The U.S. Veterans Health Administration (VHA) is the nation's largest employer of healthcare personnel (HCP), employing over 300,000 full-time healthcare professionals and support staff at 1255 medical centers and outpatient sites, serving 9 million enrolled Veterans annually.1 The Centers for Disease Control and Prevention reported 100,570 HCP with Coronavirus Disease 2019 (COVID-19) between February 12 and July 16, 2020, however this total may be an underestimation as only 22% of reports included data regarding HCP status, and only six states reported occupation type.2 Widespread community transmission of COVID-19 may contribute to HCP infections, since infection can be transmitted from asymptomatic and presymptomatic cases.3 HCP are a critical resource in a pandemic, and understanding factors associated with COVID-19 infection among HCP is important in protecting their health, preventing amplification of outbreaks within healthcare facilities and maintaining necessary staffing levels.4,5 Herein, we report demographic and occupational factors associated with risk of COVID-19 infection and death among VHA HCP.
Laboratory data for individuals tested for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) at any of the 1225 VHA medical centers or outpatient clinics were reported through 130 VHA administrative parent sites and collected from the VHA Corporate Data Warehouse. Cases of COVID-19 infection were defined as individuals with a positive Emergency Use Authorization (EUA) approved SARS-CoV-2 reverse transcription polymerase chain reaction (RT-PCR) test. Individuals were classified as HCP by one or more of the following methods: documentation of Occupational Health clinic encounter during study period or by COVID-19 testing location, employee eligibility code, or identification as current paid staff (including physician house staff and medical fellows). Full and part-time critical HCP with clinical healthcare provider duties (eg, nurses, respiratory therapists, occupational and physical therapists, medical support assistants, and physicians) and those working in support or infrastructure capacity (eg, food service, environmental management, engineering, and administrative staff)6 were included. These groups included students and trainees (eg, nursing students, medical students, and allied health trainees), volunteers, contractors, and other unpaid personnel. Variables collected for each case included sex, race and ethnicity, age, occupation, facility of employment, Veteran status, and outcome (death). Healthcare facility full and part-time HCP 2020 population (denominator) data were obtained from the VHA Support Service Center, Human Resources Employee Modules.
Total unique HCP tested by date of first SARS-CoV-2 RT-PCR test, total positive, and percent positive with 7-day moving average were analyzed over time. For each facility of HCP employment, COVID-19 test percent positivity among patients admitted and EUA-approved SARS-CoV-2 RT-PCR tested during the study period was calculated and categorized into four levels: low (less than or equal to 5%), moderate (more than 5% to 10%), high (more than 10% to 15%), or very high (more than 15%). Additionally, facilities were grouped into four U.S. Census regions (ie, Northeast, Midwest, South, and West)7 for geographic analysis. COVID-19 incidence proportions, case fatality ratios, and risk ratios (RR) with corresponding 95% confidence intervals (CI) were calculated with two-sided P-values determined using chi-square or Fisher's exact test (Open Epi version 3.01). Mann–Whitney U test was performed to compare median ages of HCP who died versus those who did not (R version 3.6.3).
Testing for SARS-CoV-2 Among VHA HCP
We identified 5925 unique VHA HCP with COVID-19 infection from March 1 to August 31, 2020 among 131,876 HCP tested during the same time period (4.5% positivity). Overall COVID-19 incidence proportion was 1.7% based on 348,798 full and part-time staff as of May 2020 (study mid-point), and proportion of VHA HCP tested was 131,876/348,798 (34.8%). The figure depicts unique HCP tested over time, showing percent positivity peaking at 9.0% in late March 2020, with a secondary peak in mid-July at 7.2%. HCP testing sharply increased in April 2020, decreased rapidly in May, then rose gradually for a secondary, less sharp peak during the summer months. Despite increased testing, percent positivity remained above 5.0% from late June through mid-August (Fig. 1).
Risk Factors for HCP COVID-19 Infection
HCP working at VHA facilities where inpatient COVID-19 test percent positivity was more than 5% were at increased risk of developing COVID-19 infection compared with those working at facilities with less than or equal to 5% inpatient positivity (Table 1). Infection risk at facilities with moderate, high, and very high inpatient percent positivity was 1.73 (95%CI = 1.62 to 1.84) (P < 0.001), 2.32 (95%CI = 2.13 to 2.51) (P < 0.001), and 3.32 (95%CI = 3.04–3.62) (P < 0.001) times greater than at facilities with low inpatient percent positivity. By U.S. Census region, HCP employed in the South and Northeast were at higher risk than those employed at facilities in the West (RR 1.41; 95%CI = 1.31 to 1.51) (P < 0.001) and (RR 1.44; 95%CI = 1.32 to 1.57) (P < 0.001), respectively, while those employed in the Midwest were at lower risk during the study period (RR 0.84; 95%CI = 0.77 to 0.92) (P < 0.001). Occupational categories at highest risk were nursing staff (RR 2.31; 95%CI = 2.17 to 2.46) (P < 0.001), followed by other clinical healthcare providers (RR 1.12; 95%CI = 1.05 to 1.21) (P = 0.001) compared with support/healthcare infrastructure staff. A listing of all occupations within each occupational category is provided in Supplemental Table 1, https://links.lww.com/JOM/A846.
TABLE 1 -
Characteristics of COVID-19-Infected Veterans Health Administration
Healthcare Personnel, March to August, 2020. N
|Characteristic (No. and Percent With Available Information)
||No. Cases (%)
||Incidence Proportion (%)
||Risk Ratio (95% CI)
|Sex: (n = 5,925; 100.0%)
|Age groups (yrs): (n = 5,925; 100.0%)
|Race/Ethnicity: (n = 2,193; 37.0%)
| Non-Hispanic Asian
| Non-Hispanic Black
| Hispanic or Latino
| Non-Hispanic Othera
| Non-Hispanic White
|Veteran status (n = 5,925; 100.0%)
| Veteran HCP
| Non-Veteran HCP
|Facility of employment inpatient COVID-19 test percent positivity: (n = 5,904: 99.6%b)
| Very high (>15%)
| High (>10–15%)
| Moderate (>5–10%)
| Low (≤5%)
|Facility of employment U.S. Census region: (n = 5,866; 99.0%c)
|Occupational categoryd (n = 5,715; 96.5%)
| Nursing Staff
| Other clinical healthcare provider
| Support/healthcare infrastructure staff
COVID-19, Coronavirus disease 2019; CI, confidence interval.
aOther race/ethnicity includes non-Hispanic American Indian or Alaska Native, non-Hispanic Native Hawaiian or Other Pacific Islander, and non-Hispanic mixed race.
bThree facilities with a total of 21 cases had no admissions during study period.
cExcludes 59 cases from Veterans Affairs Medical Center in Puerto Rico.
Occupational Categories were defined in accordance with U.S. Department of Homeland Security, Advisory Memorandum on Identification of Essential Critical Infrastructure Workers During COVID-19 Response. https://www.cisa.gov/identifying-critical-infrastructure-during-covid-19
. A listing of job titles included within each Occupational Category is provided in Supplemental Table 1.
∗P-values were determined using chi-square test.
COVID-19 infection risk was higher in men than in women (RR 1.11; 95%CI = 1.05 to 1.17) (P < 0.001) (Table 1). Among 2193 (37.0%) HCP COVID-19 infections with race/ethnicity recorded, Hispanic or Latino (Hispanic) and non-Hispanic Black (Black) race/ethnicity had 3.04 (95%CI = 2.68 to 3.46) (P < 0.001) and 2.55 (95%CI = 2.32 to 2.79) (P < 0.001) times the risk of COVID-19 infection, respectively, compared with non-Hispanic White (White) HCP. Non-Hispanic Asian (Asian) HCP had less risk of infection (RR 0.39; 95%CI = 0.29 to 0.51) (P < 0.001) compared with White HCP. When compared with HCP less than or equal to 44 years old, those 45 to 64 years and those more than or equal to 65 years were at less risk for COVID-19 infection, with 0.90 (95%CI = 0.86 to 0.95) (P < 0.001) and 0.70 (95%CI = 0.62 to 0.79) (P < 0.001) times the risk of infection, respectively. HCP with Veteran status were 1.52 (95%CI = 1.44 to 1.60) (P < 0.001) times as likely to develop COVID-19 as non-Veteran HCP.
Risk Factors for HCP Death Related to COVID-19
Eighteen of 5925 (0.3%) HCP with COVID-19 infection died. Decedents were older (median age of 61 years [interquartile range (IQR) 55 to 67 years]), compared with those who survived (median age 47 years [IQR 36 to 55 years]) (P < 0.001). Men had 4.02 (95%CI = 1.44 to 11.26) (P = 0.004) times the risk of death compared to females (Supplemental Table 2, https://links.lww.com/JOM/A847). No deaths occurred among HCP less than or equal to 44 years old; highest risk of death was seen in HCP more than or equal to 65 years (5.73 [95%CI = 2.17 to 15.14] [P = 0.004) times the risk compared with HCP 45 to 64 years). HCP with Veteran status were 2.82 (95%CI = 1.10 to 7.27) (P = 0.025) times as likely to die after COVID-19 infection as non-Veteran HCP. No differences in risk of death were observed among race/ethnicity groups.
Testing of VHA HCP and percent positivity for SARS-CoV-2 followed a similar pattern to the overall US,8 with high percent positivity early in the pandemic due to limited testing of HCP presenting with symptoms and ruling out other respiratory illness prior to COVID-19 testing as outlined in early Centers for Disease Control and Prevention COVID-19 testing criteria. A rapid increase in testing of HCP occurred in April, 2020 after the VHA Secretary for Health Operations and Management issued an internal memorandum requiring baseline SARS-CoV-2 testing of all Veterans housed and staff employed in VHA long-term community living centers (CLC) and spinal cord injury and disorder (SCI/D) centers in response to a nation-wide increase in COVID-19 cases in these care settings.9 After initial baseline testing of all CLC and SCI/D staff was completed, follow-up policy guidance provided criteria for HCP SARS-CoV-2 testing on a more routine basis, prioritizing symptomatic HCP, and allowing VHA sites to develop local guidance for testing of asymptomatic HCP as testing supply availability allowed,10 the numbers of tested HCP dropped while percent positivity gradually rose. Given the low overall percentage of HCP tested in VHA (34.8%), with testing perhaps focused on CLC and SCI/D staff as per policy guidance, and the fact that current percent positivity remained above 5%, increased SARS-CoV-2 testing of VHA HCP would likely improve COVID-19 case finding and reduce risk of transmission.
Our findings of higher occupational risk of COVID-19 infection among nursing staff and those in other clinical healthcare provider roles compared with HCP working in healthcare support and infrastructure roles likely reflects the high-risk job duties performed within these occupations, often involving extended close physical contact with patients, aerosol generating procedures, and work with patients who may be extremely ill and infectious. While HCP may become infected due to exposures occurring outside of the workplace, further study is needed to fully understand exposure patterns in healthcare and community-associated acquisition of COVID-19.2,11 Widespread community transmission COVID-19 at the time of this study may have played a role in the increased risk for HCP employed in VHA facilities in the South and Northeast regions of the United States. HCP employed at facilities with higher ranges of inpatient COVID-19 test percent positivity were also among those at highest risk for COVID-19 infection, suggesting that this variable may be an indicator of level of workplace exposure. Factors such as personal protective equipment (PPE) and staffing shortages at healthcare systems hard-hit by COVID-19 play a role in increasing workplace exposure.12–14 In September 2020, the US Government Accounting Office reported that the Department of Veterans Affairs, like healthcare institutions worldwide, faced difficulties obtaining adequate PPE for staff employed at its 170 medical centers.15
Male HCP were more likely than women to die while infected with COVID-19, as has been reported previously.16,17 While we also found men more likely to become infected, other studies have reported differing findings regarding overall population incidence of COVID-19 among men versus women.18,19 Although older HCP (45 to 64 and more than or equal to 65-year age groups) were at lower risk of developing COVID-19 infection compared with the less than or equal to 44-year age group, the more than or equal to 65-year age group was over five times as likely to die once infected. This finding is comparable to COVID-19 mortality trends in the general population.17,20 Compared with White HCP, Hispanic, and Black HCP were more likely to develop COVID-19 infection, however our data did not show any increased risk of death for these populations. A recent VHA-wide study focusing on racial and ethnic disparities in testing and COVID-19 outcomes among Veterans demonstrated similar findings.18 We found that Veteran HCP were more likely to be diagnosed with COVID-19 and were at increased risk of mortality compared with non-Veterans. This finding may be partly attributable to selection bias in that our ability to detect deaths among HCP with COVID-19 was limited to those who were cared for and died in VHA hospitals through the Department of Veterans Affairs “Fourth Mission” (humanitarian care for non-Veterans) or those who were also Veterans and whose deaths were recorded in the electronic health record, making mortality data for Veteran HCP somewhat more accessible. Nevertheless, underlying medical comorbidities are known to occur at higher rates among the Veteran population,21,22 even among Veteran HCP compared with non-Veteran HCP.23
Our study has several limitations. Race/ethnicity data were available for only 37.0% of cases, therefore associations between these characteristics and COVID-19 may be inaccurate. Some HCP position titles were missing, and others could have been misclassified which may have affected risk calculations for occupational categories. We were unable to assess proportions of full-time versus part-time HCP employed at each facility, therefore estimated correlations may vary across facilities based on the share of part-time workers. Potential for selection bias existed in that HCP who were tested outside VHA were not included in our study, nor were outcomes for those with COVID-19 infection who died at home or in non-VHA hospitals. Relative risks were unadjusted, so true association between HCP characteristics, incidence, and mortality may differ. Lastly, the following factors were not assessed in our study: (1) determination whether HCP primary exposure to COVID-19 occurred inside versus outside the workplace, (2) ascertainment of care setting and/or work location of HCP, (3) availability of adequate PPE and staff adherence to recommended infection control practices, and (4) impact of mitigation strategies such as telework and video/remote patient care on specific occupational groups.
HCP represent a critical component in battling the COVID-19 pandemic yet are at heightened risk of infection.13 Early case recognition and prevention of transmission would be improved by ensuring SARS-CoV-2 testing is available onsite for all HCP at their healthcare facilities of employment, and that mechanisms and supplies are in place to provide testing for adequate numbers of HCP. Robust local, state, and national surveillance methods are needed to accurately monitor HCP COVID-19 infections and support contact tracing and implementation of infection control measures among HCP to improve their safety. The increased risk certain categories of healthcare occupations may have with respect to COVID-19 exposure and infection should be considered when developing institutional infection prevention plans.
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