Risk of Severe COVID-19 Among Workers and Their Household Members

Employment-related exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can endanger not only workers, but also their household members.^1,2 Using prepandemic data, we examined the prevalence of Centers for Disease Control and Prevention (CDC) risk factors for severe coronavirus disease 2019 (COVID-19). We then estimated how many adults at increased risk of severe COVID-19 held essential jobs and could not work at home (WAH) or who lived in households with such workers.

We used deidentified data from the 2014-2017 Medical Expenditure Panel Survey (MEPS), an in-person household survey of the US civilian noninstitutionalized population.³ The research was approved under an Agency for Healthcare Research and Quality Institutional Review Board protocol for MEPS research. The MEPS is the only nationally representative data set providing detailed information on health and employment for all household members. It draws participants from the National Health Interview Survey, with a 62.9% average response rate (National Health Interview Survey response rates averaged 74.0%).

Essential workers were identified using federal guidance.⁴ Because of the difficulty of determining which restaurant workers were essential, we classified the entire restaurant sector as nonessential. Ability to WAH was imputed from the American Time Use Survey.⁵

Following CDC guidelines,⁶ persons at increased risk of severe illness had obesity (body mass index of 30 or higher; calculated as weight in kilograms divided by height in meters squared), age of 65 years or older, or any of the following treated conditions: diabetes, emphysema or other chronic obstructive pulmonary disease, kidney disease, cancer (other than nonmelanoma skin cancers), or coronary heart disease.² To implement the CDC’s broader guidelines for possibly being at increased risk, we created a second variable that also included current smoking, treated asthma, or treated hypertension. We implemented these definitions in MEPS by combining data that were self-reported by each adult with data reported for each adult by a single family respondent.

All analyses used Stata, version 16.0 (StataCorp). Standard errors and 2-tailed t tests were adjusted for the complex design of MEPS. Results were statistically significant at P < .05 unless otherwise noted.

The MEPS sample contained 100 064 adult observations. Of the 157.3 million workers, 112.4 million (71.5%) were essential, and of these, only 31.2 million could WAH (Table 1). Among all adults, 49.7% (123.2 million of 248.0 million) were at increased risk of severe COVID-19 using the main CDC guidelines (61.0% using the broader CDC guidelines). Although workers were at lower risk than nonworkers, 41.0% (46.1 million) and 54.4% (61.1 million) of the 112.4 million essential workers met the main and broader CDC increased-risk guidelines, respectively.

Table 2 shows that 123.2 million adults met the main CDC increased-risk guidelines. Of these increased-risk adults, 27.7% (34.1 million) held essential jobs and could not WAH. Incorporating other household members, 46.1% (56.7 million) increased-risk adults either lived with or were themselves essential employees who could not WAH. Using the broader CDC definition increased this total to 74.3 million.

Between 56.7 and 74.3 million increased-risk US adults lived with or were themselves essential workers who could not WAH. These estimates were driven by 3 factors: First, 49.7% to 61.0% of all adults were at increased risk of severe COVID-19 if infected with SARS-CoV-2 (depending on the CDC definition used). Second, 71.5% of workers held essential jobs, and many were unable to WAH. Third, we measured not only the number of adults with increased risk who were essential workers and unable to WAH, but also the many increased-risk adults living with such workers. One limitation is that the study’s prepandemic data do not reflect current employment levels, changes in ability to WAH, or local infection rates. Additionally, risk factors were reported by MEPS participants rather than measured by medical professionals, likely causing an underestimate of risk. Policy makers seeking to make efficient and equitable decisions about reopening the economy and about vaccine distribution should consider the health risks not only of workers, but also of those with whom they live.

Accepted for Publication: September 13, 2020.

Published Online: November 9, 2020. doi:10.1001/jamainternmed.2020.6249

Corresponding Author: Thomas M. Selden, PhD, Center for Financing, Access and Cost Trends, Agency for Healthcare Research and Quality, 5600 Fishers Ln, Rockville, MD 20857 (thomas.selden@ahrq.hhs.gov).

Author Contributions: Drs Selden and Berdahl had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: All authors.

Administrative, technical, or material support: Berdahl.

Conflict of Interest Disclosures: None reported.

Funding/Support: There was no external funding associated with this research; it was conducted by Selden and Berdahl as employees of AHRQ as part of AHRQ’s intramural research program.

Role of the Funder/Sponsor: Drs Selden and Berdahl are employees of the US AHRQ. Aside from the internal peer review process, AHRQ had no role in designing and conducting the study; collecting, managing, analyzing and interpreting the data; preparing, reviewing or approving the manuscript; or the decision to submit the manuscript for publication.

Disclaimer: The findings and conclusions in this manuscript are those of the authors and do not necessarily represent the views of the US Department of Health and Human Services or AHRQ.

Additional Contributions: Joel Cohen, PhD, David Meyers, MD, and G. Edward Miller, PhD, provided comments on early versions of the draft. Drs Cohen, Meyers, and Miller work for AHRQ and received no compensation.