​​There is a need for more data on COVID-19 infections among healthcare workers to track the pandemic's impact on them, writes Prof Angela Dramowksi (Paediatrics and Child Health) and her colleagues in an opinion piece for Health24 (22 June).

• Read the article below or click here for the piece as published.

Angela Dramowski*

On 3 June, the International Council of Nurses (ICN) implored governments to compile data on healthcare worker (HCW) COVID-19 infections and deaths. As yet there is no global registry to track the pandemic's impact on HCWs, although it has infected an estimated 230,000 and led to the deaths of 600 nurses. Analysis by the ICN suggests that on average, 7% of all COVID-19 cases worldwide occur among HCWs. Notable exceptions include some high-income countries (USA, Spain and Ireland) where HCWs account for 15-30% of all infections.

There is a clear need to collect standardised epidemiological data on HCW infections to identify risk factors for COVID-19 infections and deaths, with few published studies to date. A single hospital study of 9000 HCWs in Wuhan identified a 1% staff infection rate, mainly affecting female nurses under 45 years of age with mild disease. The risk of infection was highest in COVID-19 low-risk areas of the hospital, suggesting a lack of awareness among these HCW. Staff infection rates declined rapidly as the outbreak progressed, possibly owing to enhanced HCW training, preparedness and compliance with infection prevention measures. In a study from two Dutch hospitals early in the pandemic, less than 1% of 9705 HCWs became infected. The infected staff worked in 52 different hospital departments, suggesting infection acquisition in the community rather than as part of a hospital outbreak.

South African  HCWs have not been spared, with 511 HCW infections accounting for 7% of cases nationally by 6 May 2020.(4) As the outbreak gathers pace, our HCWs will be increasingly exposed to COVID-19 in the workplace, on public transport and in communities. Many will fall ill, although a large proportion will remain asymptomatic, and at risk of unknowingly transmitting infection to others (rates of asymptomatic disease range from 10-80%). In common with the country's population, many HCWs are at risk for severe COVID-19 disease due to underlying conditions such as hypertension, diabetes, HIV or obesity.

As COVID-19 infections accelerate, HCW absences due to illness and death will exacerbate pre-existing staff shortages. Even among HCWs who remain healthy, COVID-19 will contribute to chronic fatigue, psychological distress, and potential burnout. These negative direct and indirect effects of COVID-19 are already being experienced in many Cape Town hospitals, with staff fearing for their own safety and that of their patients, colleagues and family members. Numbers of HCW infections and deaths have risen in tandem with increasing community infection rates, prompting labour unions to demand an investigation of HCW safety in public hospitals.

In the Cape Metro's largest facility (Tygerberg Hospital), approximately 6% of staff were diagnosed with COVID-19 infection between 1 April and 31 May (296/4672 staff members). It is not possible to  establish definitively whether these infections were acquired in the community, on public transport or in the workplace. Similar to the Dutch COVID-19 HCW infection study, HCW infections at Tygerberg Hospital have occurred in over 50 different areas and wards, suggesting that a substantial proportion may be community-acquired rather than healthcare-associated. Indeed, three-quarters of staff diagnosed with COVID-19 infection work in non-clinical areas and COVID low-risk wards (where contact with COVID-infected patients would be absent or minimal), strengthening the likelihood that these infections were not acquired through clinical or patient contact.

It is unclear why the Western Cape and South African HCW COVID-19 infection rates are much higher than that reported from the Wuhan and Dutch hospitals. However, local HCW infection rates are in keeping with the global estimates suggested by ICN and could reflect high COVID-19 exposure in the community, as well as a need to further strengthen infection prevention practices in communities and healthcare settings.

Given the delayed COVID-19 introduction to South Africa and the flattening of the outbreak curve achieved by the national lockdown, our healthcare facilities fortunately had more time to prepare than many countries. At Tygerberg Hospital, a co-ordinated infection prevention and occupational health plan was enacted to mitigate the risk of COVID-19 infection transmission to staff and patients. Multiple measures were implemented to support staff and patient safety including:

• a COVID-19 risk assessment per department with identification of high-risk staff who required medical shielding by re-deployment to low-risk areas;
  
• COVID-19 prevention training for all categories of staff as well as daily COVID-19 educational and support messages for staff;
• daily COVID-19 symptom screening of all staff, patients and paediatric inpatient's caregivers visitor restrictions;
• a universal masking policy for staff and patients and provision of hand sanitiser at all entrances and clinical areas;
• enhanced surface and equipment cleaning and disinfection, and evaluation of symptomatic staff with priority SARS-CoV-2 testing;
• a secure supply chain for personal protective equipment (PPE) including prudent use and onsite ultraviolet decontamination of N95 respirators;
• building of showers for staff to use after shifts and installation of extraction fans and air-handling units in ICU areas.

Notwithstanding these many active measures to enhance staff and patient safety during the COVID-19 pandemic, there remain several challenges at Tygerberg Hospital and other healthcare facilities in our country. These include ageing hospital structures with minimal provision for patient isolation, inadequate bed spacing, lack of dedicated space for donning and removal of PPE and low staff to patient ratios, particularly for nurses and cleaners. Despite the many challenges and the fraught working conditions, South Africa's HCWs consistently demonstrate their optimism, tenacity and willingness to adapt to and overcome obstacles. It is this resilience that gives HCWs, including those at Tygerberg Hospital, faith to hope for the best while at the same time preparing for the worst that COVID-19 may bring.

*Angela Dramowski is a Professor in Department of Paediatrics and Child Health at Stellenbosch University (SU). Members of the Infection Prevention and Control, Infectious Diseases and Occupational Health teams at Tygerberg Hospital and SU contributed to this article.