Introduction

As at April 16^th 2020, the world had recorded over two million COVID-19 cases and 156,141 deaths.¹ The emergence of the disease and the resulting global health crisis increased demand for health care services and, consequently, health worker exposure to SARS-CoV-2 infection.²

Addressing the disease gives rise to diverse occupational risk situations: repeated exposure to the pathogen; long working hours, associated with multiple employment relationships; fatigue; occupational stress; stigmatization; physical and psychological violence;³ incipient training and insufficient/unavailable personal protective equipment (PPE).⁴

The clinical spectrum of COVID-19 infection ranges from asymptomatic infection or mild flu-like syndromes, to more severe respiratory conditions, such as severe acute respiratory syndrome (SARS), depending on the person’s constitution and comorbidities they may have. Brazil has a surveillance system for respiratory virus infections that aims to identify, record and monitor the clinical and epidemiological characteristics of these cases.⁵

Describing the profile of the profile of health workers hospitalized due to novel coronavirus infection in Brazil may inform actions to prevent and control this disease in this population which is so essential for addressing the pandemic.

The objective of this study was to describe COVID-19 hospitalized health worker cases in Brazil.

Methods

This is a descriptive study of cases hospitalized due to SARS, and with COVID-19 confirmed by real-time polymerase chain reaction testing (RT-PCR).

The Brazilian population is estimated to be 212 million people in 2020,⁶ and in January 2020 there were 1,535,523 health professionals working in Brazil,⁷ distributed among some 219,000 public and private health services.⁸

The study included as its participants health workers identified by the ‘occupation’ and ‘observations’ variable, classified according to the categories contained in Ministry of Health Ordinance MS/GM 639, dated March 31^st de 2020, which provides for the Strategic Action entitled ‘Brazil can count on me – Health Workers’ (‘O Brasil conta comigo – Profissionais de Saúde’).⁹

The source used was the Influenza Surveillance Information System (SIVEP-Gripe). Its public domain data are available on the Ministry of Health electronic portal (https://covid.saude.gov.br/) and the data for the study were retrieved on April 28^th 2020.

The study used the concept of the Epidemiological Week (EW), a form of international standardization of weeks from Sunday to Saturday, starting with the first week with most days in January and ending with the last week with most days in December. The study covered EW 8 to EW 17, 2020.

The variables studied were:

It should be noted that the ‘occupation’ variable was added to the SIVEP-Gripe system on March 31^st 2020.

The analyses were performed by calculating measurements of absolute and relative frequency, central tendency and dispersion, with the aid of the Microsoft Excel^®, Epi Info 7.2 and QGIS 2.18 computer programs.

The study was conducted using only public-access secondary data with no personal identification of cases.

Results

During the period analyzed, 15,317 cases hospitalized due to SARS were confirmed as having COVID-19 in Brazil. Occupation was recorded for 379 (2.5%) of these cases, 184 (1.2%) of whom were health workers. The first health worker case became ill on March 2^nd during EW 10. Most health workers became ill in EW 13 (Figure 1).

Figure 1 Distribution of health worker cases (N=184) hospitalized due to severe acute respiratory syndrome and confirmed as having COVID-19, by epidemiological week of symptom onset, Brazil, 2020 

The Federative Units with most health workers hospitalized with COVID-19 were São Paulo (n=101; 54.9%), Amazonas (n=15; 8.2%) and Santa Catarina (n=13; 7.1%) (Figure 2).

Figure 2 Distribution of health worker cases (N=184) hospitalized due to severe acute respiratory syndrome and confirmed as having COVID-19, by Federative Unit of notification, Brazil, 2020 

Median age of ill health workers was 44 years (variation: 23 to 85), with greater concentration in the 30-49 years (n=113; 61.4%). Females (n=110; 59.8%) and White race/skin color (n=74; 40.2%) were predominant. Information with regard to race/skin color was blank/unknown for 67 cases (36.4%). Half the hospitalized health workers (n=92) had comorbidities, 37 of whom had heart disease (including hypertension), 24 had diabetes and 16 had asthma.

Nursing (n=89; 48.4%) and medicine (n=50; 27.2%) were the main affected occupation areas. A further 29 (15.8%) cases were only recorded as ‘health workers’ (Table 1).

Fever (n=153; 83.6%), cough (n=151; 82.5%) and dyspnea (n=136; 74.3%) were the most frequent signs and symptoms, followed by breathing difficulty (n=120; 65.6%), oxygen saturation below 95% (n=90; 49.2%) and sore throat (n=49; 26.8%). Of the 96 (52.2%) health workers who had chest x-rays, 39 (49.6%) had interstitial infiltrates; 23 (12.5%) did not have x-rays and this information had been left blank or was unknown for 65 (35.3%) of them. Of the 87 (47.3%) who needed ventilatory support, 31 (35.6%) had invasive support, 74 (40.2%) did not use ventilatory support and information for 23 (12.5%) had been left blank or was unknown with regard to this.

The median period between first signs and symptoms and hospitalization was 6 days, varying between zero and 32. For cases hospitalized in ITUs, the median period was 7 days, varying between zero and 19. Of the total health worker cases, 27 (14.7%) died and 85 (46.2%) were cured, while this information was left blank or was unknown for 72 (39.1%) of them.

Median age of those who died was 44 years (minimum-maximum: 35-85), and most of them were male (n=18). The majority worked in the area of nursing (n=12) or in the area of medicine (n=9). Moreover, 24 of these health workers had comorbidities, the most frequent of which were heart disease (n=12), diabetes mellitus (n=7) and obesity (n=5). Eleven deaths were recorded in São Paulo and nine in Amazonas.

Discussion

This study described the first health workers to be hospitalized, notified and confirmed as having COVID-19 in Brazil. The cases occurred predominantly among females, young adults, those who worked in the areas of medicine and nursing, and those who had fever, cough and dyspnea and reported heart disease, diabetes mellitus and asthma more frequently.

These findings corroborate Wang et al. and their description of 138 COVID-19 cases from a hospital in Wuhan, China, whereby the most reported symptoms were fever and cough, and similar comorbidities.¹⁰ Our findings also validate the findings of Grasselli et al. who described 1,591 cases in Lombardy in Northern Italy, also with similar age ranges and comorbidities.¹¹

This study also ratifies data regarding sex, average age, race/skin color and COVID-19 case signs and symptoms among health workers in the United States, as published by the CDC (Centers for Disease Control and Prevention).¹² Despite the female sex being predominant, justified by more women dedicating themselves to these activities,^13,14 most deaths occurred among males, which also confirms the results found by Wang et al. and Grasselli et al.^10,11

More than 75% of cases were medicine and nursing workers, given their greater exposure to clinical and emergency care. Promoting and preserving the health of these workers is fundamental for maintaining essential services, such as health care, on all levels.

Work process and working conditions can represent risk to health workers as potential sources of exposure to the etiological agent and also, indirectly, risk to their families and other contacts. Increased closeness and more time spent caring for infected people, as a necessary part of their work processes, use and/or provision of inadequate PPEs and, consequently, exposure to the diverse forms of transmission of the pathogen, can lead to these workers becoming ill.¹⁵ As such, use of facemasks, adequate hand sanitization, use of eye protection and surgical caps, are measures recommended for protection against infection in the workplace.^15–19

The data source used by this study only records hospitalized cases that progressed to SARS; it does not reflect the true magnitude of health workers affected by COVID-19, consequent sick leave and proportion of mild cases.

Another limitation relates to the different forms of notification adopted since the advent of the epidemic: the first cases were notified using REDCap (Research Electronic Data Capture); later mild (non-hospitalized) cases were notified via the e-SUS VE system, a recently created tool for recording suspected and confirmed COVID-19 cases, provided by the SUS Information Technology Department (DATASUS);⁵ while cases that developed SARS were notified on the SIVEP-Gripe system. At the time this paper went to press, no linkage of these databases had been performed.

Moreover, the recent inclusion of the ‘occupation’ variable on the notification form may explain late recording of COVID-19 cases among health workers (five weeks after the first confirmed case in Brazil was notified), as well as the small number of notified cases among the data retrieved and the the low use of 'occupation' field on the records we have described; as well as notification form input onto the SIVEP-Gripe system not always being timely.

It is appropriate to note that density of health workers in the territory, along with other variables, contributes to identifying response capacities in relation to the pandemic scenario.² Notwithstanding, the true number of health workers working in this context is uncertain, as is the number of these workers who have become ill due to their work. This knowledge assist the estimation of supplies and equipment needed for health care, so as to ensure safety at work, as well as revealing the true magnitude of the risks faced by this group of workers.

As such, the following recommendations are made: (i) continuous monitoring COVID-19 cases among health workers and their description (flu-like syndrome and SARS); (ii) database linkage (SIVEP-Gripe, e-SUS VE and RedCAP), with the aim of assessing the true magnitude of COVID-19 among these workers; and (iii) standardize the use of the ‘occupation’ variable on SIVEP-Gripe system notifications.