Table 1

Studies included for risk of infection, mental health, skin injuries and headaches

Author and yearStudy designCountryExposureOutcome/ evaluation toolMain findingsQuality assessment
Centers for Disease Control and Prevention, USA, 20203Cross-sectional, quantitativeUSALaboratory confirmed contact with patients with COVID-19, n=9289 (Healthcare personnel)Infection prevalence among HCW, (assessed through laboratory testing)As of 9 April, 19% of all infected COVID-19 cases in the USA were HCW, median age was 42 years, death occurred more often among HCW aged >65, hospitalisation rate among HCW 8%–10%AXIS: 12/20
(some items not applicable due to descriptive census-like study)
Chu et al, 20204Retrospective case series, quantitativeChinaWorking in emergency departments versus low-risk departments (non-emergency and technology departments), n=54Infection and severity of disease (assessed through laboratory testing and clinical diagnosis)Much lower incidence of infection among HCW from emergency departments than from other departments (emergency department 3.7% versus other department 72.2%); severe cases were significantly younger than common casesJBI: 8-9/10
Li et al, 20205Report, Editorial
(retrospective fatality analysis based on official report data)
ChinaNo information on exposure assessment, n=24Mortality among HCW with COVID-19As of 16 March, 13 out of 24 (54.2%) HCW died from COVID-19, other causes for death were traffic injuries and sudden deathN/A
McMichael et al, 20206Case report, quantitativeUSAContact to patients with COVID-19 in a long-term care facility, n=167Infection and hospitalisation rates among staff members, residents and visitors (assessed through laboratory testing)As of 18 March, 50 out of 167 confirmed cases were HCW, of whom 6% were hospitalised; indicated lacking PPE adherence and unfamiliarity with infection control measuresJBI: 7/8
Ran et al, 20207Retrospective cohort study, quantitativeChinaWorking in a high-risk department versus low-risk department in one hospital, n=72Infection risk (assessed through laboratory testing)HCW in high-risk departments are at higher risk for COVID-19 than those of low-risk departments due to longer duty hours and suboptimal hand hygieneCASP: 5/13
Zhan et al 20208Report, EditorialChinaAs of 24 February, 4.4% of confirmed COVID-19 cases were HCW.
As of 3 April, 23 out of 3387 HCW in China had died from COVID-19
Mental health
Cao et al, 20209Qualitative study, EditorialChinaDirect exposure to COVID-19 through work in a fever clinic (doctors, nurses, clinical technicians), n=37Assessment of physical and psychological burden through interviewsHCW indicated high stress load, overworking, sleep problems and nervousness over own and family members’ infection risk, concerns over shortage of medical supplies, overall mild bodily discomfort such as tiredness, throat pain, back pain headachesCASP
(no: n=7, yes: n=2)
Chen et al, 202010Cross-sectional, quantitative, EditorialChinaHigh exposure versus non or low exposure to patients with COVID-19, n=105Depression, anxiety (assessed through SDS, SAS)Symptoms of depression accompanied by anxiety was significantly higher in high-exposure group; no difference when depression or anxiety were considered separatelyAXIS: 10/20
Chew et al, 202011Cross-sectional, quantitativeSingapore and IndiaExposure to SARS-CoV-2 not directly assessed, correlation between physical and psychological symptoms during COVID-19 outbreak, n=906Depression, anxiety and distress, PTSD (assessed through DASS-21, IES-R) and physical symptomsHeadache most commonly reported, participants who had experienced physical symptoms in the preceding month were more likely to screen positive for depression, anxiety and stress, PTSDAXIS: 13/20
Huang and Zhao, 202012Cross-sectional, quantitativeChinaComparison between several occupational groups, n=7236Depression, anxiety, sleep quality (assessed through CES-D, GAD-7, PSQI)Compared with other occupational groups, HCW had a higher prevalence of sleep disturbances, no difference in depression and anxietyAXIS: 14/20
Kang et al, 202013Cross-sectional, quantitativeChinaHigh-risk versus low-risk hospital departments, n=994Depression, anxiety, insomnia, distress (assessed through PHQ-9, GAD-7, ISI, IES-R)Staff with fewer contact to patients with COVID-19 showed less severe mental health issues, a higher degree of distress was associated with a more extensive exposure to the virusAXIS: 13/20
Lai et al, 202014Cross-sectional, quantitativeChinaInside versus outside Wuhan and Hubei (high-risk region vs low-risk region), n=1257Depression, anxiety, insomnia, distress (assessed through PHQ-9, GAD-7, ISI, IES-R)Those working in Wuhan reported more severe mental health outcomes than other HCWAXIS: 15/20
Li et al, 202015Cross-sectional, quantitativeChinaFront line versus non-front line (high risk vs low risk), n=1266Vicarious traumatisation (assessed through vicarious traumatisation scale)Non-front-line nurses had significantly higher scores in vicarious traumatisation than front-line nursesAXIS: 11/20
Liu, et al, 202016Cross-sectional, quantitativeChinaFront-line versus non front-line nurses and doctors (high risk vs low risk), n=4679Psychological stress, anxiety, depression (assessed through SRQ-20, SAS, SDS)Doctors and nurses from high-risk departments, those who live mostly without family members, those who had previous experience in treatment of infectious disease have higher scores for all mental health outcomes; younger age and higher professional degree (doctors) had lower risk of mental health problemsAXIS: 16/20
Lu et al, 202017Cross-sectional, quantitativeChinaMedical workers versus administrative staff and subgroup analysis of clinical staff (high-risk vs low-risk clinical staff), n=2299Fear, anxiety, depression (assessed through NRS, HAMA, HAMD)No significant difference in depression in medical staff compared with administrative staff, subgroup analysis: staff in high-risk department showed significantly greater fear, depressive symptoms, and anxiety compared with low-risk groupsAXIS: 14/20
Mo et al, 202018Cross-sectional, quantitativeChinaExposure to SARS-CoV-2 not directly assessed, correlation between stress and anxiety, n=180Stress and anxiety (assessed through SOS, SAS)The higher the stress load, the higher the anxiety among nurses; working long hours, being an only child, anxiety were main factors affecting nurse stressAXIS: 10/20
Sun et al, 202019Qualitative studyChinaDirect exposure to COVID-19 through work on a negative pressure ward, n=20Interview about emotions, coping styles, personal growth, positive emotions during the pandemicAt the beginning of the outbreak, the participants were mainly concerned over unknown conditions of patients, severe emergencies and patients’ psychological state, a few developed symptoms of depression and isolated themselves. Over time, the nurses developed coping strategies to deal with stress and indicated a feeling of personal growth under pressure. After 1 week positive emotions prevailed in 70% of nurses.CASP (no: n=2, yes: n=8)
Tan et al, 202020Cross-sectional, quantitativeSingaporeMedical versus non-medical staff (high risk vs low risk), n=470Depression, anxiety, stress (assessed through DASS-21, IES-R)Anxiety and stress were higher in non-medical staffAXIS:12/20
Wu et al, 202021Cross-sectional, quantitativeChinaMedical staff versus non-medical staff (college students); inside versus outside Wuhan
(high risk vs low risk), n=4268
Psychological stress (assessed via piloted questionnaire)Positive exposure effect: in all provinces of China, medical staff scored higher in psychological stress than college students; medical staff in Wuhan scored higher than staff outside WuhanAXIS: 9/20
Xiao et al, 202022Cross-sectional, quantitativeChinaExposure to SARS-CoV-2 not directly assessed, n=180Anxiety, Self-efficacy, Stress, Sleep (assessed through SAS, GSES, SASR, PSQI)During the COVID-19 pandemic, social support reduced stress and anxiety and increased self-efficacy in medical staff, no significant effect on sleep qualityAXIS: 10/20
Xu 202023Cross-sectional, quantitative, EditorialChinaOutbreak versus non-outbreak period (high vs low exposure), n=120Depression, anxiety, anxiety dreams (assessed via scoring system and SF-36)All endpoints were significantly higher in outbreak period compared with non-outbreak periodAXIS: 5-6/20
Zhang et al, 202024Cross-sectional, quantitativeChinaMedical versus non-medical staff (high risk vs low risk), n=2182Insomnia, somatisation, obsessive compulsive disorder, anxiety, anxiety and depression (assessed through ISI, SCL-90R, PHQ-4)Medical workers had a higher prevalence for all mental health disorders except for phobic anxiety, having an organic disease was independently associated with mental health outcomesAXIS: 11/20
Ong et al, 202029Cross-sectional, quantitativeSingaporeFrequent use of PPE due to SARS-CoV-2 exposure, n=158PPE-related headaches (assessed through self-administered questionnaire)81.0% of respondents developed de novo PPE-associated headaches. A pre-existing primary headache diagnosis and combined PPE usage for >4 hour per day were independently associated with de novo PPE-associated headaches.AXIS: 15/20
Skin injuries
Gheisari et al, 202025Report, EditorialIranFrequent use of PPE due to SARS-CoV-2 exposurePPE-related skin injuriesRespirator masks were found to provoke occupational dermatoses, acne, skin irritation, contact dermatitis, allergies, pigmentation, pressure damage; goggles were associated with frictional erosions, pressure damage, xerosis, skin reactions on nasal bridge including; gowns were linked to contact dermatitis, itchingN/A
Jiang et al, 202026Cross-sectional, quantitativeChinaFrequent use of PPE due to SARS-CoV-2 exposure, n=4308PPE-related skin injuries (assessed through self-administered questionnaire)Overall prevalence of skin injuries 42.8% (mostly device-related pressure injuries, moist associated skin damage and skin tear). Daily wearing time of >4 hour, high-grade PPE (PPE 3), sweating and male sex were associated with skin injuriesAXIS: 14-15/20
Lan et al, 202027Cross-sectional, quantitative, EditorialChinaFrequent use of PPE due to SARS-CoV-2 exposure, n=542PPE-related skin injuries (self-administered questionnaire)Prevalence of skin injuries among first-line HCW was 97%, most affected areas were nasal bridge, cheeks, hands and forehead, wearing time of N95 respirators>6 hour was positively correlated with skin damages, frequent hand hygiene (>10 times) was associated with hand skin damageAXIS: 6/20
Lin et al, 202028Cross-sectional, quantitative, EditorialChinaFrequent use of PPE due to SARS-CoV-2 exposure, n=376PPE-related skin injuries (assessed through self-administered questionnaire)Skin on hands, cheeks, nasal bridge and auricular areas most affected by dryness, maceration, erythema; duration of wearing PPE, frequency of hand washing significantly associated with adverse skin reactionsAXIS: 8-9/20
  • AXIS, The Appraisal Tool for Cross-Sectional Studies; CASP, Critical Appraisal Skills Programme; CES-D, Centre for Epidemiology Scale for Depression; DASS-21, Depression Anxiety and Stress Scale; GAD-7, Generalized Anxiety Disorder-7; GRADE, Grading of Recommendations, Assessment, Development and Evaluations; GSES, General Self-Efficacy Scale; HAMA, Hamilton Anxiety Rating Scale; HAMD, Hamilton Rating Scale for Depression; HCW, healthcare worker; IES-R, Impact of Event Scale; ISI, Insomnia severity Index; JBI, Joana Briggs Institute; N/A, not applicable (N/A in quality assessment was used for articles with no clear study design such as reports or editorials); NRS, Numeric rating scale; PHQ, Patient Health Questionnaire; PSQI, Pittsburgh Sleep Quality Index; PTSD, Post-traumatic stress disorder; SAS, Self-rating anxiety scale; SASR, Stanford Acute Stress Reaction Questionnaire; SCL-90-R, Symptom Checklist 90- Standard; SDS, Self-rating depression scale; SF-36, Short Form Health 36; SOS, Stress Overload Scale; SRQ-20, Self Reporting Questionnaire 20-Item.