Access to personal protective equipment in exposed healthcare workers and COVID-19 illness, severity, symptoms and duration: a population-based case-control study in six countries

BACKGROUND: Despite the widespread implementation of personal protective equipment (PPE) in the COVID-19 pandemic, there are surprisingly few studies of its impact. To assess the risk, severity and duration of COVID-19 in relation to access to PPE in at-risk healthcare workers (HCWs). METHODS: From 17 July to 25 September 2020, at-risk physicians and nurses registered as a provider in the Survey Healthcare Globus network in six countries (the UK, Germany, France, Italy, Spain and USA) were identified based on adult medical specialties with frequent and close contact with patients with COVID-19. Exposed HCWs completed a detailed questionnaire including demographics, medical, social and lifestyle factors. COVID-19 cases were defined as COVID-19 symptoms (fever, cough, fatigue, loss of taste or smell) and asymptomatic COVID-19 test positive cases. RESULTS: Among 2884 exposed HCWs (94% medical doctors and 6% nurses or physician assistants), there were 514 reports of COVID-19 illness and 54 asymptomatic COVID-19 test positive cases. COVID-19 risk was significantly associated with close contact with COVID-19 cases both inside and outside the workplace, number of work shifts and hours worked per week. Limited access to PPE compared with access to a fresh mask, gown and gloves and face shield with each patient encounter was associated with a 2.2-fold to 22-fold increased risk of reporting COVID-19 symptoms (p<0.0001), a pattern consistent across all six countries. Further, limited access to PPE was associated with symptom duration greater than 2 weeks and the presence of moderate to severe symptoms such as difficulty breathing, abnormal chest X-ray, low oxygen saturations, respiratory distress and acute lung injury. CONCLUSION: In six countries, less access to PPE was strongly associated with both increased risk of reporting COVID-19 illness as well as more prolonged and severe disease course in frontline HCWs.