At the peak of the pandemic in the United States and the United Kingdom, frontline healthcare workers (HCWs) who had adequate personal protective equipment (PPE) were still at more than three times the risk of COVID-19 infection than the general public—even after accounting for differences in testing frequency, according to a study published late last week in The Lancet Public Health.
Researchers at Massachusetts General Hospital and King's College London used data entered into the COVID Symptom Study smartphone app by 99,795 frontline HCWs and 2,035,395 community members. From Mar 24 to Apr 23, positive coronavirus tests were identified in 5,545 app users.
In a post-hoc analysis, compared with white members of the general public, the risk for a positive coronavirus test was higher in community members from black, Asian, and other minority backgrounds (adjusted hazard ratio [aHR], 2.51; 95% confidence interval [CI], 2.18 to 2.89).
Black, Asian, and other minority HCWs were also at elevated risk of infection (aHR, 21.88; 95% CI, 17.78 to 26.94) compared with their white peers (aHR, 12.58; 95% CI, 11.42 to 13.86).
A post-hoc analysis of the link between race and HCW status with risk of coronavirus infection showed that non-white HCWs were at higher risk (aHR, 1.81; 95% CI, 1.45 to 2.24) than their white counterparts.
Broken PPE supply chains, uneven distribution
Supply chain disruptions amid surging demand have led to scarce PPE, including the face masks, gloves, and gowns recommended for HCWs caring for COVID-19 patients. Frontline HCWs who said they had to reuse PPE were at higher risk of a positive COVID-19 test (aHR, 1.46; 95% CI, 1.21 to 1.76) than those who had proper PPE, with inadequate PPE tied to a comparable increase in risk (aHR, 1;31; 95% CI, 1.10 to 1.56).
In a secondary analysis, frontline HCWs with inadequate PPE caring for coronavirus patients were at an even higher risk for infection (aHR, 5.91; 95% CI, 4.53 to 7.71) than those with adequate PPE not caring for infected patients.
Frontline HCWS who cared for COVID-19 patients and reused PPE were also at elevated risk (aHR, 5.06; 95% CI, 3.90 to 6.57) compared with those with proper PPE not caring for coronavirus patients. But even frontline HCWs reporting adequate PPE but caring for patients with suspected infections were at excess risk (aHR, 2.39; 95% CI, 1.90 to 3.00), as were those caring for patients with documented COVID-19 (aHR, 4.83; 3.99 to 5.85).
In a post-hoc analysis, differences were noted in PPE adequacy according to race and ethnicity, with non-white HCWs more often reporting reuse of or inadequate access to PPE, even after adjusting for exposure to patients with COVID-19 (adjusted odds ratio, 1.49; 95% CI, 1.36 to 1.63).
International coordination, data transparency
The study authors said that while previous reports suggested that about 10% to 20% of COVID-19 infections occur among HCWs, the results of their study give a more precise indication of the increased risk that faces HCWs in the pandemic.
In a Massachusetts General Hospital news release, coauthor Andrew Chan, MD, PhD, said that frontline HCWs in many countries still face "vexing" PPE shortages. "Our results underscore the importance of providing adequate access to PPE and also suggest that systemic racism associated with inequalities to access to PPE likely contribute to the disproportionate risk of infection among minority frontline healthcare workers," he said.
In a commentary in the same journal, Linda McCauley, RN, PhD, and Rose Hayes, RN, MA, of Emory University called for universal face masking, data transparency, and cooperation among international governments to ensure equitable distribution of PPE. One such approach, they wrote, would be to use the World Health Organization's international portal for PPE orders.
"If we are ever to outpace COVID-19, there must be accountability at every level, from the community to top government officials," McCauley and Hayes said. "By combining a centralised mechanism for supply chain oversight, with universal masking and data transparency at local levels, it is possible to afford health-care workers the protection they deserve."