key: cord-0271692-j4bfn87k authors: Roemmele, C.; Ebigbo, A.; Kahn, M.; Zellmer, S.; Muzalyova, A.; Hammel, G.; Bartenschlager, C.; Beyer, A.; Rosendahl, J.; Schlittenbauer, T.; Zenk, J.; Al-Nawas, B.; Frankenberger, R.; Hoffmann, J.; Arens, C.; Lammert, F.; Traidl-Hoffmann, C.; Messmann, H. title: Health-care workers in gastrointestinal endoscopy are at higher risk for SARS-CoV-2 infection compared to other aerosol-generating disciplines date: 2021-09-22 journal: nan DOI: 10.1101/2021.09.20.21263566 sha: bc1777b1c3df128e936cf8e3f56c2831f435790a doc_id: 271692 cord_uid: j4bfn87k Objective: Healthcare workers (HCW) are at high risk of SARS-CoV-2 infection due to exposure to potentially infectious material, especially during aerosol-generating procedures (AGP). We aimed to investigate the prevalence of infection among HCW in medical disciplines with AGP. Design: A nationwide questionnaire-based study in in- and outpatient settings was conducted between 12/16/2020 and 01/24/2021. Data on SARS-CoV-2 infections among HCW and potential risk factors were investigated. Results: 2,070 healthcare facilities with 25,113 employees were included in the study. Despite a higher rate of pre-interventional testing, clinics treated three times more confirmed SARS-CoV-2 cases than private practices (28.8% vs. 88.4%, p<0.001). Overall infection rate among HCW accounted for 4.7%. Multivariate analysis revealed that ZIP-regions having comparably higher incidences were significantly associated with increased risk of infection. Furthermore, clinical setting and the GIE specialty have more than double the risk of infection (OR 2.63; 95% CI 2.501-2.817, p<0.01 and OR 2.35; 95% CI 2.245-2.498, p<0.01). The number of procedures performed per day was also significantly associated with an increased risk of infection (OR 1.01; 95% CI 1.007-1.014), p<0.01). No treatment of confirmed SARS-CoV-2 cases was tending to lower the risk of infection (OR 0.72; 95% CI 0.507-1.025, p=0.068). Conclusion: HCW in GIE seem to be at higher risk of infection than those in other AGP, especially in the clinical setting. Regions having comparably higher incidences as well as the number of procedures performed per day were also significantly associated with increased risk of infection. Health care workers (HCW) have been particularly exposed during the pandemic, and data shows an 85 increased infection rate among HCW compared to the general population, [2] . Data from different 86 countries emphasise the increased risk for HCW, especially for those with direct patient contact, [3, 4] . Based on these data and the risk of transmission between HCW, the Standing Committee on 88 Vaccination (STIKO) issued a prioritized vaccination recommendation for people working in medical 89 facilities. Transmission of SARS-CoV-2 mainly takes place via respiratory droplets as well as 90 aerosol, [5] . Numerous medical procedures typical for specific medical disciplines are widely 91 recognized to generate aerosols and therefore are supposed to increase the risk of infection. Therefore, 92 HCW who carry out aerosol-generating procedures (AGP) or activities close to patients' faces were 93 given higher priority for vaccination in Germany, even though real-world data demonstrating the 94 increased risk is limited, [5] . In particular, evidence for this within the outpatient care sector is lacking. The present study is a descriptive, explorative, cross-sectional, questionnaire-based study conducted in 111 Germany between the 16 th of December and the 24 th of January. The questionnaire for the survey was designed based on detailed literature research and on expert 113 suggestions provided by the respective disciplines GIE, ORL, OMS, and dentistry (Supplement 1). Besides descriptive data such as healthcare delivery setting and medical specialty, the questionnaire 115 focused on the prevalence of SARS-CoV-2 infection, presumed source of infection, treatment of 116 confirmed SARS-CoV-2 cases, and pre-interventional testing of patients. The first two digits of the 117 ZIP-code of each participating medical facility were inquired to assign medical facilities to one of ten 118 ZIP-code regions in order to correlate infection rate among HCW and incidence in the region. The target group of the present questionnaire was inpatient and outpatient medical facilities of the four 120 specialties of research interest with a particular focus on GIE. Eligible participants were defined as 121 healthcare delivery facilities attributed to four medical disciplines such as GIE, ORL, OMS, or 122 dentistry. Study participants were recruited via e-mail distribution of the respective professional In this scientific manuscript, the GIE data are compared with the aggregated data of the disciplines 138 ORL, OMS, and dentistry denoted as Non-GIE. When appropriate, the relationships between nominal-139 scaled variables were tested inferentially using Chi-square independence tests or Fisher's exact test. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this this version posted September 22, 2021. ; https://doi.org/10.1101 https://doi.org/10. /2021 was commissioned to acquire data on facial, and AGP-associated medical subspecialties. No patients 151 or the public were asked for advice on interpretation or writing up the results. 152 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Sample characteristics 154 Two thousand ninety-six of the more than 20,000 contacted facilities participated in the survey. Twenty-six facilities were excluded from the data analysis based on prespecified eligibility criteria. Consequently, 2,070 remaining questionnaires were analysed, of which 113 (5.5%) had non-157 exclusionary missing data. Of the 2070 facilities, 1,828 (88.3%) were private practices and 242 158 (11.7%) were clinics/hospitals. Among included facilities, GIE private practices accounted for 284 159 (13.7%) facilities, whereas GIE clinics were represented by 145 (7.0%) hospitals (Table 1 ). The 160 distribution of the Non-GIE facilities between the different disciplines can be found in the supplement 161 (Supplement 1) 162 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Two thousand seventy medical facilities included in the analysis comprised a total of 25,113 HCW in 177 the respective fields of specialisation (see Table 2 ). GIE private practices reported performing on 178 average 21.2 (SD=15.3) procedures per day. In contrast, Non-GIE practices stated to carry out 179 significantly more procedures 34.6 (SD=27.7, p<0.01). Clinics performed overall significantly more 180 procedures compared to private practices (41.5 (SD=23.4) vs. 32.9 (SD=26.8), p<0.01), with Non-GIE 181 performing significantly more procedures as GIE (58.6(SD=35.6) vs. 24.9 (SD=12.9), p <0.01). 182 32.7% of the GIE private practices reported having had at least one COVID-19 case among HCW, 183 whereas this share was significantly lower in Non-GIE (21.2%, p<0.01). The proportion of SARS-184 CoV-2 infections was significantly higher in the clinical setting than private practices in both 185 specialties (56.1% vs. 23.0%, p<0.01) and accounted in GIE for 58.6% and 48.5% in Non-GIE. 186 However, this difference was not significant. Overall, the rate of HCW who were reported to have had 187 a COVID-19 infection was 4.7%. The rate was significantly higher in the GIE compared to the Non-188 GIE (7.7% vs. 3.5%, p>0.01). The number of infected HCW was significantly higher in clinics than in 189 private practices (6.3% vs. 4.0%, p<0.01). A significant difference between the examined specialties 190 was reported for private practices, with 5.3% of GIE HCW and only 3.6% SARS-CoV-2-infected 191 HCW in Non-GIE facilities. The same applies to the clinical setting: a significantly higher proportion 192 of SARS-CoV-2-positive employees was also found for GIE in comparison to Non-GIE (9.9% vs. 193 3.1%, p<0.01). Consequently, a higher risk of infection was reported for GIE than for the other AGP-194 associated disciplines for private practices and clinical settings. 200 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The implied source of infection identified by the heads of the facilities was predominantly the private 208 environment (66%), followed by an unclear origin of infection (14%) (Figure 2 ). Only 14% of cases 209 were attributed to patient contact or medical procedures. In GIE, the proportion of HCW with an 210 implied source of infection during patient care ("During interventions" and "During other patient 211 contacts") was significantly higher than in Non-GIE 10% vs. 5%, p < 0.001, and 13% vs. 4%, p < 212 0.001 respectively). Accordingly, the proportion of employees who reported being infected in their 213 private environment was substantially higher in Non-GIE specialty (73% vs. 56%, p < 0.001). In private practices, Non-GIE specialties were testing their outpatients significantly more frequently 217 than GIE (15.2% vs. 7.7%, p < 0.01). Regarding clinical settings, both out-and inpatients were 218 significantly more often tested pre-interventionally compared to private practices. 58.9% of Non-GIE 219 outpatients and 72.2% GIE outpatients were tested before procedures (p < 0.05), whereas among 220 inpatients in all specialties, the testing rate was relatively high, accounting for 96.1% and 93.1% in 221 Non-GIE and GIE, respectively. Furthermore, GIE clinics reported to test both their out-and in 222 patients significantly more frequently using antigen than PCR (36.8% vs. 21.1%, p < 0.01 and 23.4% 223 vs. 11.7% p<0.05 respectively) ( Table 3 ). a Rates refer to the total of answers given by participating facilities 228 229 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (Table 5 ). 257 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this this version posted September 22, 2021. This study is the first to present cumulated data on the prevalence of SARS-CoV-2 infection in HCW 264 in different medical subspecialties and healthcare delivery settings. In particular, this manuscript 265 focuses on medical disciplines associated with AGP, including GIE, ORL, OMS, and dentistry. Data Our study revealed a significantly higher proportion of infected HCW in clinics with 6.3% compared 295 to 4.0% in private practices. Furthermore, according to the multivariate model, clinical setting was 296 associated with more than doubled risk of SARS-CoV-2 infection among HCW. Assuming that 297 patients are a potential source of infection in a medical facility, the number of patients seen per day 298 and, thus, procedures performed might influence the risk of infection. This consideration was 299 confirmed in our study by a significant association of occurrence of infection and number of 300 procedures performed per day. Indeed, clinics perform on average more procedures than private 301 practices, bringing HCW at higher risk of transmission. Furthermore, besides the higher accumulation 302 of people, clinics treat more patients with urgent or emergency procedures. In line with this, clinics 303 have treated confirmed SARS-CoV-2 patients almost four times more often than private practices. According to the multivariate model, treatment of confirmed SARS-CoV-2 cases was tending to be a 305 risk of infection in a medical unit, however, this association was marginally not significant. In our study, GIE was shown to have a significantly higher positive HCW rate than Non-GIE in both 307 examined healthcare delivery settings. Interestingly, GIE clinics have been stated to treat confirmed 308 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this this version posted September 22, 2021. ; https://doi.org/10.1101 https://doi.org/10. /2021 SARS-CoV-2 cases more often than Non-GIE, whereas in private practices, an opposite tendency was 309 observed: GIE reported having had significantly fewer confirmed cases under treatment. Moreover, 310 GIE performed significantly fewer procedures per day compared to Non-GIE medical disciplines. Despite that, GIE showed a significantly higher HCW infection rate in both healthcare delivery One possible action to prevent transmission of SARS-CoV-2 into medical facilities is pre-327 interventional testing. According to the findings of our study, in private practices, pre-interventional 328 testing of patients was performed only in roughly 10% of the cases, with Non-GIE testing twice as 329 often as GIE. In the clinical setting, all specialties tested their patients before intervention substantially 330 more frequently, with inpatients being tested in over 90% of cases. Despite that, the prevalence of 331 SARS-CoV-2 positive HCW was significantly higher in clinics than private practices, indicating that 332 testing may not play a crucial role at low to moderate incidence levels as discussed by guidelines,[30, 353 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Like other cross-sectional studies, our study has some limitations. Due to the recruitment strategy via 362 the professional associations, a selection bias cannot be ruled out. In particular, facilities that 363 established elaborate protection and hygiene measures might have been higher motivated to 364 participate. On the other hand, facilities with infected HCWs may also be more motivated to 365 participate. Moreover, there is an uneven distribution of the medical facility types between examined 366 specialties. For instance, in dental medicine, hardly any clinic was represented in comparison to the 367 more than 1000 participating private practices.Nonetheless, Non-GIE specialties had significantly 368 more private practices due to the regional specificity of the respective fields of activity. Another 369 shortcoming of the study worth mentioning is that this study is cross-sectional inquiring information 370 over a considerable period comprising three quarters of the year 2020. Moreover, all calculations 371 presented in the manuscript are based on the assessments and judgments made for a private practice or 372 a hospital ward and its workforce by one person. Despite the limitation mentioned above, the present study is the first to provide data on prevalence and 374 revealing risk factors of SARS-CoV-2 infection among HCW in medical disciplines associated with 375 AGP, such as GIE, ORL, OMS, and dentistry. Due to the results provided in this scientific manuscript, 376 GIE seems to be at a higher risk of infection compared to the other investigated disciplines. 377 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this this version posted September 22, 2021. ; https://doi.org/10.1101/2021.09.20.21263566 doi: medRxiv preprint All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this this version posted September 22, 2021. ; https://doi.org/10.1101 https://doi.org/10. /2021 COVID-19-Associated Hospitalizations Among Health 408 Care Personnel -COVID-NET, 13 States Specific risk factors for SARS-CoV-2 transmission among health 411 care workers in a university hospital SARS-CoV-2 seroprevalence survey among 17,971 healthcare and 414 administrative personnel at hospitals, pre-hospital services, and specialist 415 practitioners in the Central Denmark Region Airborne or droplet precautions for health workers treating COVID-418 19? Prevalence and risk indicators of first-wave COVID-19 among oral 425 health-care workers: A French epidemiological survey Seroprevalence of antibodies against SARS-CoV-2 444 among health care workers in a large Spanish reference hospital SARS-CoV-2 exposure, symptoms and seroprevalence in 447 healthcare workers in Sweden COVID-19 in Health-Care Workers: A Living Systematic 455 Review and Meta-Analysis of Prevalence, Risk Factors, Clinical Characteristics, and 456 Outcomes Factors involved in the aerosol transmission of infection and 468 control of ventilation in healthcare premises Diarrhea During COVID-19 Infection Prevention, and Management. Clinical Gastroenterology and 472 Hepatology SARS-CoV-2 antibodies in ICU and clinic staff Germany's region with the highest infection rate Seroprevalence of SARS CoV-2 antibodies in healthcare workers and 479 administration employees: a prospective surveillance study at a 1,400-bed university 480 hospital in Germany. medRxiv, 2020. 481 29 Römmele 492 C, Ein Jahr Covid-19: Testung, Verwendung von Schutzausrüstung und Auswirkungen 493 auf die Gastrointestinale Endoskopie in Deutschland. Zeitschrift für 494 Gastroenterologie Performance of antigen testing for diagnosis of COVID-19: a direct 496 comparison of a lateral flow device to nucleic acid amplification based tests. BMC 497 Infect Dis SARS-CoV-2 serology in 4000 health care and administrative staff 499 across seven sites in Lombardy All rights reserved. No reuse allowed without permission preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this this version posted We thank all medical facilities for participating in this study.