18 4 688 1 840 0
June 4 3 1 082 385 5
July 5 10 486 239 3
August 2 18 222 220 6
September 0 1 55 29 0
Table 2 Footnote a

If the date of illness onset was not available, the earliest of the following dates were used as an estimate: Specimen Collection Date and Laboratory Testing Date.

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Table 2 Footnote b

37 cases have been excluded from this table due to missing dates, for a total of 23 050 included.

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Table 2 Footnote c

Source: PHAC database as of September 14, 2020.

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Identification of the most likely source of exposure can be difficult owing to the fact that people may have more than one type of exposure and exposure data may be missing or incomplete for some cases. Of the 16 612 (72%) healthcare workers who reported being exposed to a confirmed case of COVID-19, the location of exposure was available for 7 165 (43%). Of these, 87% (n=6 323) reported exposure either in the workplace or in a healthcare setting. These data should be interpreted with great caution as they represent only three provinces. Additionally, there has been no sharing of the exposure detail regarding location of exposure from any province or territory from July, 2020 to the time of extraction in September, 2020. Therefore, the information may not be generalizable across the country, nor in time. Notably, the specific circumstances of these exposures are not available from surveillance data and it is unknown whether exposure was to patients, other staff members, or visitors and whether contact occurred with or without the use of PPE.

Although exposure data is incomplete for over half of cases, available evidence to date suggests that workplace exposure is an important source of COVID-19 in PWHS. However, not all PWHS contract their illnesses at work. There is evidence from reported outbreaks that some PWHS may be acquiring their infection from contact with known cases outside of their workplace (e.g. social gatherings, family clusters). Ongoing improvements to standardize exposure setting data collection will allow a better assessment of the relative contribution of occupational exposure to overall transmission risk and whether the risk for acquisition of COVID-19 is different for different types of PWHS.

Infected PWHS tend to be female and are mostly of working age

On average, COVID-19 cases who are PWHS are younger compared with non-PHWS. While most COVID-19 cases in PWHS are between the ages of 20 and 59, non-PHWS are more distributed across all age groups (Figure 2). Of the COVID-19 cases who are PWHS for whom sex information is known, 79% are female. This is expected and reflects the healthcare workforce composition where a large proportion of individuals are female (83.4%) Footnote 5. Similarly, most of the infected PWHS were of working age with 89% between the ages of 20 and 59, in comparison to 53% of non-PWHS. Work is underway through the updated COVID-19 national surveillance system, to obtain more information about PWHS who have been infected with COVID-19, including their specific occupations, race/ethnicity, and gender identity.

Figure 2. Age distribution COVID-19 cases among PWHS (n=23 087 Footnote a) vs. non-PWHS (n=94 733 Footnote a), Canada 2020 Footnote b
Figure 2 - Footnotes
Figure 2 Footnote a

8 cases have been excluded from among the PWHS, in addition to 106 from non-PWHS, due to missing age group. Totals represented in this table are therefore 23 079 PWHS and 94 627 non-PWHS.

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Figure 2 Footnote b

Source: PHAC database as of September 14, 2020.

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Table 3. Age distribution of COVID-19 cases among PWHS (n=23 087 Footnote a) vs. non-PWHS (n=94 733 Footnote a), Canada 2020 Footnote b
Age group (years) People working in healthcare settings People not working in healthcare settings
0 to 19 314 (1%) 9 203 (10%)
20 to 29 4 239 (18%) 14 283 (15%)
30 to 39 5 132 (22%) 12 041 (13%)
40 to 49 6 084 (26%) 11 735 (12%)
50 to 59 5 420 (23%) 11 977 (13%)
60 to 69 1 771 (8%) 9 327 (10%)
70 to 79 102 (<1%) 7 917 (8%)
80 or plus 17 (<1%) 18 144 (19%)
Table 3 Footnote a

8 cases have been excluded from among the PWHS, in addition to 106 from Non-PWHS, due to missing age group. The totals represented in this table are therefore 23 079 PWHS and 94 627 non-PWHS.

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Table 3 Footnote b

Source: PHAC database as of September 14, 2020.

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Since PWHS are by definition in the workforce, it is more relevant to compare the age distribution of cases with the subset of COVID-19 cases in age groups most likely to be in the workforce. When the youngest and oldest age groups are removed, the age distribution of PWHS and non-PWHS are much more similar, with a higher percentage of case in non-PWHS at either end of the age spectrum (Figure 3).

Table 4. Adjusted age distribution of COVID-19 cases among PWHS (n=22 646) vs. non-PWHS (n=59 363), Canada 2020 Footnote a
Age group
(years)
People working in healthcare settings People not working in healthcare settings
20 to 29 4 239 (19%) 14 283 (24%)
30 to 39 5 132 (23%) 12 041 (20%)
40 to 49 6 084 (27%) 11 735 (20%)
50 to 59 5 420 (24%) 11 977 (20%)
60 to 69 1 771 (8%) 9 327 (16%)
Table 4 Footnote a

Source: PHAC database as of September 14, 2020.

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Figure 3. Adjusted age distribution of COVID-19 cases among PWHS (n=22 646) vs. non-PWHS (n=59 363), Canada 2020 Footnote a
Figure 3 - Footnotes
Figure 3 Footnote a

Source: PHAC database as of September 14, 2020.

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PWHS have been affected by COVID-19 in all provinces

Although PWHS have been affected in all provinces, the majority of infected PWHS have been reported in Ontario and Quebec. These two provinces have also reported the highest number of cases overall. As of September 14, 2020, no cases among PWHS have been identified in the northern territories.

Outbreaks have been an important driver of COVID-19 transmission. At least 1 400 outbreaks in long-term care facilities or acute care settings were reported by September 14, 2020 where transmission to PWHS may have occurred. Additional data on outbreaks, including setting type (healthcare vs community), and the duration and number of PWHS affected in each outbreak will be collected in the coming months and will help to further characterize the impact of outbreaks on PWHS.

PWHS are less likely to experience severe outcomes, even when adjusting for their younger age

It is uncommon for PWHS to die from COVID-19. Less than 1% of infected PWHS have died from COVID-19 and PWHS represent 3% (27/8 645) of all reported COVID-19 deaths in Canada as of September 14, 2020.

Hospitalized cases in Canada tend to be older than non-hospitalized cases Footnote 6, with men reporting more severe symptoms and requiring hospitalization more often than women Footnote 7. In cases unadjusted to include those most likely to be in the workforce, 10.8% of non-PWHS cases have been hospitalized, and only 2.8% of PWHS have required hospitalization (Table 5). Since PWHS with COVID-19 infection tend to be younger females, this may help explain why they require less hospitalization than others.

Although fewer PWHS are hospitalized, when admission is required, slightly younger and higher proportions require admission to the Intensive Care Unit (ICU) compared with all non-PWHS COVID-19 patients (Table 5). Additionally, of the infected PWHS admitted to the ICU, 78% of them were between the ages of 20-59, in comparison to 37% of non-PWHS. The reasons for this are unclear but may be due to artifacts in reporting, since more complete data on hospitalization is available for PWHS compared with other types of patients.

When the population under comparison is restricted to those between 20 and 69 years of age, PWHS remain much less likely than non-PWHS to be hospitalized (7.3% in non-PWHS vs. 2.8% in PWHS), however the proportion that is admitted to ICU is now similar between the two groups (28.1% in non-PWHS and 30.3% in PWHS) (Table 6). While the proportion of cases that die in non-PWHS is still ten times higher than in PWHS (1.5% vs. 0.1%), this difference is far less than in the unadjusted population, where the proportion that died among non-PWHS is 90 times higher than in PWHS (Table 6). 

There are currently no data available on other consequences of COVID-19 infection, such as lung or other organ damage that have been reported by some individuals. While surveillance may not be the mechanism best suited to exploring long term sequelae of COVID-19 infection, research should be undertaken to assess the overall impact of this new disease, and its impact on PWHS in particular.

Table 5. Comparison of hospitalization outcomes between COVID-19 cases among PWHS (n=23 087 Footnote a) and non-PWHS (n=94 733 Footnote a), Canada 2020 Footnote b
Outcome People working in healthcare settings People not working in healthcare settings
Hospitalized 2.8% (n=651/23 087 Footnote c) 10.8% (10 249/94 733 Footnote c)
Admitted to ICU 30.7% (200/651) 19.4%  (1 991/10 249)
Deaths 0.1% (27/23 087 Footnote d) 9.3% (8 766/94 733 Footnote d)
Table 5 Footnote a

This table includes cases for whom occupation status is known.

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Table 5 Footnote b

Source: PHAC database as of September 14, 2020. 

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Table 5 Footnote c

4 369 PWHS cases and 35 122 non-PWHS did not have a known hospitalization status and are assumed in this analysis to be not hospitalized.

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Table 5 Footnote d

693 PWHS and 7 596 non-PWHS did not have a recorded disposition status (i.e. deceased, ill, recovered, stable) and are assumed in this analysis to be not deceased.

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Table 6. Comparison of hospitalization outcomes between COVID-19 cases among PWHS (n=22 646 Footnote a) vs non-PWHS (n=59 363 Footnote a), aged 20-69 years, Canada 2020 Footnote b
Outcome People working
in healthcare settings
People not working
in healthcare settings
Hospitalized 2.8% (n=628/22 646 Footnote c) 7.3% (4 341/59 363 Footnote c)
Admitted to ICU 30.3% (190/628) 28.1%  (1 221/4 341)
Deaths 0.1% (25/22 646 Footnote d) 1.5% (880/59 363 Footnote d)
Table 6 Footnote a

This table includes cases for whom occupation status is known.

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Table 6 Footnote b

Source: PHAC database as of September 14, 2020.

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Table 6 Footnote c

4 271 PWHS cases and 20 456 non-PWHS did not have a known hospitalization status and are assumed in this analysis to be not hospitalized.

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Table 6 Footnote d

677 PWHS and 5 260 non-PWHS did not have a recorded disposition status (i.e. deceased, ill, recovered, stable) and are assumed in this analysis to be not deceased.

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Box 2. Data sources and limitations

The Public Health Agency of Canada (PHAC) receives data for cases reported by provinces and territories (P/Ts) through case report forms.

The national COVID-19 surveillance system was initially developed to characterize the clinical and epidemiologic features of COVID-19 to better inform prevention and control efforts. It was not intended to specifically collect information about exposures among PWHS.

PWHS may have acquired COVID-19 in other locations such as travelling outside Canada, in the community or in the workplace.

  • Difficult to ascertain where and how PWHS with COVID-19 were exposed due to:
    • limited or no information on the exposure setting is collected;
    • PWHS could be exposed in multiple settings such as to patients, to other PWHS, or within the community;
    • no information is collected on whether PWHS wore Personal Protective Equipment (PPE) upon exposure;
    • PWHS also reported both travel and contact with cases in the community.
  • Workplace/healthcare exposure information has been provided by only three provinces, and cannot be generalizable to the entire country.

P/Ts collect and report on occupation with varying degrees of completeness:

  • available only for cases who self-reported as a PWHS;
  • definition of PWHS may vary by P/Ts and may include individuals with or without direct patient contact;
  • not all P/Ts systematically collect data on occupation;
  • reporting on occupation has varied in time.

PWHS include a wide range of roles in healthcare settings:

  • medical or healthcare professionals (physician, nurses, dentists, pharmacists, physiotherapists, etc.);
  • support workers (aides, residential home workers, food service workers, cleaners/janitorial, office administrators, volunteers, etc.);
  • lack of a standard surveillance definition means variability in roles reported by P/Ts;
  • may include current, previous, and retired PWHS.

Box 3. Addressing data gaps

Several strategies under development will strengthen data on COVID-19 in people working in healthcare settings:

  1. Revising the National COVID-19 case dataset will allow for:
    • more detailed and standardized information on PWHS most likely source(s) of exposure and acquisition and asymptomatic status to better understand where and how transmission and exposures are occurring;
    • standardization and finer categorization of PWHS roles in order to understand differences in risk by occupation and sector, and to allow for comparison of cases working in other settings;
    • defined exposure settings to allow better assessment of occupational vs. other types of exposures (e.g. travel, close contact with a case outside a work setting).
  2. Data collection on issues specific to the healthcare workplace and workforce to recognize and support decision making on the inequities and outcomes among PWHS by undertaking specific surveys of PWHS will:
    • assess the impact of COVID-19 and associated workplace changes on the general health and well-being of people working in healthcare settings;
    • understand the experience of PWHS with respect to Personal Protective Equipment and Infection Control Practices in their worksites, the organizational supports made available to them and their perceived level of risk for contracting COVID-19;
    • provide more detail on intersectional issues, such as the role of race and ethnicity in relation to the health workforce and level of risk;
    • explore the long term effects of COVID-19 infection in both the general population and in PWHS;
    • facilitate policy and decision making within specific health care settings.
  3. Performing genetic sequencing concurrent of epidemiological data will:
    • facilitate contact tracing and outbreak control within PWHS settings;
    • inform whether or not PWHS shared a common exposure setting;
    • estimate the true infected population size to assess the impact and burden of COVID-19 on PWHS.

References

Footnote 1

Kisely S, Warren N, McMahon L, Dalais C, Henry I, Siskind D. Occurrence, prevention, and management of the psychological effects of emerging virus outbreaks on healthcare workers: rapid review and meta-analysis. BMJ. 2020 May 5;369:m1642. doi: 10.1136/bmj.m1642. PMID: 32371466; PMCID: PMC7199468.

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Footnote 2

World Health Organization. Mar 2020. Coronavirus disease (COVID-19) outbreak: rights, roles and responsibilities of health workers, including key considerations for occupational safety and health.

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Footnote 3

Government of Canada. Interim national surveillance guidelines for human infection with Coronavirus disease (COVID-19), February 10, 2020. Available at https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/health-professionals/interim-guidance-surveillance-human-infection.html.

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Footnote 4

Statistics Canada. Table 14-10-0023-01 Labour force characteristics by industry, annual (x 1,000). Available at https://www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1410002301

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Footnote 5

Statistics Canada. Labour Force Survey, 2019. Table 14-10-0027-01 Employment by class of worker, annual (x 1,000). Available at https://doi.org/10.25318/1410002701-eng.

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Footnote 6

Government of Canada. Coronavirus disease 2019 (COVID-19): Epidemiology update, August 6, 2020. Available at https://health-infobase.canada.ca/covid-19/epidemiological-summary-covid-19-cases.html#a7.

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Footnote 7

Maleki Dana P, Sadoughi F, Hallajzadeh J, Asemi Z, Mansournia MA, Yousefi B, Momen-Heravi M. An Insight into the Sex Differences in COVID-19 Patients: What are the Possible Causes? Prehosp Disaster Med. 2020 Aug;35(4):438-441. doi: 10.1017/S1049023X20000837. Epub 2020 Jun 18. PMID: 32600476; PMCID: PMC7327162.

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Footnote 8

Chou R, Dana T, Buckley DI, Selph S, Fu R, Totten AM. Update Alert 3: Epidemiology of and Risk Factors for Coronavirus Infection in Health Care Workers. Ann Intern Med. 2020 Sep 15;173(6):W123-W124. doi: 10.7326/L20-1005. Epub 2020 Aug 3. PMID: 32744870; PMCID: PMC7418491.

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Footnote 9

Verbeek JH, Ijaz S, Mischke C, Ruotsalainen JH, Mäkelä E, Neuvonen K, Edmond MB, Sauni R, Kilinc Balci FS, Mihalache RC. Personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff. Cochrane Database Syst Rev. 2016 Apr 19;4:CD011621. doi: 10.1002/14651858.CD011621.pub2. Update in: Cochrane Database Syst Rev. 2019 Jul 01;7:CD011621. PMID: 27093058.

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