key: cord-0881288-lf3ckczk authors: Zhang, Min; Kim, Rokho title: Occupational health protection for health workers during the coronavirus disease 2019 (COVID-19) pandemic: 6P-approach in China date: 2021-11-25 journal: Glob Health J DOI: 10.1016/j.glohj.2021.11.007 sha: 572edf898af431db016486a804edb908fa078a89 doc_id: 881288 cord_uid: lf3ckczk Health workers (HW) are on the frontline fighting against the COVID-19 pandemic, they are exposed to multiple occupational hazards. This article analyzed the comprehensive measures of protecting HWs during the COVID-19 response in China. Occupational health protection of HWs was one of the key strategies of the public health measures adopted against the COVID-19 outbreak from the earliest stage in China. This prioritization of HWs health protection was based on the technical and policy guidance of WHO and International Labor Organization as well as the experiences from previous outbreaks in China. The comprehensive measures in China can be summarized as ‘6P-approach’: public health emergency response, prompt learning from lessons, proactive measures of occupational health, precaution strategies against occupational hazards, personal protective equipment and medical devices supply, and professional networking. Through this 6P-approach, China was able to minimize the incidence of COVID-19 infection among HWs, while successfully containing the outbreak during the first quarter of 2020. Although the COVID-19 vaccines have been rolled out, however, the COVID-19 pandemic is still under rapidly evolving situation. Experiences from China may provide other countries with an example of prioritizing and incorporating occupational health protection of HWs in their public health measures responding to the COVID-19 pandemic. (COVID-19) outbreak, putting them at higher risk of infection. In addition to pathogen exposure, HWs are exposed to occupational hazards of long working hours, psychological distress, X-rays, noise, poor ergonomic condition, stigma, and physical and psychological violence and harassment. The occupational health and safety of HWs are among the top priorities when responding to the COVID-19 pandemic. [1] [2] As of 20 January 2020, the first official confirmed case of coronavirus infection among HWs in China were reported in 15 medical workers (one doctor and thirteen nurses) from a neurosurgery department during an operation in the epicenter of Wuhan City of Hubei Province (hereafter referred as Wuhan, Hubei, respectively). [3] [4] According to the official announcement of the accumulated infection in February 2020, among 2 055 confirmed cases of coronavirus infection were reported among HWs in China, accounting for 2.7% of the total confirmed cases (75 465) in the same period. 5 However, the protection of frontline HWs in all settings was only implemented in January 24. Among more than 42 000 HWs, of whom 28 000 were women, dispatched to Hubei from provinces and military personnel in order to respond to the COVID-19 outbreak, none of them was infected until late March. 6 To date, the publications and national situation reports that provide information on the number of [8] [9] Meanwhile, international technical tools were used in China; e.g., since 2013, a joint International Labor Organization (ILO)/WHO technical tool for health and safety improvement at a certain workplace in the health sector (HealthWISE) had been promoted across China. [10] [11] The Model of Hospital Initiative on Systematic Occupational Health (HISOH) was gradually created and developed in China. 12 At the beginning of 2018, the National Health Commission (NHC) of the People's Republic of China was established, aiming to promote the national health strategy -Healthy China 2030‖. From then on, the responsibility and functionality of occupational health management had been merged and assigned to NHC. 13 China is working closely with the WHO's Regional Office for Western Pacific, in order to maintain the occupational health of HWs, e.g., the public health emergency response. 14 Such efforts laid a solid foundation of the occupational health for HWs during the COVID-19 outbreak in China. In this paper, we tried to summarize those China's lessons and experiences of protecting HWs during COVID-19 into -6P-approach‖: public health emergency response, prompt learning from lessons, proactive occupational health measures, preventive strategies against occupational hazards, personal protective equipment (PPE) and medical devices supply, and professional networking. On 8 April 2020, the travel restrictions in Wuhan were lifted, ending the hardest-hit area since 23 January 2020, which was an important milestone against the COVID-19. 17 HWs were infected at the workplace, while 60% of them were infected in the community. Most of infected HWs from Hubei (especially Wuhan) was confirmed and diagnosed at the early stages of COVID-19 pandemic. Compared with the reported number on 11 February 2020, 339 HWs were as newly confirmed cases of COVID-19 on February 20.; Although at least 22 Hws died at the end of February 2020 reported by the local media. 23 No accurate figures of HWs who died due to COVID-19 were reported. However, some of the deaths may not be directly caused by COVID-19. For example, a doctor in a township hospital in Hubei experienced a sudden unexplained death in midnight at his home, 24 and an epidemiologist dispatched from Guangdong Province died in Hubei by traffic accident while working. 25 The infection rate among HWs was higher at the early stage of the initial phases of the outbreak, a possible reason for that was lack of PPE, such as suits, masks, and eye protection. [26] [27] [28] The top two hospital departments with high HWs infection rate were respiratory and emergency department. More than half of the infected HWs were nurses (51.46%). 29 After 11 February 2020, there were HWs who worked in other departments besides emergency department, infectious disease department, or the designated hospitals for COVID-19, reported being infected. For instance, five medical workers in a Beijing hospital's cardiology department were infected in April 2020. 30 Comprehensive policies were introduced and strictly enforced to improve the occupational health protection of HWs since the initial phases of the fight against COVID-19, leading to a remarkable success. According to the official information, none of the 42 000 medical workers from different hospitals nationwide who were dispatched to Hubei were infected with COVID-19. The occupational health protection of HWs is largely dependent on the etiology and epidemiological characteristics of the novel coronavirus, whose evolution remains unknown; hence, further studies are warranted to obtain more evidence regarding the characteristics of this virus. Along with airborne pathogens, HWs are also exposed to other multiple occupational risks such as blood borne pathogens, long working hours/workload, poor ergonomic condition, fatigue, psychosocial factors (such as stigma, discrimination, violence, depression, anxious, and burnout), chemical substances (such as disinfectants and medicine), physical agents (e.g. X-ray), mechanical injury, and skin diseases. Eventually, those occupational risks will cause complex physical and mental health problems. In particular, universal precaution principles were followed in healthcare facilities. And various models based on the risk assessment were classified, in order to prevent and control the transmission of COVID-19, including HWs to HWs, HWs to patients, patients to HWs, HWs to community/family, and family/community to HWs. All staff working at the healthcare facilities must wear medical surgical masks. All HWs working at the departments of emergency, outpatient infectious diseases, outpatient respiratory care, stomatology, and endoscopic examination (such as gastrointestinal endoscopy, bronchofibroscopy, and laryngoscopy) must upgrade their surgical masks to medical protective masks/N95 respirator according to the protection protocol level one. Standard precautions have been applied, which included: (1) provision of hand washing and eye cleaning facilities; ensuring that all hand hygiene products are available, such as clean water and alcohol-based hand rub; (2) use of appropriate PPE; Accommodation arrangement was crucial for maintaining the safety, health, and well-being of HWs and their family/community. During their medical supports in Wuhan, the local authorities requisitioned hotels near hospitals to provide accommodation for every HW, with single living room and living support (i.e., healthy food, laundry machine, physical excise facilities, and transportation when commuting from the living place to the hospital). After that, all HWs undergo a 14-day quarantine and testing before they returned to their routine service. [33] [34] In May 2020, the development of COVID-19 vaccine was announced with a striking progress in China. By far, the Sinovac-CoronaVac COVID-19 vaccine and the Sinopharm COVID-19 vaccine were validated by the WHO for emergency use. 35 Until April 2021, 80% of HWs nationwide have been vaccinated as the priority groups. 36 In August 2021, Chinese government committed to provide a total of two billion doses of COVID-19 vaccines to the world within this year, to promote international vaccine cooperation and build a community with a shared future for humanity. 37 Sufficient supply of medical equipment was the key to winning the fight against the COVID-19 outbreak; the medical equipment shortage was a formidable challenge in the early stage. After the countrywide and worldwide efforts, ample supplies of PPE were provided to the HWs, and the designated COVID-19 treatment hospitals were equipped with essential devices. In Hubei, the daily supply of medical protective uniform increased from 21 000 before January 27 to 270 000 on February 29, while the daily supply of N95 respirators increased from 72 000 to 562 000. 38 Within a very short time, 86 designated hospitals and 16 Fangcang shelter hospitals were established with over 60 000 beds. Fangcang shelter hospitals were implemented for the first time in Wuhan; they were rapidly built by converting existing public venues (such as stadiums and exhibition centers) into healthcare facilities, which serviced to isolate patients with mild and moderate COVID-19 cases. Prevention of nosocomial infection is the priority of Fangcang shelter hospitals. 39 Science and technology is the most powerful weapon in the battle against the COVID-19 in China; professional network played a critical role. Virus respects no borders; hence, a collective action has been carried out in China by applying international standards/guidelines. In this article, we Based on the experiences and lessons in learned in China's fight against the COVID-19 pandemic, comprehensive measures to protect the occupational health of HWs (6P-approach) played a critical role. The core of 6P-approach is the safety, health, and well-being of HWs. To prevent and control the occupational hazards of it, the key policies and actions are developed. These three elements are essential and all necessary for 6P-approach's implementation. The achievement of the battle against COVID-19 in China was based on the former system, especially the regulation of occupational health and comprehensive measures for HWs, with the contributions of international organizations and national institutions. Although the COVID-19 vaccines have already been rolled out worldwide, none of these vaccines provide 100% protection against the infection. Infection cases still occurred among vaccinated HWs. Therefore, comprehensive measures should be employed to protect HWs from occupational health hazards. Long-term mechanism is fundamental to tackling the formidable challenges of protecting HWs from complex occupational risks. Moreover, we suggest some recommendations in three levels. For China, the emergency response HWs should timely submit action reports to gather information on the deployment process and improve the further operation plans. Both isolation and monitoring are essential of the health of HWs and, helpful to identify the adverse effects for health or functional consequences that potentially associated with emergency response (e.g., illness, injury, disability, and emotional trauma), in order to provide early interventions and maximize the chances of recovery. Furthermore, the government should make these measures becoming a comprehensive system, to ensure that the occupational health investment for HWs could be included in the annual budget of all healthcare facilities and provide them comprehensive health protection. In the long term, the national occupational health programmes for health workers need to be initiated, as a substantial action in the 14th Five-Year-Plan in the health sector of China. For other countries, policy makers and health professionals could learn from China and other countries with experiences against the infectious disease pandemic, because most issues related to the occupational health of HWs during the COVID-19 pandemic were similar globally. The international and national tools are recommended. However, the differences among economic, social, and political contexts should be considering. In addition, lessons could learn from the historical practices. Industrial and occupational data must be incorporated into the public health surveillance and healthcare information system. Workers in appreciation and gratitude for their unwavering dedication in the fight against the COVID-19 pandemic. 42 Hence, WHO developed COVID-19: Occupational health and safety for health workers: interim guidance, 2 February 2021, which complements the relevant other WHO guidelines and should be used in conjunction with them. Collaboration and communications are crucial. Professional network will contribute to the identification, review, and synthesis of the evidence related to the occupational health impacts and the preventive strategies for HWs and healthcare facilities against the COVID-19 pandemic. The best talents around the world working together will help to find a much better and faster solution. World Health Organization. Coronavirus disease 2019 (COVID-19) Situation Report-82 World Health Organization. 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Year of Health and Care Workers 2021: Protect, Invest The authors would like to thank Dr. Ivan D. Ivanov (Occupational and Workplace Health, WHO headquarter) for his professional comments to this article. The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.