Vulnerability of nurse and physicians with COVID‐19: Monitoring and surveillance needed

SARS‐CoV‐2, the virus that causes COVID‐19, is wreaking havoc around the world. This unprecedented pandemic has led to illness, death, and economic destruction. The pandemic has challenged health care systems globally for a range of reasons. In developed economies the focus on non‐communicable diseases rather than infectious diseases have caught us short. A period of complacency and a lack of focus on potential pandemics has meant that documented shortages of personnel, workforce and equipment has limited healthcare delivery.


| INTRODUC TI ON
SARS-CoV-2, the virus that causes COVID-19, is wreaking havoc around the world. This unprecedented pandemic has led to illness, death and economic destruction. The pandemic has challenged healthcare systems globally for a range of reasons. In developed economies, the focus on noncommunicable diseases rather than infectious diseases has caught us short. A period of complacency and a lack of focus on potential pandemics have meant that documented shortages of personnel, workforce and equipment have limited healthcare delivery. The lack of access to personal protective commitment (PPE), lack of training and workforce shortages have exposed the vulnerability of healthcare workers (Daly, Jackson, Anders, & Davidson, 2020). The COVID-19 pandemic is a highly fluid and dynamic with new information emerging daily.
Nurses are the only profession that spends a considerable amount of time in providing one-on-one care to COVID-19 patients.
COVID-19 is highly contagious, and anyone providing direct health care to an affected patient is a high risk of being infected. Though there is a lot we do not yet fully understand, such as correlations between viral load and risk and severity of infection, we do know that nurses are at considerable risk of becoming infected.
The actual number of healthcare workers infected with the COVID-19 virus across the world is unknown. In this editorial, we aim to firstly provide an overview of some of the known demographic characteristics of physicians and nurses who are known to have died from COVID-19, and secondly, to explore factors that may have contributed to mortality and most importantly cast a spotlight of an area of important emphasis. To date, reports have focused on recognition and mourning, not on the investigation of workplace deaths and identification of root causes. In fact, in the United States, the Guardian and Kaiser Health News (2020) note that many cases have been "shrouded in secrecy" and they have launched a site, Lost on the Frontline to bring visibility to this critical issue. This approach limits our capacity to develop resilient systems to protect healthcare workers nor recognise robust systems who have treated many patients with COVID-19 and had no staff deaths.

| WHERE IS THE DATA?
There is no aggregated database at a global level accurately tracking deaths from healthcare workers, and this is problematic for many reasons but importantly it prevents us from implementing strategic models for worker protection. The methods used in this report rely upon published data from various sources including governmental health websites. Governmental websites are inconsistent in the data that they have been able to collect, so for this editorial, we also used data from data compiled by health-related publications. The validity and reliability of this information are unknown, and reports suggest that around the world there has been an under-reporting of all cases of COVID-19. Self-reported data in the public domain are assumed to be relatively accurate, and many cases identified are linked to obituaries. In examining the existing data, we have attempted to compile information from these sources, and such serves as the foundation for our analysis. The analysis only uses information regarding physicians' and nurses' deaths due to the virus although we acknowledge that other health workers have also died because of the COVID-19 pandemic.
To understand the magnitude of mortality effect by profession caused by COVID-19, we performed regression analysis on the population of fatalities to determine whether some professions were safer off than others, stratified by seven countries (United States of America (USA), Italy, Spain, France, Brazil, United Kingdom (UK) and Australia). The professions examined were medical doctors (MD), registered nurses (RN) and licensed practical nurses (LPN). Logistic regression was used to study the differences in mortality rates between professions. We analysed results at the 95% confidence level, stratified by country where the deaths of profession occurred, as well as adjusting for age and sex of the individual who passed while providing professional services to COVID-19 patients.

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EDITORIAL report, there were no data on the number of deaths by profession.
Thus, it is unknown how many physicians and nurses who were working primarily with COVID-19-infected patients are among those who died. These data are quite limited in that it is only a snapshot of self-reported information. The extent of the death rate of healthcare workers may well be much higher than that reported in the CDC report. All employers are required to notify Occupational Safety and Health Administration when an employee is killed on the job or suffers a work-related hospitalisation. COVID-19 is included in this framework but it is likely interpretation of attribution is broad, and it may be difficult to be sure whether the virus is community acquired or infection is directly workplace related.
Medscape medical news has a website for the self-report of healthcare workers who have died of COVID-19. The in-memoriam page has self-reported tests of healthcare workers from around the world. As of 28 April, the number of deaths in the USA from this database was reported at 71. Of those, 44 were registered nurses and 25 were physicians. The reporting of deaths on the memorial page is ongoing, and the deaths continue to rise (In Memoriam, 2020).
Using the Medscape self-report information for some of the hardest-hit countries with COVID-19, the self-report information provides some insight into the deaths in the USA, Italy, the UK, Brazil, Spain and France. The death of the Australian nurse was reported in the Australian media (Sakkal, 2020). Table 1 illustrates the death of nurses and physicians. While Table 1 provides a snapshot of the deaths, these data are limited and do not allow a conclusive statement. In further reviewing the data, Table 2   Missing age information was present in 44 cases. The age data tend to follow the general infection rate of the public. Most of the deaths were in those aged 50 years and older. The finding is congruent with the CDC report on age and deaths. They report that 97% of deaths in the general population are older than 45 years (National Center, 2020).
The regression analysis of mortality rates by profession and by country has provided useful insights into the higher-risk professions. Overall, nurses were associated with a significantly (p < .05) higher rate of death than physicians in Italy, Brazil, Spain and France (Table 4). The increased risk of nurse death relative to physician death in Spain exceeded an odds ratio of 50.0, and in France, nurse risk of death exceeds an odds ratio of 120.0. There were not significant differences in mortality between physicians and nurses in USA, UK or Australia. Licensed practical nurses did not have enough observed deaths in order to provide conclusive results in this analysis, which limited our analysis to a simple logistic regression (MD vs. RN mortality) as opposed to multinomial logistic regression (MD vs. RN vs. LPN).

| MODEL S OF INFEC TI ON CONTROL AND HE ALTH WORK ER V ULNER AB ILIT Y
MacIntyre and colleagues argue that many infection control procedures, which health workers follow, are driven primarily by concerns about patient safety (MacIntyre, Chughtai, Seale, Richards, & Davidson, 2015). Protecting patients from nosocomial infection and the protection, occupational health and safety of the healthcare worker, as well as preventing transmission of infections and patient safety, should be equally weighted. Beurhaus and colleagues report that many hospital-based registered nurses, non-hospitalbased registered nurses and physicians are 55 years of age or older (Buerhaus, Auerbach, & Staiger, 2020). The higher risk of  in older individuals and in particular those with chronic conditions has led to recommendations for those older than 60 years, to stay at home and practice social distancing to slow the spread of infection and help avoid overwhelming hospitals. However, we know that many nurses and physicians in this age group and with cardiovascular and other conditions are still going to work, increasing their vulnerability. Many stories of heroism and sacrifice have been presented in the media.

| OCCUPATIONAL HE ALTH , MONITORING AND SURVEILL AN CE
Occupational health services for all workers, irrespective of age, sex, nationality, type of employment, and size or location of workplace, has been a recommendation of the World Health Organization  (Fan et al., 2020). In the Emergency Response Framework, the WHO define an emergency as a situation that has an impact on the lives and well-being of a large number of people or a significant percentage of a population and requires substantial multisectoral assistance (WHO, 2018). There appears to be a disconnect in some organisations between the approaches of usual work and a crisis. Although some organisations increased preparedness following recent infectious disease outbreaks, this has not been consistent across healthcare systems and countries. Moreover, COVID-19 challenges many models of mandatory reporting where causation and attribution of the infectious source may not be clear. There are also hot spots of infection and death such as nursing homes where detailed forensic analysis is warranted (Davidson, Padula, Daly, & Jackson, 2020).

| WHAT THE S E DATA TELL US?
We recognise the many gaps in these data and methodological limitations but it is important to present this information, provide a voice to the voiceless and place this important issue front and centre. The highly dynamic nature of the COVID-19 pandemic means that the pictures provided by these data may change over time. But we hope this information will make countries take a deeper look at the well-being of their workforce. The percentage of deaths from healthcare workers compared to the general population is lower given they are using PPE to decrease the risk of exposure and have the skills to protect themselves.
The general population risk without social distancing could mean that 81% of the world population could be infected (Ferguson, 2020). The modelling for projecting the actual number has varied widely. The bottom line is the number of healthcare workers who potentially can be infected remains high-nurses are particularly vulnerable to COVID-19 mortality given the number of contact hours that they have with infected patients compared to physicians, and specific groups, such as anaesthetists, are at a higher risk in activities such as intubation. Given the urgent need for health care services in time of pandemic, the need to keep health workers well and uninfected is critical and efficient and effective models of prevention are vital.