COVID-19 - What We Know So Far About the Risks to Health Care Workers - Public Health Ontario
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SYNOPSIS
02/27/2020
COVID-19 – What We Know So Far About…the
Risks to Health Care Workers
Preamble
“What We Know So Far About…” documents are intended to provide a brief overview of some of the
published and unpublished reports related to emerging issues with respect to coronavirus disease 2019
(COVID-19). The reports are found through ongoing scanning of the published literature and scientific
listservs (e.g., ProMED, CIDRAP, Johns Hopkins Situation Reports), as well as media reports. It is
recognized that there may be additional information not captured in this document. As this is a rapidly
evolving outbreak, the information will only be current as of the date the document was written.
Key Findings
Based on current information, the proportion of health care-associated COVID-19 infection in
health care workers (HCWs) is relatively low compared to Severe Acute Respiratory Syndrome
(SARS) and Middle-East Respiratory Syndrome (MERS).
The exposure history and infection prevention and control practices of the infected HCWs are
largely unknown.
Reports of infections in HCWs are coming from China, which has reported the majority of
patients and where there are resource constraints related to the availability of personal
protective equipment (PPE), as well as from Japan, Thailand, England and France.
Background
Since December 31, 2019 when China issued a public statement on an outbreak of pneumonia
originating in Wuhan, China, the global incidence of confirmed cases of COVID-19 has grown quickly to
75,204 as of February 19, 2020, affecting 26 countries and killing 2,006 persons (based on World Health
Organization’s situation report on February 19, 2020). The rapid climb in incidence and death toll,
together with the novelty of COVID-19, have raised concerns regarding the risk of health care-associated
infections amongst health care workers.
COVID-19 - What We Know So Far About…the Risks to Health Care WorkersWhat Do We Know So Far About the Risk of COVID-19 in
HCWs?
Currently, there are a limited number of reports on COVID-19 in HCWs, and those identified to date do
not provide sufficient information to precisely evaluate the risk of health care-associated acquisition of
COVID-19, such as:
The extent of exposure outside of the health care setting, i.e., in the community.
HCW knowledge of, and compliance with, routine practices to protect against this novel
pathogen.
Availability and accessibility of hand hygiene facilities for HCWs.
Performance of hand hygiene at the correct indications and with the correct techniques.
Availability and accessibility of the right kind and quality of PPE.
Adherence to best practices when putting on and taking off PPE to avoid self-contamination;
adherence to best practices or manufacturers’ recommendations for changing PPE to ensure
integrity is not compromised.
Performance of aerosol-generating medical procedures in an adequately ventilated room to
reduce the risk of contaminating the health care environment.
Effectiveness and frequency of cleaning surfaces and health care instruments to reduce the risk
of HCWs contaminating their hands and spreading infection.
While additional studies addressing the above information gaps will help evaluate the risk of COVID-19
to HCWs, evidence from prior SARS and MERS outbreaks, in which 21% and 18% of cases were HCWs,
respectively, suggests that protection of HCWs from health care-associated COVID-19 can be achieved
when existing best practices are followed.
Reports
Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical characteristics of 138 hospitalized patients with
2019 novel coronavirus–infected pneumonia in Wuhan, China. JAMA. 2020 Feb 07 [Epub ahead of print].
Available from: https://jamanetwork.com/journals/jama/fullarticle/2761044
In a study of 138 hospitalized patients at Zhongnan Hospital of Wuhan University, Wuhan,
China, 29.0% (40/138) of patients were HCWs. Of these, one HCW was admitted to the intensive
care unit (ICU).
Of the infected HCWs, 31/40 (77.5%) worked in the general wards; 7/40 (17.5%) worked in
the emergency department; and 2/40 (5.0%) worked in the ICU. The authors note that one
COVID-19 patient that was transferred to the surgical department with abdominal
symptoms is thought to have infected 10 HCWs.
Guan W, Ni Z, Hu Y, Liang W, Ou C, He J, et al. Clinical characteristics of 2019 novel coronavirus infection
in China. medRxiv. 2020 Feb 09 [Epub ahead of print]. Available
from: https://www.medrxiv.org/content/10.1101/2020.02.06.20020974v1
The authors describe the epidemiologic and clinical characteristics of 1,099 confirmed cases of
COVID-19 infections from 552 hospitals in 31 provinces/provincial municipalities in China (data
up to January 29, 2020).
COVID-19 - What We Know So Far About…the Risks to Health Care Workers 2 Of the 1,099 infections, 23 (2.1%) were in HCWs.
This article has not been peer-reviewed.
Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y, et al. Early transmission dynamics in Wuhan, China, of novel
coronavirus-infected pneumonia. N Engl J Med. 2020 Jan 29 [Epub ahead of print]. Available from:
https://www.nejm.org/doi/10.1056/NEJMoa2001316
This study is a case series of 425 confirmed COVID-19 cases diagnosed between December 2019
and January 22, 2020. The authors state that the proportion of cases who were HCWs increased
over the three periods studied.
COVID-19 infections in HCWs:
Before January 1, 2020: 0/47 (0%) (Note: Most exposures during this period were likely
concentrated in the Wuhan seafood market, with little opportunity for HCWs to develop
infections)
January 1-11, 2020: 7/248 (2.8%)
January 12-22, 2020: 8/122 (6.6%)
Lu C, Liu X, Jia Z. 2019-nCoV transmission through the ocular surface must not be ignored. The Lancet.
2020 Feb 06 [Epub ahead of print]. Available
from: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30313-5/fulltext
In this correspondence, the authors state that a member of the national expert panel on
pneumonia in China was infected with COVID-19 while in Wuhan.
After visiting with a patient, the HCW developed eye redness and then pneumonia.
The HCW wore an N95 mask, but did not wear eye protection. The authors suggest the HCW
acquired the infection via the ocular route.
World Health Organization (WHO). Novel coronavirus (2019-nCoV): Situation report - 12 [Internet].
Geneva, Switzerland: WHO; 2020 [cited 2020 Feb 11]. Available from:
https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200201-sitrep-12-
ncov.pdf?sfvrsn=273c5d35_2
On February 1, 2020 (data as of February 1, 2020), the WHO reported on the first case of COVID-
19 infections in a HCW from outside China, in France.
The HCW case cared for two probable COVID-19 patients.
World Health Organization (WHO). Coronavirus disease (COVID-19) 14 February 2020 press conference.
Geneva: World Health Organization; 2020 [cited 2020 Feb 16]. Available from:
https://www.who.int/docs/default-source/coronaviruse/transcripts/who-audio-emergencies-
coronavirus-full-press-conference-14feb2020final.pdf?sfvrsn=a96402ed_4
On February 14, 2020, the WHO quoted data released by China that 1,716 health care workers
had been infected with COVID-19, with six deaths.
At the press conference, it was noted that exposure details of the COVID-19 infections reported
in health care workers require further exploration, including whether these infections were
acquired while in a healthcare setting; levels of training and awareness; availability, use and
handling of PPE; workload; and the circumstances in which transmissions occurred.
COVID-19 - What We Know So Far About…the Risks to Health Care Workers 3Li X, Zai J, Wang X, Li Y. Potential of large ‘first generation’ human‐to‐human transmission of 2019‐nCoV.
J Med Virol. 2020 Jan 31 [Epub ahead of print]. Available from:
https://onlinelibrary.wiley.com/doi/10.1002/jmv.25693
The authors mention the account of a colleague that visited Wuhan on January 20, 2020, noting
that 14 healthcare workers had been infected by one person.
Bajema K, Oster A, McGovern O. Persons evaluated for 2019 novel coronavirus - United States, January
2020. Morb Mortal Wkly Rep. 2020 Feb 07 [Epub ahead of print]. Available
from: http://dx.doi.org/10.15585/mmwr.mm6906e1
The study examined 210 patients evaluated for COVID-19 infection in the USA (January 17 to
January 31, 2020). Of these, 17 (8.1%) HCWs were evaluated; however, none of the HCWs had
infection.
Media
Crossley, G; Lee, S.Y. China says 1,716 health workers infected by coronavirus, six dead. Reuters World
News [Internet], 2020 Feb 14 [cited 2020 Feb 14]. Available from: https://www.reuters.com/article/us-
china-health-medics/china-says-1716-health-workers-infected-by-coronavirus-idUSKBN2080MA
This media article reports that the Vice Minister of National Health Commission in China
reported on February 14, 2020 that 1,716 HCWs had acquired COVID-19; as of February 11,
2020, six of these HCWs had died.
The number of HCWs who became infected while working in hospitals is unclear.
Extreme workload, mental stress and PPE shortages are cited as contributing towards the risk of
infection among HCWs.
Centers for Disease Control and Prevention (CDC). Transcript for CDC media telebriefing: update on
COVID-19. CDC Newsroom. 2020 Feb 14. Available from:
https://www.cdc.gov/media/releases/2020/t0214-covid-19-update.html.html
The director of the CDC Center for Immunization and Respiratory Diseases reported that the
United States had 15 COVID-19 cases and no HCWs in the United States had become infected.
Kyodo. Questions raised over protective gear as Japan quarantine officer gets COVID-19. The Japan
Times. National/Science & Health [Internet], 2020 Feb 13 [cited 2020 Feb 15]. Available from:
https://www.japantimes.co.jp/news/2020/02/13/national/science-health/concern-medical-staff-japan-
covid-19/#.Xkgp3flKhPY
This media article reports that a quarantine officer tested positive for COVID-19, a week after
having been dispatched to screen contacts for two days on a cruise ship off the coast of Japan,
according to the health ministry of Japan.
The article reports that the officer stated he was washing hands frequently and wearing a mask
and gloves, but did not use any eye protection while on board the ship.
COVID-19 - What We Know So Far About…the Risks to Health Care Workers 4Reuters. First case of medical worker found. Bangkok Post. General [Internet], 2020 Feb 15 [cited 2020
Feb 15]. Available from: https://www.bangkokpost.com/thailand/general/1858164/first-case-of-
medical-worker-found
This media article reports on a HCW who became infected from contact with a patient who was
not yet diagnosed with COVID-19. An investigation found that the HCW did not wear a mask or
other protective equipment at the time.
The article reports that 24 of the HCW’s colleagues tested negative for COVID-19.
Ma J, Zheng W, Pinghui Z. At least 500 Wuhan medical staff infected with coronavirus. South China
Morning Post [Internet], 2020 Feb 11 [cited 2020 Feb 11]; Society. Available from:
https://www.scmp.com/news/china/society/article/3050077/least-500-wuhan-medical-staff-infected-
coronavirus
This media article reports that at least 500 HCWs in Wuhan had been infected with COVID-19 by
mid-January 2020.
The article reports at least three fatalities in HCWs infected with COVID-19.
The article also states that doctors and other experts have noted a shortage of PPE, long
working hours and a lack of awareness regarding how contagious the virus is and that these
have contributed to the large number of infections observed in HCWs.
Deng C, Chin J. Chinese doctor who issued early warning on virus dies. The Wall Street Journal [Internet],
2020 Feb 7 [cited 2020 Feb 11]; World. Available from: https://www.wsj.com/articles/chinese-doctor-
who-issued-early-warning-on-virus-dies-11581019816
This media article reports on the death of Li Wenliang, a 33-year-old ophthalmologist who
worked in Wuhan, from COVID-19 infection.
The article reports that the physician did not wear PPE during the initial days of the outbreak.
Campbell D, Perraudin F. Coronavirus: number of confirmed UK cases rises from four to eight. The
Guardian [Internet], 2020 Feb 10. [cited 2020 Feb 11]; World. Available from:
https://www.theguardian.com/world/2020/feb/10/coronavirus-uk-declares-outbreak-serious-threat-to-
health
A media outlet reports that two of four new cases in England are HCWs; however, they were not
infected while caring for patients, but rather when they came into contact with a confirmed UK
case at a ski resort in France.
Citation
Ontario Agency for Health Protection and Promotion (Public Health Ontario). COVID-19 - What we know
so far about…the risks to health care workers. Toronto, ON: Queen’s Printer for Ontario; 2020.
Disclaimer
This document was developed by Public Health Ontario (PHO). PHO provides scientific and technical
advice to Ontario’s government, public health organizations and health care providers. PHO’s work is
guided by the current best available evidence at the time of publication.
COVID-19 - What We Know So Far About…the Risks to Health Care Workers 5The application and use of this document is the responsibility of the user. PHO assumes no liability resulting from any such application or use. This document may be reproduced without permission for non-commercial purposes only and provided that appropriate credit is given to PHO. No changes and/or modifications may be made to this document without express written permission from PHO. Public Health Ontario Public Health Ontario is a Crown corporation dedicated to protecting and promoting the health of all Ontarians and reducing inequities in health. Public Health Ontario links public health practitioners, front- line health workers and researchers to the best scientific intelligence and knowledge from around the world. For more information about PHO, visit publichealthontario.ca. COVID-19 - What We Know So Far About…the Risks to Health Care Workers 6
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