Risk of COVID-19 among front-line health-care workers and the general community: a prospective cohort study

doi:10.1016/S2468-2667(20)30164-X

Observational Study

. 2020 Sep;5(9):e475-e483.

doi: 10.1016/S2468-2667(20)30164-X. Epub 2020 Jul 31.

Risk of COVID-19 among front-line health-care workers and the general community: a prospective cohort study

Long H Nguyen¹, David A Drew², Mark S Graham³, Amit D Joshi², Chuan-Guo Guo⁴, Wenjie Ma¹, Raaj S Mehta¹, Erica T Warner⁵, Daniel R Sikavi⁶, Chun-Han Lo⁷, Sohee Kwon², Mingyang Song⁸, Lorelei A Mucci⁹, Meir J Stampfer¹⁰, Walter C Willett¹¹, A Heather Eliassen¹⁰, Jaime E Hart¹², Jorge E Chavarro¹³, Janet W Rich-Edwards¹⁴, Richard Davies¹⁵, Joan Capdevila¹⁵, Karla A Lee¹⁶, Mary Ni Lochlainn¹⁶, Thomas Varsavsky³, Carole H Sudre³, M Jorge Cardoso³, Jonathan Wolf¹⁵, Tim D Spector¹⁶, Sebastien Ourselin³, Claire J Steves¹⁶, Andrew T Chan¹⁷; COronavirus Pandemic Epidemiology Consortium

Collaborators, Affiliations

Collaborators

COronavirus Pandemic Epidemiology Consortium:
Christine M Albert, Gabriella Andreotti, Bijal Bala, Bijal A Balasubramanian, Laura E Beane-Freeman, John S Brownstein, Fiona J Bruinsma, Joe Coresh, Rui Costa, Annie N Cowan, Anusila Deka, Sandra L Deming-Halverson, Maria Elena Martinez, Michael E Ernst, Jane C Figueiredo, Pedro Fortuna, Paul W Franks, Laura Beane Freeman, Christopher D Gardner, Irene M Ghobrial, Christopher A Haiman, Janet E Hall, Jae H Kang, Brenda Kirpach, Karestan C Koenen, Laura D Kubzansky, James V Lacey Jr, Loic Le Marchand, Xihong Lin, Pam Lutsey, Catherine R Marinac, Maria Elena Martinez, Roger L Milne, Anne M Murray, Denis Nash, Julie R Palmer, Alpa V Patel, Eric Pierce, McKaylee M Robertson, Lynn Rosenberg, Dale P Sandler, Shepherd H Schurman, Kara Sewalk, Shreela V Sharma, Christopher J Sidey-Gibbons, Liz Slevin, Jordan W Smoller, Claire J Steves, Maarit I Tiirikainen, Scott T Weiss, Lynne R Wilkens, Feng Zhang

Affiliations

¹ Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Department of Biostatistics, Harvard T H Chan School of Public Health, Boston, MA, USA.
² Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
³ School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK.
⁴ Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Department of Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong Special Administrative Region, China.
⁵ Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Center on Genomics, Vulnerable Populations, and Health Disparities, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
⁶ Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
⁷ Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, MA, USA.
⁸ Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, MA, USA; Department of Nutrition, Harvard T H Chan School of Public Health, Boston, MA, USA.
⁹ Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, MA, USA.
¹⁰ Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, MA, USA; Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
¹¹ Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, MA, USA; Department of Nutrition, Harvard T H Chan School of Public Health, Boston, MA, USA.
¹² Department of Environmental Health, Harvard T H Chan School of Public Health, Boston, MA, USA; Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
¹³ Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, MA, USA; Department of Nutrition, Harvard T H Chan School of Public Health, Boston, MA, USA; Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
¹⁴ Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, MA, USA; Division of Women's Health, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
¹⁵ Zoe Global, London, UK.
¹⁶ Department of Twin Research and Genetic Epidemiology, King's College London, London, UK.
¹⁷ Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Department of Immunology and Infectious Disease, Harvard T H Chan School of Public Health, Boston, MA, USA; Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA, USA; Massachusetts Consortium on Pathogen Readiness, Cambridge, MA, USA. Electronic address: achan@mgh.harvard.edu.

PMID: 32745512
PMCID: PMC7491202
DOI: 10.1016/S2468-2667(20)30164-X

Observational Study

Risk of COVID-19 among front-line health-care workers and the general community: a prospective cohort study

Long H Nguyen et al. Lancet Public Health. 2020 Sep.

. 2020 Sep;5(9):e475-e483.

doi: 10.1016/S2468-2667(20)30164-X. Epub 2020 Jul 31.

Authors

Collaborators

COronavirus Pandemic Epidemiology Consortium:
Christine M Albert, Gabriella Andreotti, Bijal Bala, Bijal A Balasubramanian, Laura E Beane-Freeman, John S Brownstein, Fiona J Bruinsma, Joe Coresh, Rui Costa, Annie N Cowan, Anusila Deka, Sandra L Deming-Halverson, Maria Elena Martinez, Michael E Ernst, Jane C Figueiredo, Pedro Fortuna, Paul W Franks, Laura Beane Freeman, Christopher D Gardner, Irene M Ghobrial, Christopher A Haiman, Janet E Hall, Jae H Kang, Brenda Kirpach, Karestan C Koenen, Laura D Kubzansky, James V Lacey Jr, Loic Le Marchand, Xihong Lin, Pam Lutsey, Catherine R Marinac, Maria Elena Martinez, Roger L Milne, Anne M Murray, Denis Nash, Julie R Palmer, Alpa V Patel, Eric Pierce, McKaylee M Robertson, Lynn Rosenberg, Dale P Sandler, Shepherd H Schurman, Kara Sewalk, Shreela V Sharma, Christopher J Sidey-Gibbons, Liz Slevin, Jordan W Smoller, Claire J Steves, Maarit I Tiirikainen, Scott T Weiss, Lynne R Wilkens, Feng Zhang

Affiliations

¹ Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Department of Biostatistics, Harvard T H Chan School of Public Health, Boston, MA, USA.
² Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
³ School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK.
⁴ Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Department of Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong Special Administrative Region, China.
⁵ Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Center on Genomics, Vulnerable Populations, and Health Disparities, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
⁶ Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
⁷ Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, MA, USA.
⁸ Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, MA, USA; Department of Nutrition, Harvard T H Chan School of Public Health, Boston, MA, USA.
⁹ Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, MA, USA.
¹⁰ Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, MA, USA; Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
¹¹ Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, MA, USA; Department of Nutrition, Harvard T H Chan School of Public Health, Boston, MA, USA.
¹² Department of Environmental Health, Harvard T H Chan School of Public Health, Boston, MA, USA; Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
¹³ Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, MA, USA; Department of Nutrition, Harvard T H Chan School of Public Health, Boston, MA, USA; Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
¹⁴ Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, MA, USA; Division of Women's Health, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
¹⁵ Zoe Global, London, UK.
¹⁶ Department of Twin Research and Genetic Epidemiology, King's College London, London, UK.
¹⁷ Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Department of Immunology and Infectious Disease, Harvard T H Chan School of Public Health, Boston, MA, USA; Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA, USA; Massachusetts Consortium on Pathogen Readiness, Cambridge, MA, USA. Electronic address: achan@mgh.harvard.edu.

PMID: 32745512
PMCID: PMC7491202
DOI: 10.1016/S2468-2667(20)30164-X

Abstract

Background: Data for front-line health-care workers and risk of COVID-19 are limited. We sought to assess risk of COVID-19 among front-line health-care workers compared with the general community and the effect of personal protective equipment (PPE) on risk.

Methods: We did a prospective, observational cohort study in the UK and the USA of the general community, including front-line health-care workers, using self-reported data from the COVID Symptom Study smartphone application (app) from March 24 (UK) and March 29 (USA) to April 23, 2020. Participants were voluntary users of the app and at first use provided information on demographic factors (including age, sex, race or ethnic background, height and weight, and occupation) and medical history, and subsequently reported any COVID-19 symptoms. We used Cox proportional hazards modelling to estimate multivariate-adjusted hazard ratios (HRs) of our primary outcome, which was a positive COVID-19 test. The COVID Symptom Study app is registered with ClinicalTrials.gov, NCT04331509.

Findings: Among 2 035 395 community individuals and 99 795 front-line health-care workers, we recorded 5545 incident reports of a positive COVID-19 test over 34 435 272 person-days. Compared with the general community, front-line health-care workers were at increased risk for reporting a positive COVID-19 test (adjusted HR 11·61, 95% CI 10·93-12·33). To account for differences in testing frequency between front-line health-care workers and the general community and possible selection bias, an inverse probability-weighted model was used to adjust for the likelihood of receiving a COVID-19 test (adjusted HR 3·40, 95% CI 3·37-3·43). Secondary and post-hoc analyses suggested adequacy of PPE, clinical setting, and ethnic background were also important factors.

Interpretation: In the UK and the USA, risk of reporting a positive test for COVID-19 was increased among front-line health-care workers. Health-care systems should ensure adequate availability of PPE and develop additional strategies to protect health-care workers from COVID-19, particularly those from Black, Asian, and minority ethnic backgrounds. Additional follow-up of these observational findings is needed.

Funding: Zoe Global, Wellcome Trust, Engineering and Physical Sciences Research Council, National Institutes of Health Research, UK Research and Innovation, Alzheimer's Society, National Institutes of Health, National Institute for Occupational Safety and Health, and Massachusetts Consortium on Pathogen Readiness.

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Figures

**Figure**
Risk of testing positive for COVID-19 among front-line health-care workers (A) Between March 24 and April 23, 2020, considerable disparities were noted in prevalence of a positive COVID-19 test among front-line health-care workers compared with the general community, in both the UK and the USA. (B) Prevalence of a positive COVID-19 test reported by front-line health-care workers in the UK and the USA. Regions in grey did not have sufficient data for analysis. app=COVID-19 Symptom Study smartphone application.

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Update of

Risk of COVID-19 among frontline healthcare workers and the general community: a prospective cohort study.
Nguyen LH, Drew DA, Joshi AD, Guo CG, Ma W, Mehta RS, Sikavi DR, Lo CH, Kwon S, Song M, Mucci LA, Stampfer MJ, Willett WC, Eliassen AH, Hart JE, Chavarro JE, Rich-Edwards JW, Davies R, Capdevila J, Lee KA, Lochlainn MN, Varsavsky T, Graham MS, Sudre CH, Cardoso MJ, Wolf J, Ourselin S, Steves CJ, Spector TD, Chan AT. Nguyen LH, et al. medRxiv [Preprint]. 2020 May 25:2020.04.29.20084111. doi: 10.1101/2020.04.29.20084111. medRxiv. 2020. Update in: Lancet Public Health. 2020 Sep;5(9):e475-e483. doi: 10.1016/S2468-2667(20)30164-X PMID: 32511531 Free PMC article. Updated. Preprint.

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References

1. Anderson RM, Heesterbeek H, Klinkenberg D, Hollingsworth TD. How will country-based mitigation measures influence the course of the COVID-19 epidemic? Lancet. 2020;395:931–934. - PMC - PubMed
1. Johns Hopkins University of Medicine Coronavirus resource center. July 22, 2020. https://coronavirus.jhu.edu/map.html
1. Kirby T. Evidence mounts on the disproportionate effect of COVID-19 on ethnic minorities. Lancet Respir Med. 2020;8:547–548. - PMC - PubMed
1. Garg S, Kim L, Whitaker M. Hospitalization rates and characteristics of patients hospitalized with laboratory-confirmed coronavirus disease 2019: COVID-NET, 14 States, March 1–30, 2020. MMWR Morb Mortal Wkly Rep. 2020;69:458–464. - PMC - PubMed
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[1] Anderson RM, Heesterbeek H, Klinkenberg D, Hollingsworth TD. How will country-based mitigation measures influence the course of the COVID-19 epidemic? Lancet. 2020;395:931–934. - PMC - PubMed

[2] Anderson RM, Heesterbeek H, Klinkenberg D, Hollingsworth TD. How will country-based mitigation measures influence the course of the COVID-19 epidemic? Lancet. 2020;395:931–934. - PMC - PubMed

[3] Johns Hopkins University of Medicine Coronavirus resource center. July 22, 2020. https://coronavirus.jhu.edu/map.html

[4] Johns Hopkins University of Medicine Coronavirus resource center. July 22, 2020. https://coronavirus.jhu.edu/map.html

[5] Kirby T. Evidence mounts on the disproportionate effect of COVID-19 on ethnic minorities. Lancet Respir Med. 2020;8:547–548. - PMC - PubMed

[6] Kirby T. Evidence mounts on the disproportionate effect of COVID-19 on ethnic minorities. Lancet Respir Med. 2020;8:547–548. - PMC - PubMed

[7] Garg S, Kim L, Whitaker M. Hospitalization rates and characteristics of patients hospitalized with laboratory-confirmed coronavirus disease 2019: COVID-NET, 14 States, March 1–30, 2020. MMWR Morb Mortal Wkly Rep. 2020;69:458–464. - PMC - PubMed

[8] Garg S, Kim L, Whitaker M. Hospitalization rates and characteristics of patients hospitalized with laboratory-confirmed coronavirus disease 2019: COVID-NET, 14 States, March 1–30, 2020. MMWR Morb Mortal Wkly Rep. 2020;69:458–464. - PMC - PubMed

[9] Black JRM, Bailey C, Przewrocka J, Dijkstra KK, Swanton C. COVID-19: the case for health-care worker screening to prevent hospital transmission. Lancet. 2020;395:1418–1420. - PMC - PubMed

[10] Black JRM, Bailey C, Przewrocka J, Dijkstra KK, Swanton C. COVID-19: the case for health-care worker screening to prevent hospital transmission. Lancet. 2020;395:1418–1420. - PMC - PubMed

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Risk of COVID-19 among front-line health-care workers and the general community: a prospective cohort study

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Risk of COVID-19 among front-line health-care workers and the general community: a prospective cohort study

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