key: cord-0077543-xtbw79ei
authors: Bauernfeind, Stilla; Huppertz, Gunnar; Mueller, Karolina; Hitzenbichler, Florian; Hardmann, Loredana; Pemmerl, Sylvia; Hollnberger, Harald; Sieber, Wolfgang; Wettstein, Matthias; Seeliger, Stephan; Kienle, Klaus; Paetzel, Christian; Kutz, Norbert; Daller, Dionys; Zorger, Niels; Mohr, Arno; Lampl, Benedikt M. J.; Salzberger, Bernd
title: Health care workers’ sick leave due to COVID-19 vaccination in context with SARS-CoV-2 infection and quarantine - a multicenter cross-sectional survey
date: 2022-04-14
journal: Open Forum Infect Dis
DOI: 10.1093/ofid/ofac203
sha: c22c5db21af63630d7145d82ef586fd1f7f706be
doc_id: 77543
cord_uid: xtbw79ei

BACKGROUND: Reactogenicity of coronavirus disease 2019 (COVID-19) vaccines can result in inability to work. The object of this study was to evaluate health care workers’ sick leave after COVID-19 vaccination and to compare it with sick leave due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and quarantine leave. METHODS: A multi-center cross-sectional survey was conducted at Regensburg University Medical Center and ten teaching hospitals in South-East Germany from July 28(th) to October 15(th) 2021. RESULTS: Of 2662 participants, 2309 (91.8%) were fully vaccinated without a history of SARS-CoV-2 infection. Sick leave after first/second vaccination occurred in 239 (10.4%) and 539 (23.3%) participants. In multivariable logistic regression, the adjusted odds ratio for sick leave after first/second vaccination compared to BNT162b2 was 2.26/3.72 for mRNA-1237 (95% confidence interval (CI) 1.28-4.01/1.99-6.96) and 27.82/0.48 for ChAdOx1-S (95% CI 19.12-40.48/0.24-0.96). The actual median sick leave was one day (interquartile range (IQR) 0-2) after any vaccination. 251 participants (9.4%) reported a history of SARS-CoV-2 infection (median sick leave 14 days, IQR 10-21), 353 (13.3%) were quarantined at least once (median quarantine leave 14 days, IQR 10-14). Sick leave due to SARS-CoV-2 infection (4642 days) and quarantine leave (4710 days) accounted for 7.7 times more loss of workforce than actual sick leave after first and second vaccination (1216 days) in all fully vaccinated participants. CONCLUSIONS: Sick leave after COVID-19 vaccination is frequent and associated with the vaccine applied. COVID-19 vaccination should reduce the much higher proportion of loss of workforce due to SARS-CoV-2 infection and quarantine.

In multivariable logistic regression, the adjusted odds ratio for sick leave after first/second vaccination 10 compared to BNT162b2 was 2.26/3.72 for mRNA-1237 (95% confidence interval (CI) 1.28-4.01/1.99-11 6.96) and 27.82/0.48 for ChAdOx1-S (95% CI 19.12-40.48/0.24-0.96). The actual median sick leave was 12 one day (interquartile range (IQR) 0-2) after any vaccination. 251 participants (9.4%) reported a history 13 of SARS-CoV-2 infection (median sick leave 14 days, IQR 10-21), 353 (13.3%) were quarantined at least 14 once (median quarantine leave 14 days, IQR 10-14). Sick leave due to SARS-CoV-2 infection (4642 days) 15 and quarantine leave (4710 days) accounted for 7.7 times more loss of workforce than actual sick leave 16 after first and second vaccination (1216 days) in all fully vaccinated participants. 17

Conclusions. Sick leave after COVID-19 vaccination is frequent and associated with the vaccine applied. immunogenicity of the BNT162b2 vaccine in health care workers, we realized that sick leave due to 13 adverse reactions after vaccination was considerable with 32 (4.3%) and 249 (33.9%) of vaccinees unable 14 to work after first and second vaccination (n=735) [9] . 15

Next to adverse reactions after vaccination, COVID-19-related absences of work include severe acute 16 respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and quarantine. The isolation period for 17 SARS-CoV-2 infection in Germany was generally 14 days during study time and has been reduced 18 recently [10, 11]. The regulations for quarantine leave after a close contact with a SARS-CoV-2 positive 19 case have changed several times in Germany. During study time, if someone was fully vaccinated or had 20 a history of SARS-CoV-2 infection within the last 6 months, no quarantine was imposed. For SARS-CoV-2 21 naïve persons with a close contact, quarantine was initially 14 days and got reduced to 10 days in 22

September with the option to be shortened by a negative PCR-test or Antigen test to 5 or 7 days [12] . 23

The present study aimed to further evaluate sick leave due to severe adverse reactions after COVID-19 1 vaccination in health care workers and to compare it with sick leave due to SARS-CoV-2 infection and 2 quarantine leave. 3 4

Study design and participants 6 From July 28 th to October 15 th , we conducted a cross-sectional survey among hospital employees at 7

Regensburg University Medical Center and its ten participating teaching hospitals (Table S1,  8 Supplementary Appendix). 9

The survey was carried out by distributing paper tickets that provided electronic access to an online 10 survey ( Figure S1 , Supplementary Appendix). This method was previously used to evaluate health-care 11 workers attitude towards COVID-19 vaccination in our hospital [13] . A ticket contained both a unique 12 QR-Code and a unique access code for the survey website. The survey could be accessed either with an 13 electronic device via QR-Code-App or by visiting the survey website using the access code, thus ensuring 14 anonymity of the participants and preventing multi-use. 15 We defined health care workers as all hospital employees including clinical administrative staff and 16 further personnel without patient contact. 17

We developed an 87-item survey evaluating health care workers experiences with COVID-19 vaccination, 19 SARS-CoV-2 infection and quarantine ( 

Survey participants were asked whether they were fully vaccinated against COVID-19. According to 2 German regulations, full vaccination during study time was defined as two vaccinations with an mRNA 3 vaccine or ChAdOx1-S, a heterologous combination of ChAdOx1-S with an mRNA vaccine, one 4 vaccination with Ad26.COV2-S or one vaccination with any approved COVID-19 vaccine 6 months after a 5 laboratory confirmed SARS-CoV-2 infection. The recommendation to administer only one vaccination 6 after a history of SARS-CoV-2 infection was given late March 2021, therefore there may be both 7 vaccinees with one and two vaccinations after a history of SARS-CoV-2 in the study population [14] . If not 8 fully vaccinated, participants were asked if they were within a vaccination process, whether they were 9 willing to get vaccinated and, if not, what was the main reason for refusal. 10

If fully vaccinated, it was asked if the decision for getting vaccinated was easy to make and if they were 11 willing to get a booster vaccination, which COVID-19 vaccines had been applied, whether the vaccinees 12 had taken antipyretic medication before and after vaccination and which, whether they had experienced 13 adverse reactions after first and second vaccination categorized as mild (defined as only local on the 14 injection side), moderate (not further classified) and severe (defined as any symptom(s) resulting in sick 15 leave). 16

Those with severe adverse reactions (i.e. resulting in sick leave) were asked to state how many days they 17 would have been unable to go to work independently if the following days were working days or days off 18 (potential sick leave). They were additionally asked how many days they actually were on sick leave 19 (actual sick leave) and whether they had to see a doctor. 20

All survey participants were asked whether they ever had COVID-19. In German colloquial language, the 22 term "SARS-CoV-2 infection" is not used -COVID-19 generally includes both asymptomatic SARS-CoV-2 23 infection and symptomatic COVID-19. No classification in asymptomatic or symptomatic course was 24 done. They were further asked whether they ever were in quarantine because of a close contact to a 25

SARS-CoV-2 case and, if yes, how often. In both cases, they stated the potential infectious source 1 (patient/colleague/family/friends/others/unknown) and the number of days they were off work. 2

Participants with a history of SARS-CoV-2 infection reported whether they were hospitalized, suffered 3 from long COVID symptoms, and, if yes, what symptoms they had and whether these symptoms 4 impaired their working life. 5

The survey was programmed in REDCap, a web-based clinical data management system hosted by the 7 University of Regensburg [15] . responses were generated (response rate 13.9%). Participants were from all working age groups. Most 24 survey participants were female (72.3%). The majority were nurses (34.4%). Any chronic disease was 25

reported by 22.2% and immunosuppression by 2.7%. The vast majority was fully vaccinated against 1 COVID-19 (94.5%). Baseline characteristics of survey participants are shown in Table 1 . (Table 2a) . Antipyretic medication before any vaccination was taken by about 7% of survey 5 participants. BNT162b2 was the vaccine predominantly applied in first (73.5%) and second (81.5%) 6 vaccination. ChAdOx1-S administration decreased from first (15.3%) to second (5.0%) vaccination -the 7 reduction probably attributable to a recommendation for heterologous vaccine combinations after 8 ChAdOx1-S prime because of incidents with thrombosis with thrombocytopenia syndrome [16]. The 9 detailed vaccine combinations are listed in the Supplementary Appendix (Table S3 ). In total, more 10 participants suffered from any type of adverse reaction after second vaccination (61.6%) compared to 11 first vaccination (46.5%). Consequently, sick leave as a result of severe adverse reactions occurred more 12 often after second (23.3%) than after first vaccination (10.4%). Despite a high rate of adverse reactions, 13 most vaccinees would have been willing to get a booster vaccination (90.6%). 14

In univariate logistic regression, older age groups 50 years and above had significantly less sick leave 16 after any COVID-19 vaccination compared to those < 30 years (Table 2b ). The odds of sick leave after first 17 and second vaccination were significantly higher in females compared to males (odds ratio (OR) 1.69, 18 95% confidence interval (CI) 1.21-2.35 after first vaccination, and 1.50, 95% CI 1.20-1.89 after second 19 vaccination). Compared to nurses, there was significantly less sick leave in physicians after both 20 vaccinations (OR 0.58/0.59 respectively, 95% CI 0.36-0.95 after first and 0.43-0.80 after second 21 vaccination). There was strong evidence for an association between sick leave and vaccine type after first 22 and second vaccination. There was no evidence of an association between sick leave after first or second 23 vaccination and BMI, any chronic disease, immunosuppression and antipyretic medication before second 24 vaccination. 25

In multivariable logistic regression analyses, severe adverse reactions resulting in sick leave after first 2 and second COVID-19 vaccination were described in reference to BNT162b2 (Table 2c) The study is subject to limitations. First the response rate was low (13.9%) which makes the results prone 24 to selection bias. In our survey, we linked severe adverse reactions and sick leave. Therefore, the option 25

to report sick leave was not possible for vaccinees with mild or moderate adverse reactions. As there is 1 sick pay in Germany, this link might have resulted in misinterpretation of vaccine reactogenicity. We also 2 did not assess half days for sick leave that may have occurred in vaccinees who got their vaccination 3 early in the morning and fell sick sometime later but were able to return to work the following day. This 4 is possibly the reason why some vaccinees who reported sick leave after vaccination indicated zero days 5 off. Because of different vaccine reactogenicity in seropositive and seronegative vaccinees and two 6 vaccination strategies for people with a laboratory confirmed SARS-CoV-2 infection we decided to focus 7 the logistic regression analysis on vaccine reactogenicity in participants without a history of SARS-CoV-2 8

infection. Yet, we cannot rule out that unwittingly seropositive vaccinees were included in our analysis. 9

For the majority of participants with a history of SARS-CoV-2 infection who are fully vaccinated, we do 10 not know whether the infection occurred before, during or after the vaccination. Finally, there are other 11 causes of pandemic induced loss of workforce not addressed in the study, for example the necessity to 12 care for quarantined or SARS-CoV-2 positive children and relatives or compulsory quarantine after an 13 entry from countries with high SARS-CoV-2 incidences. 14 We would like to thank Marion Schweiger for graphical support in designing the tickets and Edith 22

Faltermeier for logistic support in delivering the tickets. 23

The study was performed in accordance with the ethical standards of the Helsinki Declaration. 

Risk of COVID-19 among front-line health-2 care workers and the general community: a prospective cohort study

COVID-19 vaccines approved in the European Union: current evidence and 5 perspectives

European medicines agency. EMA recommends Nuvaxovid for authorisation in the EU

Comparative 10 systematic review and meta-analysis of reactogenicity, immunogenicity and efficacy of 11 vaccines against SARS-CoV-2

Safety and Efficacy of NVX

Phase 1/2 trial of SARS-CoV-2 vaccine

ChAdOx1 nCoV-19 with a booster dose induces multifunctional antibody responses

Safety and Efficacy of the BNT162b2 mRNA 18

Covid-19 Vaccine

Efficacy and Safety of the mRNA

CoV-2 Vaccine

Beschluss der STIKO zur 3

COVID-19-Impfempfehlung und die dazugehörige wissenschaftliche Begründung

Research electronic data 17 capture (REDCap)--a metadata-driven methodology and workflow process for providing 18 translational research informatics support

Beschluss der STIKO zur 8

COVID-19-Impfempfehlung und die dazugehörige wissenschaftliche Begründung

Survey participants were asked how many days they would have been unable to go to work because of COVID-19 vaccination associated adverse reactions, 4 independently if the vaccination day was followed by days off (weekend, holidays etc.).

Survey participants were asked how many days they actually were on sick leave.