Slipshod data collection and poor follow-up defeat efforts to track infections and mitigate risk.


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More than a year after the first SARS-CoV-2 infection was identified in the United States, there is no reliable count of COVID-19 cases or deaths in nurses and other health care workers. The COVID Data Tracker maintained by the Centers for Disease Control and Prevention (CDC) reported 389,380 health care worker infections and 1,332 deaths as of February 1. Yet, as far back as November of last year, the Centers for Medicare and Medicaid Services (CMS) reported 1,162 staff deaths in U.S. long-term care facilities alone. Still another list, maintained by the Guardian and Kaiser Health News, has counted 3,258 health care worker deaths, 503 of them among nurses.

Figure. Image courte... - Click to enlarge in new windowFigure. Image courtesy of Statista /

These disparate numbers raise questions about both counting methodology and the definition of "health care worker" used by government and private sector organizations tracking COVID-19. And, experts say, even the largest reported numbers almost certainly represent gross undercounting of the toll on health care workers. Kent Sepkowitz, an infectious disease specialist at Memorial Sloan Kettering Cancer Center in New York City, told the news organization ProPublica that based on past epidemics and state data, health care workers would be expected to make up an estimated 5% to 15% of COVID-19 infections in the United States. With almost 20 million U.S. cases, that would translate to at least 1 million cases among health care workers, and many thousands of deaths.


No standardized reporting. Throughout the pandemic, there has been no national reporting framework for health care worker cases and deaths. Protocols for collecting and reporting this information vary widely across states. The CMS has required nursing homes to report COVID-19 infections and deaths in patients and staff only since May 2020. Similarly, the CDC's case report form did not include occupational categories (such as RN or dietician or custodian) and workplace settings of infected health care workers. Even when these categories were added last May, the forms that have been submitted since are often incomplete. In its review of case reports from February to July of 2020, the CDC found that only 22% included information on health care worker status.


Compounding these data gaps is a scarcity of COVID-19 test kits in the United States combined with inconsistent testing protocols among states and health care organizations, which has the effect of skewing case and death counts. Many health care facilities test symptomatic staff only, and in some cases, even these workers have been sent home to recover without being tested.


Why are data on health care worker cases and deaths important? Nurses, in close contact with both symptomatic and asymptomatic patients during outbreaks, are disproportionately affected by any new infectious disease. Those who fall ill provide early clues about disease transmission, morbidity, and mortality.


As Christopher R. Friese, a professor at the University of Michigan Schools of Nursing and Public Health, told AJN, "Where we have an atypical outbreak like this, the default response should be to systematically track health care workers. . . . If we had known earlier on [in this pandemic], if we had a clearer sense of health care worker infections and deaths, we would have had a better signal as to what control measures were more effective." Friese emphasized that an earlier understanding of disease epidemiology is not the only reason to care about accurate mortality data. After so many fatalities, he said, "[nursing leaders] need to begin to think how we, at the right time and place, . . . pause and commemorate those that we've lost."


Undercounting health care worker deaths also weakens arguments for better personal protective equipment (PPE). Shortages of clinical-grade N95 masks and other protective gear have persisted in the United States since the pandemic began. Accurate and comprehensive data collection, including the conditions under which health care workers became infected (many nurses have reported being forced to reuse masks for days due to supply shortages), could help make the case for improved production as well as the creation of PPE stockpiles for future viral threats.


A report last December from the National Academies of Sciences, Engineering, and Medicine (see http://www.nap.edu/read/26018/chapter/1) emphasized the need for a "robust national data reporting system" to better understand the causes of all health care worker deaths during the COVID-19 pandemic. It called for a count that includes deaths from occupational exposure to the virus, conditions related to pandemic stress and burnout, and suicide, along with details on where infections occurred and the circumstances or interventions that may have raised or lowered the risks to workers.-Betsy Todd, MPH, RN