Mortality of health workers during the COVID-19 pandemic

MORTALITY OF HEALTH WORKERS DURING THE COVID-19 PANDEMIC

Today, there is enough evidence that the COVID-19 pandemic most severely affects countries with socially specific contexts [1],[2], and in them, marginalized citizens, population groups with the least economic resources available, as well as racial and ethnic minorities [3],[4],[5],[6]. This pandemic has also been called the syndemic of interactions between the biological and social context [7] that can reflect the logistical preparedness of a country for crisis [8], which is why communities differ with respect to susceptibility to disease and dying. Due to more than a threefold risk of infection, as compared to the general population [9], health workers have, without doubt, borne the greatest burden of the fight with the COVID-19 pandemic.

In the first year of the pandemic, in a prominent journal, experts warned about the need for preventing a ‘parallel pandemic’ amongst health workers [10]. The collective opinion of the activists of The National Academies of Sciences, Engineering, and Medicine is that there is a necessity for comprehensive measuring of the crisis that is transferred onto the healthcare workforce, as well the necessity of reporting on the mortality in that population [11]. Indicators of mortality are considered to be the soundest proof of the health status of the population, while the mortality of health workers, as one of the key resources of the healthcare system, reflects the vulnerability of existing capacities for maintaining and improving the health of the population.

It is important to note the fact that, during the first severe acute respiratory syndrome (SARS) epidemic in 2003, health workers made up a third of deceased worldwide [12]. In Liberia, between 2014 and 2016, 0.11% of the general population, and more than 8% of the healthcare workforce died due to the Ebola virus infection [13]. At the time, similar disproportion was also registered in other countries of West Africa affected by the Ebola epidemic, such as Sierra Leone and Guinea [13].

According to meta-analyses [14],[15] carried out in the period before the COVID-19 pandemic, the suicide rate in doctors was higher than the suicide rate in the general population, which is why it is important to analyze whether this rate has changed in the context of increased workload required of the healthcare employees during the pandemic, which placed additional physical and emotional pressure on their health.

In order to assess direct and indirect effects of COVID-19 on health workers, it is necessary to assemble data on the number of deceased health workers from the registers recording mortality resulting from work-related exposure to the coronavirus, from registers recording mortality that can be connected to conditions such as fatigue, stress, and burnout during COVID-19, as well as from registers recording suicides in the period since the pandemic was declared.

In September 2021, the World Health Organization (WHO) published its first working paper on the impact of COVID-19 on health workers [16], where the underregistration of health worker mortality is highlighted. Amongst the factors which need to be analyzed in the context of the strength of their connection to the elevated mortality of health workers during the COVID-19 pandemic, are the following: availability, distribution, and reallocation/relocation of health workers, work pressure, absenteeism, contracting the infection, stress, burnout, other mental disorders, use of personal protective equipment, vaccination, psychological support, quarantine, self-isolation, incentives, stigmatization, discrimination, as well as family circumstances. These factors reflect lasting weaknesses of healthcare systems in some countries and were key obstructors for intensive mobilization of staff necessary in the fight against the pandemic.

Reporting on the precise number of COVID-related deaths is a great challenge for all countries [8]. This is best illustrated by the fact that, in May 2021, the WHO reported only 6,643 registered COVID-19 related deaths amongst health workers, which is many times less than 115,493 deaths, which data was obtained through estimation based on the ratio of health workers in the population (the ratio of the healthcare workforce spans from 3%, in underdeveloped countries, to 3% – 7%, in highly developed countries) and in the population of the number of deaths due to COVID-19, i.e., on the basis of assessments made by the American Institute for Health Metrics and Evaluation, founded on global COVID-19 related mortality, which amounted to 179,500 deceased health workers [16]. Other estimations on the number of deaths caused by COVID-19 in the health sector are more or less consistent, and amount to 83,000 – 133,000 deaths, which data were obtained by source triangulation (by applying the method of indirect standardization), i.e., 80,000 – 160,000 deaths, which are data estimated by PCR related meta-analysis [16].

There are numerous reasons for the discrepancy in the numbers, including the public interest of patients using basic healthcare services without hesitation or fear. Due to the fact that COVID-19 circulates in the population, it is difficult to determine the source of infection for a deceased health worker. However, facts suggest that the COVID-19 infection is more frequent amongst health workers lacking appropriate personal protective equipment or those working in work environments lacking appropriate protocols.

To that effect, in order to estimate direct and indirect effects of COVID-19 on health workers, it is necessary to apply methodologically standardized tools to assemble data on deceased health workers from registers recording mortality caused by work-related exposure to the coronavirus, registers recording mortality that can be linked to conditions such as fatigue, stress, and burnout during the COVID-19 pandemic, and registers recording suicide from the time that the pandemic was declared.

The most commonly stated reason for underregistration is the lack of routine reporting on the number of deaths, by profession. In the death certificates, information on the occupation of the deceased is seldom recorded, and it often occurs that the occupation which the deceased had performed for the longest period of time is recorded (especially for women) rather than the occupation performed immediately before death [17]. The information as to who is recorded under the category of health or care worker is also important. The question remains as to whether mortality is recorded for all employees in a healthcare facility (including cleaners, for instance) or whether it is reported only for the deaths of medical staff. Additionally, the way of identifying the corona virus in people who die later, may offer a false picture, as it is known that the sensitivity of its detection with the help of a nasopharyngeal swab may reach up to 79%, with double testing [18].

It is equally important to state whether data from all health institutions are being entered into the register or only from those health facilities that are a part of the system for treating COVID-19 patients. It is possible to expect underregistration of the number of deceased health sector employees if there is an absence of an international or national framework for the collection, recording, and reporting of COVID-19 related mortality and morbidity data regarding health and care workers. Inconsistency of steps taken in that direction decrease the ability of the authorities to meaningfully compare and carry out representative combined analyses and reach correct conclusions on the extent of the mortality of health and care workers during the COVID-19 pandemic.

The completeness of reporting is also affected by the capacities for testing and monitoring infection and death. Depending on the the available capacities, it is possible for the registration of the deceased to vary. The same also applies to data on the staff and beneficiaries of retirement homes and facilities for long-term care. Namely, it has happened that only those health and care workers, i.e., citizens, in whom the COVID-19 infection had been confirmed though a positive SARSCoV-2 test or who had died while being treated for COVID-19 in a healthcare facility, were registered.

At present, the exact extent of COVID-related mortality of health and care workers remains unknown, due to the incidence of such deaths amongst untested persons, amongst deaths outside of healthcare facilities, and amongst the deceased for whom the cause of death remained unidentified and was coded with so called garbage codes [19]. These deaths are covered by indicators of crude mortality, but it is necessary to calculate the COVID-19-related burden of mortality of the healthcare system.

Bearing in mind that we are now in the third year of the pandemic, the concern for the health of health and care workers is understandable, which is why the matter of the exact number of deaths in this population which can be attributed to COVID-19 has become an important policy and public health issue which needs to be dealt with, not only in order to precisely identify the mortality of health and care workers, but also in order to stimulate investment into their safety and the sustainability of the healthcare system, in the context of high-risk emergency situations.