COVID-19–Associated Hospitalizations Among Health Care Personnel — COVID-NET, 13 States, March 1–May 31, 2020

Health care personnel (HCP) can be exposed to SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), both within and outside the workplace, increasing their risk for infection. Among 6,760 adults hospitalized during March 1-May 31, 2020, for whom HCP status was determined by the COVID-19-Associated Hospitalization Surveillance Network (COVID-NET), 5.9% were HCP. Nursing-related occupations (36.3%) represented the largest proportion of HCP hospitalized with COVID-19. Median age of hospitalized HCP was 49 years, and 89.8% had at least one underlying medical condition, of which obesity was most commonly reported (72.5%). A substantial proportion of HCP with COVID-19 had indicators of severe disease: 27.5% were admitted to an intensive care unit (ICU), 15.8% required invasive mechanical ventilation, and 4.2% died during hospitalization. HCP can have severe COVID-19-associated illness, highlighting the need for continued infection prevention and control in health care settings as well as community mitigation efforts to reduce transmission.

, CNA/nursing assistant/nurse aide (50), patient aide/care aide/caregiver/patient care assistant (25), home health personnel (17), phlebotomist/technician (16), social work/behavioral health/counseling (16), physician (15), physical therapist/occupational therapist/chiropractor (nine), dentist/dental hygienist (seven), emergency medical services personnel/paramedic (seven), medical assistant (six), nursing home/long-term care/assisted living staff members (three), respiratory therapist (three), and other (four). HCP generally not expected to have direct patient contact included human resources/administrative staff members (22), housekeeping/maintenance staff members (13), nursing home/long-term care/assisted living staff members, role unspecified (12), food service (seven), pharmacist/pharmacy staff members, role unspecified (six), environmental services (three), laboratory staff members, role unspecified (one), security (one), other (five), and unspecified (75). HCP categorized as "role unspecified" were those for whom only a location of work was indicated with no other detail about occupation; all such HCP were assumed generally not to have direct patient contact and were classified according to their location of work.
Because of high case counts, nine of 13 sites conducted indepth medical chart abstractions for an age-stratified random sample of all reported COVID-19 patients hospitalized during March 1-May 31. § Six sites completed chart abstractions for all patients aged <50 years (including all pregnant patients), 20% of patients aged 50-64 years, and 10% of patients aged ≥65 years. Three sites completed abstractions for 10% of patients aged ≥18 years, in addition to all pregnant patients. The remaining four sites completed chart abstractions for all reported patients. As of September 12, chart abstractions were complete for 86% of sampled patients identified through COVID-NET. Descriptive statistics were calculated for all sampled HCP aged ≥18 years hospitalized with COVID-19 during March 1-May 31, 2020, for whom full chart abstraction was completed. Weights were applied to reflect the probability of being sampled for complete chart abstraction; weighted percentages and unweighted case counts are presented throughout this report. Analyses were conducted using SAS (version 9.4; SAS Institute), and 95% confidence intervals (CIs) were generated using the Taylor series linearization method in SUDAAN (version 11; RTI International). COVID-NET activities were determined by CDC to meet the requirements of public health surveillance. ¶ All sites participating in COVID-NET obtained approval from their respective state and local Institutional Review Boards, as applicable.

Discussion
During March 1-May 31, 2020, HCP accounted for approximately 6% of adults hospitalized with COVID-19 for whom HCP status was documented in COVID-NET. The median age of hospitalized HCP (49 years) was substantially lower than that previously reported for hospitalized adults (62 years) (3). More than two thirds (67.4%) of HCP hospitalized with COVID-19 were generally expected to have direct patient contact, and over one third (36.3%) were in nursing-related occupations. Similar to the proportion of underlying conditions among all hospitalized adults reported to COVID-NET during March-May,** approximately 90% of hospitalized HCP reported at least one underlying condition, with obesity being the most common and reported for over two thirds (72.5%) of patients. A high proportion of hospitalized HCP had indications of severe disease: approximately one in four were admitted to an ICU, and approximately 4% died. The proportion of HCP with these severe clinical outcomes was similar to that of adults aged 18-64 years hospitalized with COVID-19 during March-May. † † Findings from this analysis are comparable to those reported among HCP with COVID-19 in China, which found that nursing-related occupations accounted for the largest proportion of COVID-19 cases among HCP (4). COVID-NET does not specifically collect information on exposure history; however, nurses are frontline workers and might be at particular risk for exposure because of their frequent and close ** https://gis.cdc.gov/grasp/COVIDNet/COVID19_5.html. † † https://gis.cdc.gov/grasp/COVIDNet/COVID19_5.html.    * Reported HCP were categorized as those generally expected and those generally not expected to have direct patient contact based on HCP type. † Sites located in the following 13 states: California, Colorado, Connecticut, Georgia, Maryland, Michigan, Minnesota, New Mexico, New York, Ohio, Oregon, Tennessee, and Utah. § Defined as any of the following: chronic lung disease, chronic metabolic disease, blood disorder/hemoglobinopathy, cardiovascular disease, neurologic disorder, immunocompromised condition, renal disease, gastrointestinal/liver disease, rheumatologic/autoimmune/inflammatory condition, obesity (body mass index ≥30 kg/m 2 ), and pregnancy. ¶ Excluding hypertension. ** Pregnancy was assessed among female patients aged 18-49 years; two pregnant patients were admitted to the ICU, and one required invasive mechanical ventilation. † † Assessed as nonmutually exclusive treatment categories. § § Includes treatments administered as off-label, for compassionate use, or as part of randomized controlled trials (RCTs) for which the patient might have received treatment or a placebo: hydroxychloroquine (two), remdesivir (six), tocilizumab (one), and sarilumab (two). ¶ ¶ Given with at least one other COVID-19 investigational treatment. *** Not given for human immunodeficiency virus infection. † † † Eight patients received at least one of the following treatments: RCT for baricitinib (three), dexamethasone (three), cyclosporine (one), RCT for losartan (one), and RCT for LY3127804 (one). § § § Five (1.9%) patients received extracorporeal membrane oxygenation, and two (0.2%) received intravenous immunoglobulin. ¶ ¶ ¶ Highest level of respiratory support for each patient that needed respiratory support. patient contact, leading to extended cumulative exposure time. Nursing-related occupations also account for a large proportion of the U.S. health care workforce: in 2019, registered nurses alone represented approximately one third of health care practitioners (5). This has implications for the capacity of the health care system, specifically nursing staff members, to respond to increases in COVID-19 cases in the community.

TABLE. (Continued) Demographic and clinical characteristics of health care personnel (HCP) with COVID-19-associated hospitalizations, overall and by type of patient contact* -COVID-NET, 13 states, † March 1-May 31, 2020
To decrease the risk for SARS-CoV-2 transmission in health care facilities, CDC recommends that HCP use face masks (i.e., medical masks, such as surgical or procedure masks) at all times while they are in health care facilities, including patientcare areas, staff member rooms, and areas where other HCP might be present (2). In addition, in areas with moderate to substantial community transmission of SARS-CoV-2, CDC * HCP categorized as "unspecified" or "other" have not been included in the figure but are included in the denominator. † Error bars represent 95% confidence intervals. § Sites located in the following 13 states: California, Colorado, Connecticut, Georgia, Maryland, Michigan, Minnesota, New Mexico, New York, Ohio, Oregon, Tennessee, and Utah. recommends that HCP wear eye protection for all patient care encounters. An N95-equivalent or higher-level respirator is recommended for aerosol-generating procedures and certain surgical procedures to provide optimal protection against potentially infectious respiratory secretions and aerosols (2). Similar to the distribution of the U.S. health care workforce overall, a majority of hospitalized HCP in this report were female (5). However, compared with previously reported demographic characteristics of U.S. HCP with COVID-19, HCP identified by COVID-NET were older, and a larger proportion were Black (6). Given that COVID-NET conducts surveillance specifically for hospitalized patients, these differences might reflect the association between increased age and severe outcomes associated with SARS-CoV-2 infection as well as disproportionate effects among Black populations (1,3,7,8).
These results are consistent with previously reported data suggesting that underlying conditions, including obesity, diabetes, and cardiovascular disease, are risk factors for COVID-19associated hospitalization and ICU admission (3,9,10). Among the approximately 90% of HCP in this analysis with at least one underlying condition, obesity was most commonly reported. A recent study found that obesity was highly associated with risk for death among COVID-19 patients who sought health care, even after adjusting for other obesity-related underlying conditions (10). The findings in this report highlight the need for prevention and management of obesity through evidence-based clinical care as well as policies, systems, and environmental changes to support HCP in healthy lifestyles to reduce their risk for poor COVID-19-related outcomes. § §

Summary
What is already known about this topic? Data on characteristics and outcomes of U.S. health care personnel (HCP) hospitalized with COVID-19 are limited.
What is added by this report?
Analysis of COVID-19 hospitalization data from 13 sites indicated that 6% of adults hospitalized with COVID-19 were HCP. Among HCP hospitalized with COVID-19, 36% were in nursing-related occupations, and 73% had obesity. Approximately 28% of these patients were admitted to an intensive care unit, 16% required invasive mechanical ventilation, and 4% died.
What are the implications for public health practice?
HCP can have severe COVID-19-associated illness, highlighting the need for continued infection prevention and control in health care settings as well as community mitigation efforts to reduce SARS-CoV-2 transmission.
The findings in this report are subject to at least five limitations. First, HCP status is determined through medical chart review, and although chart abstractions will be completed on all sampled cases, abstraction was pending at the time of analysis for approximately 14% of sampled cases hospitalized during March-May. Thus, the proportion of identified HCP among all adults hospitalized with COVID-19 from March-May might represent an overestimate or underestimate of HCP in this population. Second, because of small sample sizes for some variables, some estimates might be unstable, as evidenced by wider confidence intervals. Third, although COVID-NET collects HCP status, data on the degree, frequency, and duration of contact with patients are not collected. HCP were stratified by presumed level of patient contact, based on general understanding of health care professions; the level of patient contact for some HCP might have thus been misclassified. Fourth, COVID-NET does not collect data regarding exposure history. It is unknown whether HCP were exposed to SARS-CoV-2 in the workplace or community, highlighting the need for community prevention efforts as well as infection prevention and control measures in health care settings. Finally, laboratory confirmation is dependent on clinicianordered testing and hospital testing policies for SARS-CoV-2; as a result, COVID-19-associated hospitalizations might have been underestimated.
Findings from this analysis of data from a multisite surveillance network highlight the prevalence of severe COVID-19-associated illness among HCP and potential for transmission of SARS-CoV-2 among HCP, which could decrease the workforce capacity of the health care system. HCP, regardless of any patient contact, should adhere strictly to recommended infection prevention and control guidance at all times in health care facilities to reduce transmission of SARS-CoV-2, including proper use of recommended personal protective equipment, hand hygiene, and physical distancing (2). Community mitigation and prevention efforts in households and congregate settings are also necessary to reduce overall SARS-CoV-2 transmission. Continued surveillance of hospitalized HCP is necessary to document the prevalence and characteristics of COVID-19 among this population. Further understanding of exposure risks for SARS-CoV-2 infection among HCP is important to inform additional prevention strategies for these essential workers.