Assessing coronavirus disease 2019 (COVID-19) transmission to healthcare personnel: The global ACT-HCP case-control study

Infect Control Hosp Epidemiol. 2021 Apr;42(4):381-387. doi: 10.1017/ice.2020.455. Epub 2020 Sep 9.


Objective: To characterize associations between exposures within and outside the medical workplace with healthcare personnel (HCP) SARS-CoV-2 infection, including the effect of various forms of respiratory protection.

Design: Case-control study.

Setting: We collected data from international participants via an online survey.

Participants: In total, 1,130 HCP (244 cases with laboratory-confirmed COVID-19, and 886 controls healthy throughout the pandemic) from 67 countries not meeting prespecified exclusion (ie, healthy but not working, missing workplace exposure data, COVID symptoms without lab confirmation) were included in this study.

Methods: Respondents were queried regarding workplace exposures, respiratory protection, and extra-occupational activities. Odds ratios for HCP infection were calculated using multivariable logistic regression and sensitivity analyses controlling for confounders and known biases.

Results: HCP infection was associated with non-aerosol-generating contact with COVID-19 patients (adjusted OR, 1.4; 95% CI, 1.04-1.9; P = .03) and extra-occupational exposures including gatherings of ≥10 people, patronizing restaurants or bars, and public transportation (adjusted OR range, 3.1-16.2). Respirator use during aerosol-generating procedures (AGPs) was associated with lower odds of HCP infection (adjusted OR, 0.4; 95% CI, 0.2-0.8, P = .005), as was exposure to intensive care and dedicated COVID units, negative pressure rooms, and personal protective equipment (PPE) observers (adjusted OR range, 0.4-0.7).

Conclusions: COVID-19 transmission to HCP was associated with medical exposures currently considered lower-risk and multiple extra-occupational exposures, and exposures associated with proper use of appropriate PPE were protective. Closer scrutiny of infection control measures surrounding healthcare activities and medical settings considered lower risk, and continued awareness of the risks of public congregation, may reduce the incidence of HCP infection.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Aged
  • COVID-19 / prevention & control
  • COVID-19 / transmission*
  • Case-Control Studies
  • Female
  • Global Health / statistics & numerical data
  • Humans
  • Infectious Disease Transmission, Patient-to-Professional / prevention & control*
  • Infectious Disease Transmission, Patient-to-Professional / statistics & numerical data
  • Logistic Models
  • Male
  • Middle Aged
  • Occupational Exposure / prevention & control
  • Occupational Exposure / statistics & numerical data
  • Personal Protective Equipment / statistics & numerical data
  • Personal Protective Equipment / virology
  • Respiratory Protective Devices / statistics & numerical data
  • Respiratory Protective Devices / virology
  • Young Adult