key: cord-0769679-udwti3et
authors: Maltezou, Helena C.; Giannouchos, Theodoros V.; Pavli, Androula; Tsonou, Paraskeui; Dedoukou, Xanthi; Tseroni, Maria; Papadima, Kalliopi; Hatzigeorgiou, Dimitrios; Sipsas, Nikolaos V.; Souliotis, Kyriakos
title: Costs associated with COVID-19 in healthcare personnel in Greece: a cost-of-illness analysis
date: 2021-04-22
journal: J Hosp Infect
DOI: 10.1016/j.jhin.2021.04.018
sha: a982466c69fbf2312e929aecc04c3520feb646d5
doc_id: 769679
cord_uid: udwti3et

BACKGROUND: Healthcare personnel (HCP) are at increased risk for SARS-CoV-2 infection. AIM: To estimate the costs related to COVID-19 exposure and infection among HCP in Greece. METHODS: Data were retrieved from the national database of SARS-CoV-2 infections and from the database of HCP exposed to COVID-19. A cost-of-illness analysis was performed to estimate total, direct and indirect, costs. RESULTS: We studied 254 HCP with COVID-19 and 3,332 HCP exposed to COVID-19 during the first epidemic wave. Of the 254 HCP with COVID-19, 49 (19.3%) were hospitalized (mean hospitalization: 11.6 days) and four were admitted to intensive care unit (mean duration: 10.8 days). Overall, 1,332 (40%) exposed HCP had a mean duration of absenteeism of 7.5 days while 252 (99.2%) HCP with COVID-19 had a mean duration of absenteeism of 25.8 days. The total costs for the management of the two groups were estimated at 1,735,830 Euros (772,890 Euros for the HCP with COVID-19 and 962,940 Euros for the exposed HCP). Absenteeism accounted for the large share of total costs (80.4% of all expenditures), followed by costs for RT-PCR and hospitalization costs (10.2% and 6.5% of all expenditures, respectively). CONCLUSION: Our study confirms that COVID-19 is associated with increased rates and duration of absenteeism among HCP. Indirect costs and particularly absenteeism is the major driver of total costs among exposed to and infected with COVID-19 HCP. The estimated total costs are underestimated. Studies are needed to explore the impact of COVID-19 vaccination of HCP on absenteeism and COVID-19-associated costs.

Starting in late 2019 the world has faced a devastating pandemic caused by a new coronavirus named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the etiological agent of coronavirus disease 2019 . Ιt is estimated that until February 22 nd 2021 more than 111 million people have been infected and almost 2.5 million have died [1] . Moreover, several countries are facing an unprecedented pressure on their healthcare systems, which far exceeds that of healthcare demands during influenza seasons [2] [3] [4] . Faust and del Rio estimated a 20.5-times increased mean of COVID-19 deaths compared to the deaths observed during the peak of influenza in the past seven influenza seasons in the United States [2] . From the very beginning of the pandemic, healthcare personnel (HCP) have been recognized as a high-risk group for SARS-CoV-2 infection, and increased rates of absenteeism and shortages of healthcare workforce were noted [5] [6] [7] [8] [9] [10] . A recent systemic review of 594 sources found a total of 152,888 reported infections and 1,413 fatalities among HCP during the first pandemic wave worldwide [6] . Beyond the safety concerns of HCP, exposure and infection of forefront HCP result not only in the allocation of financial resources for their monitoring and management, but also exacerbate shortages of healthcare workforce through increased rates of absenteeism [8] , particularly in settings with already constrained capacity, such as the Greek healthcare system [11] .

Despite the evidence on the high rates of SARS-CoV-2 infection among HCPs, the burden of SARS-CoV-2 infection in HCP on healthcare costs remains largely unknown. The objective of this study was to estimate the direct and indirect costs associated with SARS-CoV-2 infection and exposure to COVID-19 among HCP during the first epidemic wave in Greece. Our findings can enable health policy makers understand the major cost-drivers of COVID-19 in HCPs, to efficiently J o u r n a l P r e -p r o o f allocate economic and physical healthcare resources and to support HCPs as the pandemic continues to challenge the healthcare systems globally.

SARS-CoV-2 infection is a notifiable disease in Greece. We retrieved data about notified HCP with SARS-CoV-2 infection from the national database and actively followed their clinical course and outcome through telephone contact with them or their physicians in charge. In addition, HCP occupationally exposed to a COVID-19 case were traced by the infection control committees of their healthcare facility and actively notified to the National Public Health Organization; exposed HCP were followed for the onset of symptoms for 14 days post-exposure, as described previously [5] . The study period extended from February 26 th 2020 (first case detected in Greece) through May 3 rd 2020 (last date of the first nationwide lockdown). Data from HCP with SARS-CoV-2 infection and data from HCP exposed to a COVID-19 case were collected using two structured questionnaires separately. Data included demographic and professional characteristics, co-morbidities, use of healthcare services, laboratory investigations, imaging tests, and treatment. The duration of absenteeism and presentism (if any) was recorded.

HCP were defined as all persons employed in healthcare facilities, regardless of status of employment or direct contact with patients or biologic specimens. HCP were groups as follows: physicians, nursing personnel (nurses, midwifes, nurse assistants), paramedical personnel (pharmacists, biologists, physiotherapists, laboratory technicians, social workers, health visitors, ambulance drivers), supportive personnel J o u r n a l P r e -p r o o f (waiters, cleaners, security personnel), and administrative personnel. Healthcare facilities were defined as public or private sector structures where healthcare services are provided. Healthcare seeking was defined as any healthcare visit related to SARS-CoV-2 infection or to occupational exposure to a COVID-19 case. Occupational exposure was defined as exposure within the healthcare facility. Absenteeism was defined as absence from work duties because of COVID-19 or because of exclusion from work for isolation purposes. Presentism was defined as continuing to attend work despite being symptomatic due to COVID-19 or having symptoms compatible with COVID-19 following occupational exposure to a COVID-19 case.

The cost analysis was conducted using the payer's perspective and included direct and indirect costs. Direct costs included costs for healthcare seeking, laboratory tests, RT-PCR tests, imaging tests, treatment, hospitalization, admission to intensive care unit (ICU) and intubation [12, 13] . Indirect costs included only costs related to absenteeism and presentism. The indirect costs of lost productivity due to morbidity-related absenteeism or presentism were estimated as lost wages, with one day of absenteeism accounting for the full daily wage, while one day of presentism accounted for half of the daily wage [14] . The different wages per HCP category were considered. Wage 

Data were managed in accordance with the national and European laws. Approval was received by the Committee for Research of the National Public Health Organization.

During the study period, a total of 3,398 HCP exposed to a COVID-19 case were notified from 88 healthcare facilities (66 hospitals, 20 primary healthcare centers and 2 private laboratories) [5] . Of them, 66 HCP developed COVID-19 and were included in the analysis of HCP with COVID-19 (see next paragraph), in order not to duplicate cost estimations. Therefore, the study group of exposed HCP consisted of 3,332 HCP.

Their demographic, occupational and clinical characteristics are presented in Table I. Of the 3,332 exposed HCP, 689 (20.7%) developed symptoms within 14 days after exposure, 31 (0.9%) sought healthcare and 30 (0.9%) received treatment. Overall, 1,528 (45.9%) exposed HCP were tested for SARS-CoV-2 infection by RT-PCR.

During the study period there were 254 notified cases of COVID-19 among HCP from 77 healthcare facilities (60 hospitals, 11 primary healthcare centers, 4 private laboratories and 2 long-term care facilities), including 66 HCP as described above. in-hospital mortality). Table III shows the rates of absenteeism and presentism among HCP. Among the 3,332 HCP who were exposed to COVID-19, 1,332 (40%) were absent from work from a mean duration of 7.5 days, while working with symptoms (presentism) was 

The aim of the current study was to estimate the direct and indirect costs associated with COVID-19 in HCP in Greece using a payer's perspective. The total costs for the management of HCP with COVID-19 and HCP exposed to COVID-19 during the first epidemic wave of COVID-19 in Greece amount to approximately 1.73 million Euros, which is conservative. In our study total costs for exposed HCP far exceeded total costs for HCP with COVID-19, which is explained by the large number of traced and self-isolated contacts per COVID-18 case in healthcare facilities. In our previous study we estimated that a median of 14 HCP were traced per source of COVID-19 exposure, ranging from 1 to as high as 113 exposed HCP [5] .

In our study absenteeism was the major driver of total costs in both groups of HCP.

The considerable impact of absenteeism is partially attributed to its prolonged duration either for isolation purposes (healthy absenteeism) in accordance with the national guidelines [5] or in the context of symptomatic illness (COVID-19).

Absenteeism was documented in 40% of exposed HCPs for a mean duration of 7.5 days and in 99% of HCP with COVID-19 for a mean duration of 25.8 days. It should be noted that the largest burden of absenteeism among exposed HCP concerned highrisk exposure (defined as neither the HCP nor the infectious patient wearing a surgical mask), and therefore could be largely preventable [5] . Our results are in line with a study from Spain, where 65 symptomatic employees (24.6% of all) at a long-term care facility leaved for a mean of 19.2 days during a COVID-19 outbreak [16] .

Moreover, 15% of HCP with COVID-19 in our study reported presentism at a mean duration of 2.2 days. Beyond loss of productivity, poorer quality of services and financial losses [17] , presentism represents a threat for infection control in the context of the ongoing pandemic, given the potential of SARS-CoV-2 shedding, especially J o u r n a l P r e -p r o o f shortly after onset of symptoms when viral load peaks [18] . The increased needs on workforce due to absenteeism were mainly managed by internal movement of HCP from low-to high-demand departments; this was facilitated by the fact that selective surgical procedures and healthcare services for chronic co-morbidities were transferred later.

In our study direct costs, driven mostly by costs for RT-PCR tests and hospitalization costs, were relatively low accounting for 18.8% of total costs. This result is explained by the small proportion of HCP that required inpatient care coupled with the relatively lower re-imbursement prices for such services in Greece compared to other European countries, as a result of austerity policies over the last decade [19] .

Furthermore, our study sheds light on the disproportionately increased risk of exposure to COVID-19, SARS-CoV-2 infection and absenteeism among HCP, consistent with the growing literature on this topic [5, [8] [9] [10] 20, 21] . In accordance with the World Health Organization, HCP constitute a high-priority group for COVID-19 vaccination [22] . It is highly likely that the implementation of vaccination programmes for HCP will have a considerable impact on reducing their risk for SARS-CoV-2 infection, COVID-19 and eventually absenteeism. Further studies are needed in order to investigate the impact of COVID-19 vaccines on the COVID-19associated morbidity and absenteeism among HCP and the protection of essential healthcare services.

Our study has few limitations. First, total cost of SARS-CoV-2 infection in HCP is underestimated in the context of the Greek healthcare system. This is due to the underpricing of medical services and HCP salaries and it has traditionally produced deficits for the healthcare system, retrospectively subsidised by the government budget [23] . Therefore, third party payer perspective is rarely representative of actual J o u r n a l P r e -p r o o f cost for healthcare services in Greece. Additionally, in the third party payer context, the study excludes any indirect/societal cost. Repeated imaging tests also were not considered. In particular, only costs related to acute phase of infection were considered, and not the follow-up costs, which may be considerable in patients with COVID-19-associated complications. Further, we were not able to estimate costs potentially resulting from adverse patient outcomes attributed to decreased work productivity for both HCP who were on-site with symptoms (presentism) and those who had to work longer shifts (fatigue/burnout). Another limitation is that the notification and follow-up of exposed HCP started on March 13 th 2020, which is two weeks after the first COVID-19 case was detected in the country. Lastly, costs associated with personal protective equipment use were not considered, although their provision has been identified as a primary concern by HCP during epidemics [24] . A clear strength of the current study is the retrieval of all notified cases of SARS-CoV-2 infection and exposure to COVID-19 among HCP during the study period in Greece.

This offered the opportunity to prospectively record case-based incurred costs and no data generated by the healthcare system. (11), obesity (10), chronic pulmonary disease (7), diabetes mellitus (6), immunosupression (5), malignancy (5), chronic neuromuscular disease (2) **excludes three HCP who died HCP: healthcare personnel; COVID-19: coronavirus disease 2019; SD: standard deviation; RT-PCR: reverse transcriptase polymerase chain reaction; SARS-CoV-2: severe acute respiratory syndrome coronavirus 2; CT: computer tomography; ARDS: acute respiratory distress syndrome; ICU: intensive care unit 2.5 (3.1) *Excludes 2 employees who missed work due to clinic closure (first case) and receiving a special permission to miss work for non-COVID-19 reasons (second case) HCP: healthcare personnel; COVID-19: coronavirus disease 2019; SD: standard deviation -J o u r n a l P r e -p r o o f Table IV . Healthcare costs for HCP overall and stratified by group of HCP (exposed HCP versus HCP with COVID- 19) 

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We are thankful to all HCP who provided data for this study. We also thank Caterina Liona and Sofia Poufta for technical assistance. The opinions presented in this article are those of the authors, and do not necessarily represent those of their institutions.Funding: no funds were received for this study Conflicts of interest: none to declare J o u r n a l P r e -p r o o f