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What risk factors are associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) seropositivity among health care personnel (HCP) inside and outside the workplace?
In this cross-sectional study of 24 749 HCP in 3 US states, contact with an individual with known coronavirus disease 2019 (COVID-19) exposure outside the workplace was the strongest risk factor associated with SARS-CoV-2 seropositivity, along with living in a zip code with higher COVID-19 incidence. None of the assessed workplace factors were associated with seropositivity.
In this study, most risk factors associated with SARS-CoV-2 infection among HCP were outside the workplace, suggesting that current infection prevention strategies in health care are effective in preventing patient-to-HCP transmission in the workplace.
Risks for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among health care personnel (HCP) are unclear.
To evaluate the risk factors associated with SARS-CoV-2 seropositivity among HCP with the a priori hypothesis that community exposure but not health care exposure was associated with seropositivity.
Design, Setting, and Participants
This cross-sectional study was conducted among volunteer HCP at 4 large health care systems in 3 US states. Sites shared deidentified data sets, including previously collected serology results, questionnaire results on community and workplace exposures at the time of serology, and 3-digit residential zip code prefix of HCP. Site-specific responses were mapped to a common metadata set. Residential weekly coronavirus disease 2019 (COVID-19) cumulative incidence was calculated from state-based COVID-19 case and census data.
Model variables included demographic (age, race, sex, ethnicity), community (known COVID-19 contact, COVID-19 cumulative incidence by 3-digit zip code prefix), and health care (workplace, job role, COVID-19 patient contact) factors.
Main Outcome and Measures
The main outcome was SARS-CoV-2 seropositivity. Risk factors for seropositivity were estimated using a mixed-effects logistic regression model with a random intercept to account for clustering by site.
Among 24 749 HCP, most were younger than 50 years (17 233 [69.6%]), were women (19 361 [78.2%]), were White individuals (15 157 [61.2%]), and reported workplace contact with patients with COVID-19 (12 413 [50.2%]). Many HCP worked in the inpatient setting (8893 [35.9%]) and were nurses (7830 [31.6%]). Cumulative incidence of COVID-19 per 10 000 in the community up to 1 week prior to serology testing ranged from 8.2 to 275.6; 20 072 HCP (81.1%) reported no COVID-19 contact in the community. Seropositivity was 4.4% (95% CI, 4.1%-4.6%; 1080 HCP) overall. In multivariable analysis, community COVID-19 contact and community COVID-19 cumulative incidence were associated with seropositivity (community contact: adjusted odds ratio [aOR], 3.5; 95% CI, 2.9-4.1; community cumulative incidence: aOR, 1.8; 95% CI, 1.3-2.6). No assessed workplace factors were associated with seropositivity, including nurse job role (aOR, 1.1; 95% CI, 0.9-1.3), working in the emergency department (aOR, 1.0; 95% CI, 0.8-1.3), or workplace contact with patients with COVID-19 (aOR, 1.1; 95% CI, 0.9-1.3).
Conclusions and Relevance
In this cross-sectional study of US HCP in 3 states, community exposures were associated with seropositivity to SARS-CoV-2, but workplace factors, including workplace role, environment, or contact with patients with known COVID-19, were not. These findings provide reassurance that current infection prevention practices in diverse health care settings are effective in preventing transmission of SARS-CoV-2 from patients to HCP.
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Accepted for Publication: January 19, 2021.
Published: March 10, 2021. doi:10.1001/jamanetworkopen.2021.1283
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Jacob JT et al. JAMA Network Open.
Corresponding Author: Jesse T. Jacob, MD, School of Medicine, Emory University, 550 Peachtree St NE, Orr Bldg #1018, Atlanta, GA 30308 (firstname.lastname@example.org).
Author Contributions: Drs Jacob and Baker had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs Jacob and Baker contributed equally to this work.
Concept and design: Jacob, Baker, Fridkin, Lopman, Steinberg, Christenson, King, Schrank, Hayden, Lin, Milstone, C. Rock, Harris.
Acquisition, analysis, or interpretation of data: Jacob, Baker, Fridkin, Lopman, Steinberg, Leekha, O’Hara, P. Rock, Schrank, Hayden, Hota, Lin, Stein, Caturegli, Milstone, C. Rock, Voskertchian, Reddy, Harris.
Drafting of the manuscript: Jacob, Baker, Fridkin, Christenson, P. Rock, Harris.
Critical revision of the manuscript for important intellectual content: Jacob, Baker, Fridkin, Lopman, Steinberg, King, Leekha, O’Hara, Schrank, Hayden, Hota, Lin, Stein, Caturegli, Milstone, C. Rock, Voskertchian, Reddy, Harris.
Statistical analysis: Baker, O’Hara, Hota, Caturegli.
Obtained funding: Lopman, Hayden, Milstone, C. Rock, Harris.
Administrative, technical, or material support: Baker, Steinberg, Christenson, King, Leekha, O’Hara, P. Rock, Schrank, Hayden, Hota, Lin, Stein, C. Rock, Voskertchian, Reddy.
Supervision: Jacob, Fridkin, Lopman, Steinberg, Leekha, P. Rock, Stein, C. Rock.
Conflict of Interest Disclosures: Dr Jacob reported receiving grants from the National Institutes of Health outside the submitted work. Dr Baker reported receiving personal fees from the World Health Organization outside the submitted work. Dr Lopman reported receiving grants and personal fees from Takeda Pharmaceutical and receiving personal fees from the World Health Organization outside the submitted work. Dr Christenson reported receiving personal fees from Siemens Healthineers, Quidel, Roche Diagnostics, Beckman-Coulter, Sphingotech, PixCell Medical, and Becton Dickinson outside the submitted work. Dr King reported receiving personal fees from UpToDate outside the submitted work. Dr P. Rock reported receiving personal fees from the American Board of Anesthesiology and Johns Hopkins University and receiving grants from Zygood and the National Institutes of Health outside the submitted work. Dr Hayden reported serving on the clinical adjudication panel for Sanofi and receiving grants from Abbott Molecular outside the submitted work. Dr Milstone reported receiving grants from Merck, the Agency for Healthcare Research and Quality, and the National Institutes of Health outside the submitted work. No other disclosures were reported.
Funding/Support: This study was in part supported by the US Centers for Disease Control and Prevention Prevention Epicenters Program and grant number T32AI074492 from the National Institute of Allergy and Infectious Disease to Dr Baker.
Role of the Funder/Sponsor: The US Centers for Disease Control and Prevention was involved in the interpretation of the data; and preparation, review, and approval of the manuscript. It was not involved in design of the study; conduct of the study, collection, analysis or management of the data; or the decision to submit the manuscript for publication.
Disclaimer: The findings and conclusion in this report are those of the authors and do not necessarily represent the official position of the US Centers for Disease Control and Prevention.
Additional Contributions: We thank our colleagues in the state health departments for data acquisition of the zip code–based data on coronavirus disease 2019 cases: Chinyere Alu, MPH, and Dejan Jovanov, BS, Illinois; David Blythe, MD, MPH, Maryland; and Laura Edison, DVM, Georgia. For data management and analytics, we thank Carly Adams, MPH (Emory University); Elizabeth Overton, MSPH (Emory Healthcare); Ellen C. Benson, MPH, Jinal Makhija, MBBS, MPH, Lahari Thotapalli, MPH (Rush University Medical Center); and Avi Gadala, MS (Johns Hopkins University). For laboratory work and guidance, we thank John D. Roback, MD (Emory University), and Kristin Mullins, PhD (University of Maryland). For local study design, we thank Michael Schoeny, PhD, and Latania K. Logan, MD, MSPH (Rush University Medical Center). For manuscript review and local study design, we thank Robert A. Weinstein, MD (Rush University Medical Center). For study management and oversight, we thank Danielle Koontz, MAA, Emily Egbert, MPH, B. Mark Landrum, MD, Pooja U. Gupta, MD, Morgan Katz, MD, MHS, and Sarojini Qasba, MD, MPH (Johns Hopkins University). For helping to determine the infection prevention timeline, Kari Love, RN, MS (Emory Healthcare). None of these individuals were compensated for their work in this study. Finally, we thank all health care personnel, especially our study participants, who have been working tirelessly to deliver safe and compassionate care to patients during this pandemic.
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