This study shows that the risk of hospitalization and death due to COVID-19 varies among occupational cohorts of Peruvian healthcare workers. It is also noted that non-occupational factors have a significant impact on the probability of SARS-CoV-2 infection-related complications.
Death from COVID-19 represents the main adverse outcome of SARS-CoV-2 infection. The case fatality rate (CFR) in healthcare workers in Peru infected by SARS-CoV-2 found in our study was 1.7%, which is higher than that CFR reported by Gholami [21], who found mortality of 1.5% in a meta-analysis of 28 studies which grouped healthcare workers from five countries (China, USA, Netherlands, Italy, Germany, and Spain). A second meta-analysis by Gómez-Ochoa [22] that included 97 studies carried out in healthcare workers in the USA, countries of Asia and Europe, found that mortality from COVID-19 in infected workers was 0.5%, notably lower than that reported for Peruvian healthcare workers. Our results were also higher than mortality from COVID-19 obtained by Bandyopadhyay [23] in a systematic review that included studies up to May 2020 where global mortality among healthcare workers was 0.92%. However, the regional analysis shows similar results since, in Americas, 2.0% of healthcare workers with COVID-19 had died, which represents an intermediate situation among regions with low mortality such as Europe (0.6%) and other with greater mortality such as Eastern Mediterranean (5.7%) and Southeast Asia (3.1%). The countries that reported the highest number of deaths from COVID-19 in Bandyopadhyay’s study were Italy, USA, United Kingdom, Russia, Iran, Ecuador, Indonesia, Mexico, Spain, Philippines, China, Turkey and France. Gholami, Gomez-Ochoa, as well as Bandyopadhyay, included studies that reported the CFR of healthcare workers without carrying out comparisons with the general public.
It should be emphasized that the meta-analysis conducted by Gholami included 119,883 healthcare workers infected with SARS-CoV-2, whereas the meta-analysis conducted by Gómez-Ochoa contained 96,813, and the Peruvian health worker cohort alone had 90,672 infected healthcare workers. This shows the great impact caused by the pandemic among Peruvian healthcare workers in absolute terms. Some reasons for this high risk among Peruvian healthcare workers may be the high workload, continuous exposure, and lack of personal protective equipment (especially at the beginning of the pandemic), but also because of the informal nature of work and the worsening labor conditions observed in many countries before the pandemic, particularly in low- and middle-income countries [16, 24,25,26].
The results of our research show that the cohort with the highest risk of death from COVID-19 was that of technicians and health assistants, who had a 25.6% higher risk of dying than other healthcare workers. One possible explanation is that the cohort of technicians and health assistants includes technicians and auxiliaries in nursing, laboratory, dental, pharmacy, nutrition, radiology, rehabilitation, and physical therapy. This occupational cohort, particularly nursing technicians, who collaborate with patient care in consulting rooms, emergencies, hospitalization (including feeding, cleaning, mobility, and patient oxygen administration, among others), as well as radiology and laboratory technicians, have close contact with patients while taking X-rays (radiology technicians) or while drawing blood samples and/or manipulation of biological samples for their analysis (laboratory technicians) [27]. This leads to a higher viral load exposure and would explain their greater overall risk [28,29,30]. The bibliographic review does not find studies with the category of technicians and health assistants like that defined in Peru, but an approximation is found in the cohort of Mexican healthcare workers that finds a higher risk of death in medical assistants, laboratory technicians, pharmacy, and radiology staff [31].
The case of the doctors is particular because they present an occupational risk of dying similar to other healthcare workers; however, they are the ones with the highest unadjusted mortality (2.6%). This is consistent with the results of a systematic review [23] that found that the group with the highest mortality among infected healthcare workers was doctors (6.0%). One possible explanation for this phenomenon is that in Peru, the doctors cohort is the one with the highest proportion of older adults and comorbidities compared to the other cohorts of healthcare workers, which could explain their higher mortality from COVID-19, regardless of their occupational risk. Another possible explanation is that doctors have performed diagnostic tests less frequently in the presence of mild disease and more frequently in the presence of moderate and severe disease, which could have biased the results towards greater lethality [32].
It is observed that non-occupational risk factors lead to a higher risk of death from COVID-19 than occupational factors, the main one being older adults; thus, older adults have about nine times the risk of dying than those under 65 years of age. Male gender, as well as the presence of comorbidities, are risk factors for death from COVID-19. This agrees with other studies carried out on healthcare workers, such as the one carried out by Ferland in 9 European countries [33] and the one by Robles-Pérez in Mexico [30]. The main comorbidities identified were cardiovascular disease, obesity, bronchial asthma, and diabetes mellitus, representing 8.9% of the total healthcare workers infected in this study. These values are similar to those found in the meta-analysis by Gómez-Ochoa, who found that the prevalence of comorbidities was 7% (95% CI: 4–10%) [22].
The trend of COVID-19 mortality among healthcare professionals is comparable to that of the general Peruvian population; however, this correlation breaks down following the introduction of immunization. Thus, the trend in mortality reduced following vaccination, whereas the tendency in the general population was to climb until reaching its peak during the second wave of the pandemic. This confirms the results of Escobar-Agreda [34], who found a higher survival rate in Peruvian healthcare workers in 2021 after the start of vaccination. This would show the effectiveness of vaccination since, without it, the number of deaths from COVID-19 would likely have increased, similar to the Peruvian population.
In the instance of COVID-19 hospitalizations, doctors had a 72.0% higher risk than other healthcare workers, whereas technicians and health assistants had a 10.7% higher risk of hospitalization. The fact that technicians and health assistants have the highest risk of mortality, but a modestly increased chance of hospitalization may indicate inequity in access to hospitals, which may also explain the greater risk of COVID-19-related deaths in this cohort. It is possible that the efforts of the professional associations in obtaining air transport for their members and the coordination for their referrals, as is the case of the Peruvian Medical Association, have contributed to the timely hospitalization of its members, reducing their mortality [35]. Unfortunately, there is no school, society, or association of technicians and health assistants support in Peru that would ensure the timely hospitalization of its members, which may have put them at a disadvantage with other occupations that do have professional associations. Although it is true that our bibliographic review has not found studies that show inequities in access to hospitalization services in occupational groups of healthcare workers, this is possible since there is evidence of inequities for hospitalization in more disadvantaged or invisible groups during the SARS-CoV-2 pandemic [36, 37].
Probable reinfection was documented in 1.7% of healthcare workers. It was observed that the risk of probable reinfection was similar in the cohorts of healthcare workers studied; however, other occupational factors were relevant. The greatest risk of probable reinfection was found in those who worked outside the capital, particularly in establishments in the Amazon and the Andean region; a higher risk was also documented in those who had direct contact with COVID-19 cases in their workplace. It is possible that the greater limitations existing in the establishments of the MINSA/GORE, PNP/FAA, and outside the capital of Peru have contributed to the reinfection of healthcare workers during the pandemic’s greatest activity, moments in which there have been documented deficit of personal protective equipment, as well as greater exposure to COVID-19 due to the overwhelming patient demand [17, 34, 38,39,40].
Our study was conducted utilizing secondary sources, so it is probable that there are quality issues with data and some degree underreporting of adverse outcomes of SARS-CoV-2 infection; nevertheless, the fact that we considered many sources of information, as well as the verification and investigation of deaths, somewhat compensates for these limitations. Similarly, the data utilized could not identify which healthcare staff provided in-person care and which worked remotely nor measure the impact of the personal protective equipment deficit on infected healthcare worker hospitalization and death. Because the identification of SARS-CoV-2 lineages is not routinely performed in all cases of infection in Peru, it was not possible to confirm the reinfection of healthcare workers; therefore, probable reinfection was investigated. Lastly, our study did not have a control group made up of healthcare workers not infected by SARS-CoV-2 to compare our results, since, aside from the SINADEF base, the other databases used only provided data of infected people.
Despite these constraints, we believe that the acquired results are similar and comparable to what was observed in Peruvian healthcare workers during the pandemic.