key: cord-1022449-y6i6g4cw authors: Colomb-Cotinat, M.; Poujol, I.; Monluc, S.; Vaux, S.; Olivier, C.; Le Vu, S.; Floret, N.; Golliot, F.; Berger-Carbonne, A.; group, the Geres-study title: Burden of COVID-19 on workers in hospital settings: the French situation during the first wave of the pandemic date: 2021-07-07 journal: Infect Dis Now DOI: 10.1016/j.idnow.2021.06.308 sha: c28f2c343625301572988669e89f0c7c87bfe4b4 doc_id: 1022449 cord_uid: y6i6g4cw We launched a survey in April 2020 to assess the number and proportion of hospital workers infected during the first wave of the COVID-19 pandemic in France, and to assess the attributable mortality. All French hospital settings (HS) were invited to declare new cases and attributable deaths by occupation category each week. Between March 1 and June 28, 2020, participating HS accounted for 69.5% of the total number of HS workers in France, and declared 31,088 infected workers; 16 died from the infection. We estimated that 3.43% (95%CI: 3.42-3.45) of French workers in HS, and 3.97% (95%CI: 3.95-3.99) of healthcare workers were infected during the first wave. Workers in regions with a cumulative rate of hospitalized COVID-19 patients equal or above the national rate, HS other than tertiary hospitals, or occupations with frequent patient contacts were particularly impacted. Targeted prevention campaigns should be elaborated. The GERES study group A Abstract: We launched a survey in April 2020 to assess the number and proportion of hospital workers infected during the first wave of the COVID-19 pandemic in France, and the attributable mortality. All French hospital settings (HS) were invited to declare new cases and attributable deaths by occupation category each week. Between 1 March and 28 June 2020, participating HS cover 69.5% of the total number of HS workers in France, and declared a total of 31,088 infected workers; 16 died from the infection. We estimate that 3.43% (95%CI: 3.42-3.45) of French workers in HS, and 3.97% (95%CI: 3.95-3.99) of HCW were infected during the first wave. Workers in regions with a cumulative rate of hospitalized COVID-19 patients equal or above the national rate, HS other than tertiary hospitals, or occupations with frequent patient contact were particularly impacted. In the light of these findings, focused prevention campaigns should be elaborated. We thanks the reviewer for his/her useful comments, and hope this totally rewrited version of the manuscript will answer the points he raised. Please find below our pointby-point answers. In addition, we made a minor correction on figure 1 in the number of hospitalized COVID-19 patients. Comment : " It is a poll, but not at all a report of the incidence and prevalence of the disease in this population. We regret the absence of global report of occupational medicine in this field." Answer : We totally agree that a more global study on the impact of the pandemic on hospital workers would be essential. We regret that no other national study except ours has been published in France. Therefore we reaffirm the added value of our article. To our knowledge, our survey is the only one giving a national quantitative estimation on infected workers in HS. No other figure are available for France. We are very confident that the vast majority of HS that admitted COVID-19 patients during the first wave have participated, considering the participation rate in tertiary (98% of tertiary hospitals J o u r n a l P r e -p r o o f workers) and secondary hospitals (68%). We believe that our survey provides the most robust estimation of the national proportion of hospital workers infected during the first wave, with a breakdown by occupational categories. This information is much needed to communicate on the need to protect workers during the pandemic. Comment :"Authors are reporting demonstrated cases with positive PCR as well as possible case based only on the local epidemiological and clinical evaluation. It is obviously not the same at all. " Answer :We also agree that the different diagnostic methods may not identify the same types of patients. However, national case definitions have fluctuated throughout the first wave. Especially at the very beginning where the majority of our cases were reported, there was a lack of diagnostic tests and heterogeneity in testing practices between settings. Therefore, we chose to include all diagnostic methods that were used in this period in our case definition, according to the national guidelines. We have added this precision in the manuscript : "Considering the lack of diagnostic tests in the first wave of the pandemic and heterogeneity in testing practices between settings, a case was either defined by a positive RT-PCR, a positive serological test following clinical symptoms, or by an assessment of the local COVID-19 investigation team based on clinical and epidemiological data." Comment :"At the end of the paper, it is impossible to know what is the exact burden of the infection in HCWs in France." Answer :Regarding this comment, we would like to reiterate that only few local estimates are available so far to quantify the proportion of infected HCWs in France. Our results bring a much more general and precise picture of the burden of the infection among the hospital personnel in France than the current evidence. We are now making this clearer in the revised manuscript, we hope it is more clear like that : "We estimate that the 31,088 infected workers account for 3.43% (95%CI: 3.42-3.45) of French workers in HS (table 1) . Among HCW, this proportion is 3.97% (95%CI: 3.95-3.99)" "This survey highlights the high burden of COVID-19 in workers in HS in France, with more than 1 in 30 hospital workers infected over the first four months of the pandemic. Workers in regions with a cumulative rate of hospitalized COVID-19 patients equal or above the national rate, HS other than tertiary hospitals, or occupations with frequent and prolonged patient contact were particularly impacted. In the light of these findings, focused prevention campaigns should be elaborated, and protecting HCW to reduce the risk of SARS-CoV-2 transmission and preserve the healthcare workforce in the face of an outbreak must remain a priority" Comment :"We suggest submission as letter to the editor, adressing the previous comments" Answer :We understand that the reviewer and editor recommend a shorter format. We have completely redrafted the text and divided the number of words and tables/figures by two, according to the "short communication" format. The "Letters for editor" format seems to be intended to comment on an article that has already been published or to present a relevant personal experience or a clinical case. The format "short communication" appears to us more in adequacy with our article, as we report original results in a condensed form. We hope you will agree with this proposition. In this nationwide study, we estimated that more than 1 in 30 hospital workers were infected during the first wave of the COVID-19 pandemic in France. Workers were at higher risk of infection in regions with a cumulative rate of hospitalized COVID-19 patients above the national rate, in primary or secondary hospitals, and in occupations with frequent and prolonged patient contacts. Targeted prevention campaigns should be organized. We launched a survey in April 2020 to assess the number and proportion of hospital workers infected during the first wave of the COVID-19 pandemic in France, and to assess the attributable mortality. All French hospital settings (HS) were invited to declare new cases and attributable deaths by occupation category each week. J o u r n a l P r e -p r o o f affected regions" with a rate equal or above the national rate, and 12 "less-affected regions" with a rate below the national rate (Grand-Est, Haut de France, Ile-de-France, and Bourgogne-Franche-Comté for mainland regions and Guyana and Mayotte for overseas regions, were classified as "highly-affected regions". The 12 remaining regions were classified as "lessaffected regions") [1] . We defined teaching hospitals or military hospitals as tertiary hospitals; local hospitals as secondary hospitals; local private clinics as primary hospitals; psychiatric hospitals or oncology centers as specialized hospitals; long-term HS providing rehabilitation care as rehabilitation care centers; and dialysis centers or day hospitals as "other". During the 17-week period between March 1 and June 28, 2020, 1,132 HS participated at least once in the survey. These settings account for 69.5% of the total number of HS workers in France, 98% of workers of French tertiary hospitals, and 68% of secondary hospitals [7] . No difference was observed between coverage in "highly-affected regions" and "less-affected regions" (69.8% vs 69.3%). Regarding occupation, coverage of the survey was almost the same between HCW (69.1%) and non-HCW (70.6%). The coverage was above 58% for every occupation sub-category. A total of 31,088 infections and 16 deaths among workers were reported by 829 HS (with a median of 10 cases per HS) while 303 HS reported no case. Based on the hypothesis that nonparticipating HS were less impacted by the outbreak, we estimated that the vast majority of HS workers infected during the first wave were reported in this survey. We note that reporting of infections in workers dropped faster than the number of patients hospitalized with COVID- The vast majority (n=25,337; 82%) of infections occurred in HCW, especially in nurses (29%) and healthcare assistants (25%). Among the 16 deaths reported, 10 were reported in HCW. Various proportions of HCW among the total number of COVID-19 cases during the first wave have been reported in different countries. HCW accounted for 3% of all COVID-19 cases in the United States [8] , 5% in China [9] , and much more in Italy (10%) [10] and Spain (20%) [11] . In France, the 25,337 cases reported in our survey represent 15% of the 164,801 confirmed cases reported during the same period [1] . However, as testing policies at the start of the pandemic were not homogenous and targeted in priority professionals and patients in hospitals, this proportion is probably overestimated. We estimate that the 31,088 infected workers account for 3.43% (95%CI: 3.42-3.45) of French workers in HS (Table 1) . Among HCW, this proportion is 3.97% (95%CI: 3.95-3.99). Five regions had a higher proportion of infected workers than the national proportion ( Figure 2 ). After adjustment, "highly-impacted regions" had significantly more infected workers than "lessimpacted regions". Again, the proportions of infected HCW reported by studies in other countries vary greatly. A living review [12] reported this proportion ranging from 0.4% to 49.6% and when based on serological testing from 1.6% to 31.6%. This variability is linked to differences in study design, selection criteria, and sample sizes. Overall, most early studies were small and single centered. Our large coverage of both existing employees and hospital settings in France could explain why our proportion of infected HCW lies within the lower part of the range of estimates. Interestingly, we found that infections were significantly more frequent among workers from secondary and primary hospitals than from tertiary hospitals. Tertiary settings were identified J o u r n a l P r e -p r o o f as referral hospitals at the start of the pandemic. We hypothesize that staff from these hospitals were more aware and better trained to apply preventive measures against the risk of SARS-CoV-2 infection, and may also have had better access to personal protective equipment. On the contrary, workers in secondary and primary hospitals may have received patients with fewer or atypical symptoms, especially at the start of the pandemic, and been unconsciously exposed to COVID-19. Healthcare assistants and physiotherapists, followed by nurses and residents were the most affected workers (Table 1 ). Those categories have already been reported to be especially at risk in the literature [2, 13] , as they have frequent and prolonged contacts with patients. This highlights the need for prevention strategies targeting these specific occupational categories. The proportion of infected workers was higher in all types of HCW compared with non-HCW, except for midwives. Several articles reported a higher infection rate among HCW compared with non-HCW or the general population [2, 3, 14] , suggesting the strong contribution of occupational exposure to the infection of HCW. In this study, we found a parallel trend between the weekly number of infected workers and the number of hospitalized COVID-19 patients. But notably, we observed a faster decline of COVID-19 cases in workers than in COVID-19 cases admitted to hospitals. This reveals that the risk of infection in professionals was particularly increased at the beginning of the pandemic, probably due to the shortage of personal protective equipment and to a general lack of precaution before transmission from asymptomatic individuals was recognized. In addition, community exposure remains a common underlying factor of infection, as suggested by the temporal and spatial similarities between the proportion of infected workers and the general dynamics of the outbreak in France. Those similarities, also described in other J o u r n a l P r e -p r o o f studies [15] , show that in addition to work exposure, community and family exposure is also a driver of infection among hospital workers, as reported elsewhere [2, 16] . Determining whether workers' infections are linked to in-hospital or out-of-hospital exposure is difficult and our survey does not allow to disentangle occupational from community transmission. Some additional limitations must be considered in our survey. First, as the survey was launched mid-April, two weeks past the epidemic peak in France, data corresponding to the very first phase of the outbreak were collected retrospectively; we therefore lack the temporal distribution of these cases. Second, as testing strategies during this first part of the pandemic differed for HCW and the general public, the proportion of infected HCW among the total cases may be overestimated. Third, the proportion of HS defined as "other" was low (11.8%), and we hypothesize that participating HS in this category were the most impacted by the preserve the healthcare workforce in the face of an outbreak must remain a priority [17, 18] . This survey is still ongoing. Since July 1, 2020, the case definition includes asymptomatic cases diagnosed with serological tests and since November 2020 cases diagnosed with antigenic tests. COVID-19 : point épidémiologique du 25 juin 2020. 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