Risks of occupational illnesses among health workers providing care to patients with COVID-19: an integrative review

Vega, Edwing Alberto Urrea; Antoniolli, Liliana; Macedo, Andréia Barcellos Teixeira; Pinheiro, Jéssica Morgana Gediel; Dornelles, Thayane Martins; Souza, Sônia Beatriz Cócaro de

doi:10.1590/1518-8345.4895.3455

Brasil

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Review Article • Rev. Latino-Am. Enfermagem 29 • 2021 • https://doi.org/10.1590/1518-8345.4895.3455 linkcopy

Risks of occupational illnesses among health workers providing care to patients with COVID-19: an integrative review^*

Authorship SCIMAGO INSTITUTIONS RANKINGS

Objective: to analyze evidence concerning the risks of occupational illnesses to which health workers providing care to patients infected with COVID-19 are exposed.

Method: integrative literature review conducted in the following online databases: Medical Literature Analysis and Retrieval System Online (MEDLINE/PubMed), Web of Science (WoS), Excerpta Medica Data-Base (EMBASE), Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Scopus (Elsevier). Original articles published between November 2019 and June 2020, regardless of the language written, were included. A descriptive analysis according to two categories is presented.

Results: the sample is composed of 19 scientific papers. Most were cross-sectional studies with an evidence level 2C (n=17, 90%) written in English (n=16, 84%). The primary thematic axes were risk of contamination and risk of psycho-emotional illness arising from the delivery of care to patients infected with COVID-19.

Conclusion: the review presents the potential effects of providing care to patients with COVID-19 on the health of workers. It also reveals the importance of interventions focused on the most prevalent occupational risks during the pandemic. The studies’ level of evidence suggests a need for studies with more robust designs.

Descriptors: Coronavirus Infections; Occupational Exposure; Health Personnel; Allied Health Personnel; Nurses; Physicians

PICO^* * PICO = P- population; I- Intervention/area of interest; C- comparison; O- outcome	Search terms	Controlled descriptors
P- Population	(Health Care Provider) OR (Health Care Providers) OR (Healthcare Provider) OR (Healthcare Providers) OR (Healthcare Worker) OR (Healthcare Workers) OR (Personnel, Health) OR (Provider, Health Care) OR (Provider, Healthcare) OR (Providers, Health Care) OR (Providers, Healthcare) OR (Health AND Worker) OR (Personnel AND Health) OR (Health Care AND Provider) OR (Healthcare AND Worker) (Allied Health Professional) OR (Allied Health Professionals) OR (Assistant, Healthcare) OR (Assistants, Healthcare) OR (Health Personnel, Allied) OR (Health Professional, Allied) OR (Health Professionals, Allied) OR (Healthcare Assistant) OR (Healthcare Assistants) OR (Healthcare Support Worker) OR (Healthcare Support Workers) OR (Paramedic) OR (Paramedical Personnel) OR (Paramedics) OR (Personnel, Allied Health) OR (Personnel, Paramedical) OR (Population Program Specialist) OR (Population Program Specialists) OR (Professional, Allied Health) OR (Professionals, Allied Health) OR (Program Specialist, Population) OR (Program Specialists, Population) OR (Specialist, Population Program) OR (Specialists, Population Program) OR (Support Worker, Healthcare) OR (Support Workers, Healthcare) OR (Worker, Healthcare Support) OR (Workers, Healthcare Support) (Nurses) OR (Nurse) OR (Nurse, Registered) OR (Nurses, Registered) OR (Nursing Personnel) OR (Personnel, Nursing) OR (Registered Nurse) OR (Registered Nurses) OR (nurs) Physicians	Healthcare workers Healthcare Support Workers Nurses Physicians
I- Intervention/area of interest	(COVID-19) OR (2019 novel coronavirus Pneumonia) OR (2019-novel coronavirus Pneumonia) OR (2019 novel coronavirus Epidemic) OR (2019 novel coronavirus Outbreak) OR (2019 novel coronavirus Pandemic) OR (2019-nCoV Acute Respiratory Disease) OR (2019-nCoV Epidemic) OR (2019-nCoV Outbreak) OR (2019-nCoV Pandemic) OR (2019-nCoV Pneumonia) OR (2019-novel coronavirus (2019-nCoV) Infection) OR (2019new coronavirus Epidemic) OR (201920 China Pneumonia Outbreak) OR (201920 Wuhan coronavirus Outbreak) OR (COVID-19) OR (Coronavirus Infection) OR (Infection, Coronavirus) OR (Infections, Coronavirus) OR (MERS (Middle East Respiratory Syndrome)) OR (Middle East Respiratory Syndrome) OR (Novel Coronavirus Pneumonia) OR (Wuhan Seafood Market Pneumonia) OR (Wuhan coronavirus Epidemic) OR (Wuhan coronavirus Infection) OR (Wuhan coronavirus Outbreak) OR (Wuhan coronavirus Pandemic) OR (Wuhan coronavirus Pneumonia)	Coronavirus infections
C- Comparison	Does not apply	Does not apply
O- Outcome	(Exposure, Occupational) OR (Exposures, Occupational) OR (Occupational Exposures)	Occupational exposure

Category 1. Risk of contamination and occupational exposure among health workers providing care to patients infected with COVID-19^¶.
Primary author / Journal / Database / Year	Design / Sample / Country	Objective	Result	LE^¶¶¶ ¶¶¶ EL = Evidence Level according to the Oxford Centre for Evidence-based Medicine;
Ran L, et al./ Clinical Infectious Diseases /EMBASE^* * EMBASE = Excerpta Medica Data-base; /(2020)⁽¹⁴⁾	Retrospective cohort study /72 physicians and nurses / China	To determine the risk factors and behaviors associated with COVID-19^¶ ¶ COVID-1 9 = Coronavirus Disease 2019; among health workers.	The group of high-risk workers was 2.13 times more likely of developing COVID-19^¶ ¶ COVID-1 9 = Coronavirus Disease 2019; than the group of workers in general (RR^§§ §§ RR = Relative Risk; raw=2.13, ^\|\|\|\| \|\|\|\| CI = Confidence Interval; 95% CI: 1.45-3.95, ^¶¶ ¶¶ p = p value; p<0.05).	2B^** ****** Level of Evidence 2B = Cohort Study;
Liu M, et al./ Chinese Journal of Tuberculosis and Respiratory Diseases /MEDLINE-Pubmed^† † MEDLINE-PubMed = Medical Literature Analysis and Retrieva /(2020)⁽¹⁵⁾	Retrospective case series - 30 participants (22 physicians and 8 nurses)/China	To investigate the clinical characteristics of the medical team with the novel coronavirus pneumonia (NCP)^ NCP = Novel Coronavirus Pneumonia; .	The average time of contact was 12 hours (7.16), and the average accumulated time of contact was 2 hours (1.5,2.7). The primary manifestation of 83.33% of the participants was cough and dry cough, in most cases, approximately one week after admission. Later, 14 (46.67%) participants experienced difficulty breathing.	4^†††† †††† Level of Evidence 4 = Case report;
Korth J, et al./ Journal of Clinical Virology / SCOPUS^‡ ‡ SCOPUS = Elsevier's database; / (2020)⁽¹⁶⁾	Prospective cross-sectional study/ 316 health workers /Germany	To determine the seroprevalence of SARS-CoV-2^†† †† SARS-CoV-2 = Severe Acute Respiratory syndrome Coronavirus 2; among health workers from the Essen University Hospital, Germany.	SARS-CoV-2^†† †† SARS-CoV-2 = Severe Acute Respiratory syndrome Coronavirus 2; -^* ***** IgG = Immunoglobulin G IgG antibodies were detected in 5 of the 316 (1.6%) individuals.	2C^‡‡‡‡ ‡‡‡‡ Level of Evidence 2C = Observation of therapeutic results, ecological studies
Delgado D, et al./ International Journal of Environmental Research and Public Health / SCOPUS^‡ ‡ SCOPUS = Elsevier's database; / (2020)⁽¹⁷⁾	Cross-sectional study/ 936 health workers/ Latin American (Spanish speaking countries).	To assess the context and personal safety perceptions of health workers from Latin America countries during the COVID-19^¶ outbreak.	Most participants (699; 74.7%) accessed the COVID-19^¶ diagnosis and treatment algorithms, while 237 (25,3%) did not.	2C^‡‡‡‡ ‡‡‡‡ Level of Evidence 2C = Observation of therapeutic results, ecological studies
Ong JJY, et al./ Headache: The Journal of Head and Face Pain /SCOPUS^‡ ‡ SCOPUS = Elsevier's database; /(2020)⁽¹⁸⁾	Cross-sectional study/ 158 health workers/ Singapore	To determine risk factors associated with headaches associated with new PPE^‡‡ ‡‡ PPE = Personal Protective Equipment; and perceived impact of these headaches on personal health and work performance.	The participants with a diagnosis of preexisting primary headache (OR^††† ††† OR = Odds Ratio; = 3.44; ^\|\|\|\| \|\|\|\| CI = Confidence Interval; 95% CI 1.14-10.32; ^¶¶ ¶¶ p = p value; p=0.013) and those working in the emergency department (OR^††† ††† OR = Odds Ratio; =2.39, ^\|\|\|\| \|\|\|\| CI = Confidence Interval; 95%CI 1.05-5.47; ^¶¶ ¶¶ p = p value; p=0.019) were more likely to develop headaches associated with the prolonged use of N95 face masks and goggles.	2C^‡‡‡‡ ‡‡‡‡ Level of Evidence 2C = Observation of therapeutic results, ecological studies
Category 2. Risk of psycho-emotional illness among health workers providing care to patients infected with COVID-19^¶ ¶ COVID-1 9 = Coronavirus Disease 2019; .
Li Z, et al./ Brain, Behavior, and Immunity /EMBASE*/(2020)⁽¹⁹⁾	Descriptive cross-sectional study/ 740 individuals (214 public in general and 526 nurses)/China	To identify and provide an intervention for vicarious trauma in its initial stage.	The scores obtained by nurses working in the front line concerning vicarious trauma, including scores concerning physiological and psychological outcomes, were significantly lower than that obtained by nurses not working in the front line (^¶¶ ¶¶ p = p value; p <0.001) and the public in general (^¶¶ ¶¶ p = p value; p<0.001).	2C^‡‡‡‡ ‡‡‡‡ Level of Evidence 2C = Observation of therapeutic results, ecological studies
Lai J, et al./ JAMA Network Open /CINAHL^§ § CINAHL = Cumulative Index to Nursing and Allied Health Literature; /(2020)⁽²⁰⁾	Cross-sectional cohort study /1,257 health workers (493 physicians and 764 nurses)/China	To assess the magnitude of mental health outcomes and associated factors among health workers providing care to patients infected with COVID-19^¶ ¶ COVID-1 9 = Coronavirus Disease 2019; in China.	A considerable portion of participants presented symptoms of depression (634 [50.4%]), anxiety (560 [44.6%]), insomnia (427 [34.0%]), and anguish (899 [71.5%]).	2C^‡‡‡‡ ‡‡‡‡ Level of Evidence 2C = Observation of therapeutic results, ecological studies
Kang L, et al./ Brain, Behavior, and Immunity /EMBASE*/(2020)⁽²¹⁾	Cross-sectional cohort study /994 health workers (183 physicians and 811 nurses)/China	To verify the mental health condition of the medical and nursing staff in Wuhan, the efficacy of psychological care, and psychological care needs.	36% of the workers presented mental disorders below the average threshold; 34.4% presented mild disorders; 22.4% presented moderate disorders; and 6.2% presented severe disorders. No significant differences were found regarding demographic data.	2C^‡‡‡‡ ‡‡‡‡ Level of Evidence 2C = Observation of therapeutic results, ecological studies
Huang JZ, et al./ Chinese Journal of Industrial Hygiene and Occupational Diseases /EMBASE*/(2020)⁽²²⁾	Cross-sectional cohort study/230 health workers (70 physicians and 160 nurses)/China	To investigate the medical staff's mental health working in the front line against the COVID-19^¶ ¶ COVID-1 9 = Coronavirus Disease 2019; pandemic and provide a theoretical ground for psychological intervention.	The incidence of anxiety among the nurses was higher than among the physicians [26.88% vs. 14.29% ^¶¶ ¶¶ p = p value; p=0.039]. The incidence of stress in the health staff was 27.39%.	2C^‡‡‡‡ ‡‡‡‡ Level of Evidence 2C = Observation of therapeutic results, ecological studies
Primary author / Journal / Database / Year	Design / Sample / Country	Objective	Result	LE^¶¶¶ ¶¶¶ EL = Evidence Level according to the Oxford Centre for Evidence-based Medicine;
Xiao H, et al./Medical Science Monitor: International Medical Journal of Experimental and Clinical Research/ MEDLINE-Pubmed†/ (2020)⁽²³⁾	Cross-sectional observational study/180 participants (nurses and physicians)/China	Structural equation modeling was used to determine the effect of social support on sleep quality and function among the health workers who provided care to patients with COVID-19^¶ ¶ COVID-1 9 = Coronavirus Disease 2019; in January and February 2020 in Wuhan.	The results show that the social support provided to the medical team negatively affected (decreased) their anxiety and stress levels and positively affected their self-efficacy, though it did not directly improve sleep quality. The team's anxiety levels significantly affected stress levels and significantly decreased their self-efficacy and sleep quality.	2C^‡‡‡‡ ‡‡‡‡ Level of Evidence 2C = Observation of therapeutic results, ecological studies
Xiao X, et al./Journal of Affective Disorders/SCOPUS‡/(2020)⁽²⁴⁾	Multicenter cross-sectional study/958 participants/China	To assess stress levels and psychological morbidities such as anxiety and depression among health workers during the COVID-19^¶ ¶ COVID-1 9 = Coronavirus Disease 2019; outbreak.	The results showed that different positions (junior, intermediate and senior) (^¶¶ ¶¶ p = p value; p=0.02) and professional experience in years (fewer than 5 years, 6-10 years, and more than 11 years) (^¶¶ ¶¶ p = p value; p=0.048) affected the health workers' stress levels.	2C^‡‡‡‡ ‡‡‡‡ Level of Evidence 2C = Observation of therapeutic results, ecological studies
Wu Y, et al./Journal of Pain and Symptom Management/EMBASE*/(2020)⁽²⁵⁾	Cross-sectional study/220 participants/China	To compare the frequency of burnout between physicians and nurses working in the front line and those working in standard wards.	The frequency of burnout is significantly lower among front line workers than those working in standard wards (13% vs. 39%; ^¶¶ ¶¶ p = p value; p<0.0001). The frequency of a low level of personal achievement is lower in the front line group than in the standard wards (39% vs. 61%; ^¶¶ ¶¶ p = p value; p=0.002).	2C^‡‡‡‡ ‡‡‡‡ Level of Evidence 2C = Observation of therapeutic results, ecological studies
Samaniego A, et al./Revista Interamericana de Psicología/SCOPUS‡/ (2020)⁽²⁶⁾	Cross-sectional study /126 health professionals /Paraguay	To determine the prevalence of depression, anxiety, insomnia, anguish, and compassion fatigue and factors associated with symptoms to establish preventive strategies or evidence-based interventions.	Compassion fatigue was significantly higher among nursing workers (^¶¶ ¶¶ p = p value; p=0.004) and physicians (^¶¶ ¶¶ p = p value; p=0.022) compared to the remaining health workers.	2C^‡‡‡‡ ‡‡‡‡ Level of Evidence 2C = Observation of therapeutic results, ecological studies
Cai H, et al./Medical Science Monitor: International Medical Journal of Experimental and Clinical Research/SCOPUS‡/(2020)⁽²⁷⁾	Observational cross-sectional study/534 participants/China.	To investigate the impact of coping strategies adopted by the medical staff working in the front line in the province of Hunan, adjacent to the Hubei province, during the COVID-19^¶ ¶ COVID-1 9 = Coronavirus Disease 2019; outbreak between January and March 2020.	The nursing staff experienced more significant nervousness and anxiety than the other groups (^¶¶ ¶¶ p = p value; p=0.02). The physicians were unhappier with the overtime work performed during the COVID 19^¶ ¶ COVID-1 9 = Coronavirus Disease 2019; outbreak than the other health workers (^¶¶ ¶¶ p = p value; p=0.02). The main factors associated with stress were concerns with personal safety (^¶¶ ¶¶ p = p value; p<0.001), concerns with the family (^¶¶ ¶¶ p = p value; p<0.001), and concerns with the death of patients (^¶¶ ¶¶ p = p value; p=0.001).	2C^‡‡‡‡ ‡‡‡‡ Level of Evidence 2C = Observation of therapeutic results, ecological studies
Bostan S, et al./Electronic Journal of General Medicine/SCOPUS‡/(2020)⁽²⁸⁾	Cross-sectional study /736 health workers /Turkey	To show how health workers assessed working conditions in the Turkish population and the fight against COVID-19^¶ ¶ COVID-1 9 = Coronavirus Disease 2019; and whether their work in risk environmental and abnormal conditions affected their anxiety levels.	Assessment of the participants' working conditions (3.17±0.827) shows that their participation in social conditions (3.24±0.739) was moderate, though anxiety levels were high (4.36±0.841). A low and negative relationship was found between working conditions and anxiety levels (^‡‡‡ ‡‡‡ r = r value r=-0.194) and social conditions (^‡‡‡ ‡‡‡ r = r value r=-0.105).	2C^‡‡‡‡ ‡‡‡‡ Level of Evidence 2C = Observation of therapeutic results, ecological studies
Liu CY, et al./Epidemiology & Infection/ WoS\|\|/(2020)⁽²⁹⁾	Descriptive cross-sectional study/512 workers/China	To verify the anxiety levels of health workers in the front line and identify the risk factors for anxiety in China during the COVID-19^¶ ¶ COVID-1 9 = Coronavirus Disease 2019; pandemic.	The average score for anxiety was significantly higher in the medical team directly treating confirmed cases than among those who did not (41.11±9.79 vs. 38.83±8.38, ^¶¶ ¶¶ p = p value; p= 0.007).	2C^‡‡‡‡ ‡‡‡‡ Level of Evidence 2C = Observation of therapeutic results, ecological studies
Zhu J, et al./Frontiers in Psychiatry/SCOPUS‡/(2020)⁽³⁰⁾	Descriptive cross-sectional study /165 workers/China	To investigate the prevalence and factors influencing anxiety and depression symptoms in the medical staff in the front line in the fight against the novel coronavirus pneumonia in Gansu.	The prevalence of anxiety and depression symptoms among the physicians was 11.4% and 45.6%, respectively, and 27.9% and 43.0% among nurses, respectively.	2C^‡‡‡‡ ‡‡‡‡ Level of Evidence 2C = Observation of therapeutic results, ecological studies
Shacham M, et al./International Journal of Environmental Research and Public Health/ SCOPUS‡/ (2020)⁽³¹⁾	Cross-sectional study /338 dentists and dental hygienists /Israel.	To assess the association of COVID-19^¶ ¶ COVID-1 9 = Coronavirus Disease 2019; and psychological factors with psychological distress in the oral care team during the COVID-19^¶ ¶ COVID-1 9 = Coronavirus Disease 2019; outbreak.	A high risk of psychological distress was found in 11.5% of the sample (^§§§ §§§ n = absolute number; n=39). High psychological stress was found among those with a background disease (^††† ††† OR = Odds Ratio; OR=3.023 (\|\|\|\|95% CI: 1.186-7.705;^¶¶ ¶¶ p = p value; p=0.021), fear of contracting COVID-19^¶ ¶ COVID-1 9 = Coronavirus Disease 2019; from a patient (^††† ††† OR = Odds Ratio; OR=2.110 (\|\|\|\|95%CI: 1.236-3.603; ^¶¶ ¶¶ p = p value; p=0.006) and greater subjective overload (^††† ††† OR = Odds Ratio; OR=1.073 (\|\|\|\|95%CI: 1.010-1.141); ^¶¶ ¶¶ p = p value; p=0.022).	2C^‡‡‡‡ ‡‡‡‡ Level of Evidence 2C = Observation of therapeutic results, ecological studies
Mo Y, et al./ Journal of Nursing Management/SCOPUS‡/(2020)⁽³²⁾	Cross-sectional study/180 nurses/China.	To identify the stress levels faced by Chinese nurses supporting the fight against the COVID-19^¶ ¶ COVID-1 9 = Coronavirus Disease 2019; infection in Wuhan and verify which factors are relevant in developing psychological interventions directed to Chinese nurses to adjust to public health emergencies.	The total score for stress load (SAS^\|\|\|\|\|\| \|\|\|\|\|\| SAS = Self-Rating Anxiety Scale; ) was 32.19±7.56 points, which is higher than the national standards (29.78+0.46); the difference is statistically significant (t=4.27, p<0.001).	2C^‡‡‡‡ ‡‡‡‡ Level of Evidence 2C = Observation of therapeutic results, ecological studies

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[TFN1] ^*
PICO = P- population; I- Intervention/area of interest; C- comparison; O- outcome

Risks of occupational illnesses among health workers providing care to patients with COVID-19: an integrative review*

Risks of occupational illnesses among health workers providing care to patients with COVID-19: an integrative review^*