The longitudinal study of subjective wellbeing and absenteeism of healthcare workers considering post-COVID condition and the COVID-19 pandemic toll

This longitudinal study shows the evolution of symptoms in SARS-CoV-2 positive and negative individuals up to two years after the start of the COVID-19 pandemic. Healthcare workers have an increasing prevalence of symptoms including fatigue, headache, insomnia, cognitive impairment, stress, burnout, and pain with overall no improvement in symptoms among SARS-CoV-2 positive individuals, and a differentially larger increase in symptoms in SARS-CoV-2 negative individuals driving the increase in overall prevalence.

The prevalence of symptoms increased in healthcare workers compared to results shown previously¹⁶ and to the general population¹⁹. In a previous study using the same source population, results showed fatigue in 25.5% of healthcare workers, headache in 10.0%, insomnia in 6.2%, cognitive impairment in 7.9%, stress and burnout in 7.1% of cases¹⁶. Comparatively, individuals in the general population were shown to suffer less than healthcare workers^16,19, and the current results show an even larger gap between the two groups. This underlines the differential impact of the pandemic on healthcare workers whether through direct effects (SARS-CoV-2 infection) or indirect effects (pandemic toll, work-related reasons).

SARS-CoV-2 positive individuals had more symptoms than SARS-CoV-2 negative individuals at baseline, and the prevalence of symptoms in SARS-CoV-2 positive individuals remained elevated at follow-up. SARS-CoV-2 positive individuals attributed their symptoms to personal reasons and the pandemic in general, and 19.7% of them attributed their absence from work to post-COVID symptoms (data not shown). Post-COVID condition remains a real concern for healthcare workers and the population in general, with the risk of post-acute sequelae increasing with reinfection²⁰. Treatment options and up-to-date vaccination are some of the suggested solutions^{20,21,22,23,24}, and this topic has now opened the page to post-acute infection syndromes in general¹⁵. Some of the postulated hypotheses so far are a dysregulation of the immune system, a persistent viral infection, or microclots²⁴. A better understanding of the underlying mechanisms is needed with hopefully more and better solutions to come²³.

SARS-CoV-2 negative individuals had a significantly larger increase in their symptoms between baseline and follow-up. This shows that those that were not infected might have suffered increasingly more from a work-related burden and the pandemic in general. Previous results from the same source population showed that 21.4% of SARS-CoV-2 negative individuals had fatigue, 7.8% headache, 5.3% insomnia, 4.6% cognitive impairment, and 6.3% stress/burnout¹⁶. Additionally, in another study, 3.1% of SARS-CoV-2 negative individuals in the general population suffered from fatigue at 12–16 months after the beginning of the pandemic, 1.7% suffered from headache, 2.7% insomnia, 2.5% cognitive impairment, and 1.4% suffered from stress/burnout¹⁹. While the results cannot be directly compared, there seems to be a higher prevalence of overall symptoms in healthcare workers compared to the general population confirming pre-pandemic studies showing high levels of fatigue and burnout in healthcare workers^25,26, and potentially warning against an acceleration of this phenomenon with the COVID-19 pandemic.

When considering functional capacity, 12.7% of participants reported functional impairment at baseline compared to 23.9% at follow-up. This increase was mainly driven by a large increase in functional impairment in SARS-CoV-2 negative individuals (6.3% at baseline, 24.1% at follow-up), while the prevalence of functional impairment remained elevated in SARS-CoV-2 positive individuals (29.7% at baseline, compared to 23.3% at follow-up). The increase in functional impairment was seen in all domains of life (professional, social, and family). Similarly, the physical and mental component scores on the SF-12 quality of life scale showed a decrease in both domains, further underlining the impact of the COVID-19 pandemic on healthcare workers. Days of absenteeism, initially seen mainly in the SARS-CoV-2 positive group shifted at follow-up to include absenteeism in both SARS-CoV-2 positive and negative individuals. Participants reported personal reasons, the pandemic in general and the lack in recovery time as some of the primary reasons for their symptoms. This might be due to the added burden that healthcare workers had to endure, while some colleagues were absent for COVID-19 or other reasons. The extra burden and functional impairment need to be addressed, especially with increasing absenteeism, potentially transferring costs onto the remaining staff.

The high risk of burnout was mentioned early on during the pandemic^7,8,9, and experts cautioned against this. Transversal studies looked into the prevalence of post-COVID symptoms^12,13,14,16, as well as psychological distress in healthcare workers^13,14 independently of SARS-CoV-2 infection, and experts sounded the alarm on the state of well-being of staff “Clinicians heal thyself”¹⁸. Related works showed that a potentially considerable proportion of healthcare workers were exposed to SARS-CoV-2, with an increased relative risk related to personal protective equipment, the workplace setting, contacts, and testing¹⁴. Healthcare workers who had even mild cases of COVID-19 were at risk of developing persistent symptoms¹². In the study by Havervall et al., 15% of seropositive healthcare workers reported at least 1 moderate to severe symptom lasting for at least 8 months compared to 3% of seronegative healthcare workers (RR 4.4 [95% CI 2.9–6.7])¹². Additionally, related works reported the potential impact of the pandemic on healthcare workers, with a high prevalence of depression, anxiety and post-traumatic stress disorder²⁷. A systematic review and meta-analysis including 65 studies conducted across 21 countries between December 2019 and August 2020, showed a pooled 22.1% prevalence of anxiety, 21.7% prevalence of depression of 21.7%, and 21.5% prevalence of post-traumatic stress disorder (PTSD)²⁷. Another systematic review and meta-analysis including 31 studies indicated a 30% prevalence of anxiety, 31.1% prevalence of depression, 31.4% prevalence of psycho-traumatic disorders, and 44.0% prevalence of sleep disorders²⁸. This last study attempted to examine the effect of time suggesting an increase in the prevalence of sleep disorders with time. The study results were heterogenous and did not show other significant effects of time on the other outcomes²⁸. In comparison, this present study looked into the longitudinal aspect of the evolution of symptoms in both SARS-CoV-2 positive and negative individuals, considering the effect of post-COVID condition. This present study showed an accelerated worsening of physical health, mental health, functional capacity and overall quality of life in healthcare workers. The longitudinal evolution and increase in the prevalence of symptoms were attributed to post-COVID condition as well as the differential impact of the pandemic on SARS-CoV-2 negative individuals. Of note, most studies examining the impact of the COVID-19 pandemic considered the early waves, and additional work was needed to show the protracted toll of the pandemic¹⁸.

Limitations include the self-reported nature of the follow-ups as well as the limited response rate. With a limited response rate and the nature of the follow-ups there is a potential risk of selection bias. Yet, at this stage, the information provided is valuable as no other data are available on the evolution of symptoms and the burden of the pandemic and post-COVID condition in healthcare workers. Additionally, the similarity of baseline characteristics between the participants in this longitudinal follow-up and the initial n = 3,083 participants who were invited to participate¹⁶, mitigates selection bias. Some calculations were underpowered when comparing symptoms in different groups at baseline and at follow-up. However, more power would have given a statistical significance that would not have been clinically relevant.

Healthcare workers are the backbone of the healthcare system. Their role in the lives of patients, the healthcare system and public health in general is essential. SARS-CoV-2 infection has brought acute absenteeism as well as post-COVID symptoms, and the COVID-19 pandemic has brought an extra burden of workload and stress on healthcare workers. Post-COVID caused absenteeism and might have transferred these costs on SARS-CoV-2 negative individuals, on top of the existing pandemic toll in general. Post-COVID is an opportunity to rethink post-acute infection syndromes in general¹⁵, and the COVID-19 pandemic should be the opportunity to reconsider the conditions of the healthcare workforce. Staff well-being should be an essential strategy at this stage. Looking into the details of absenteeism (trends per unit, department, position or other), and suggesting solution-oriented work schedules or predictability by building redundancy has now become an emergency to deal with post-COVID and the pandemic burden in general.