What are return to work recommendations for individuals with high risk factors or comorbidities during SARS-CoV-2 pandemic?

General guidance:

The U.S. Centers for Disease Control and Prevention (CDC) has provided a list of risk factors or underlying medical conditions that might predispose individuals to develop more severe illness should they contract COVID-19 (People Who Are at Higher Risk for Severe Illness1)  has published People Who Need to Take Extra Precautions1.  As there is limited information available on this topic, some of this guidance is based upon their clinical expertise.

Vulnerable workers include people with chronic lung disease, including moderate to severe asthma, and serious heart conditions, as well as immunocompromised individuals (including those undergoing cancer treatment, recipients of bone marrow or organ transplants, and those with other immune deficiencies, such as poorly controlled HIV or AIDS or prolonged use of corticosteroids or other immunosuppressive  medications. Workers with severe obesity (body mass index [BMI] of 40 or higher), diabetes, chronic kidney disease undergoing dialysis, liver disease, and combinations of these comorbid conditions are also at increased risk of severe disease.  

The Chinese Center for Disease Control and Prevention published a study of over 44,000 confirmed cases of COVID-19.  The overall case-fatality rate (CFR) was 2.3% (1023 deaths among 44 672 confirmed cases). The CFR much higher for those with underlying medical conditions—"10.5% for cardiovascular disease, 7.3% for diabetes, 6.3% for chronic respiratory disease, 6.0% for hypertension, and 5.6% for cancer”.2  Elderly individuals also had higher CFRs, e.g., for those aged 70 to 79, the CFR was 8%. As per Rello, J et al, aging, hypertension and diabetes have been consistently reported as risk factors for death or increased severity.  In the US, Richardson et al. found among 5700 hospitalized patients with COVID-19 in the New York City Area that the most common comorbidities were hypertension, obesity, and diabetes4. Many patients with the disease are noted to have hypercoagulability, increasing the risk of deep venous thrombosis, pulmonary artery micro-thrombosis, distal arterial micro-thrombosis affecting fingers, and cardiovascular events such as myocardial ischemia, ischemic stroke, and pulmonary embolisms. Workers with these underlying medical conditions may be at higher risk having severe illness due to COVID-19. 

Specific guidance:

Step 1. Assess the Risk of Exposure in the Workplace
The risk of contracting COVID-19 depends upon the degree of interaction with others and the job tasks performed. Individuals working directly with sick individuals, such as healthcare workers, would be at the greatest risk. Jobs involving frequent contact with the public or close proximity to coworkers would pose an elevated risk. Jobs with limited contact with others and a single-use workstation, like many office jobs, are lower risk.

Step 2. Identify the Scope of Individual Risk
Ideally, individuals would self-identify to the occupational health provider that they have one or more of these conditions. The OEM practitioners should then assess the severity or the degree of control of the disease in that worker as it is likely that this affects the risk5

Step 3. Recommend Protective Work Practices and Work Restrictions
For those with significant underlying medical conditions and a job with increased risk of exposure, the most conservative approach would be for them to work from home. If that is not possible, measures in the workplace to reduce the risk of contact with infected individuals, such as use of a face mask and following strict social distancing guidelines, would be warranted.  In these situations, it would be important for the OEM practitioner to engage the worker in decision-making about returning to work after informing him or her of the risk.  The individual who elects to return to work should be vigilant in monitoring for symptoms and seek medical attention if these develop. 

Step 4. Recommend Reduction of Modifiable Risk Factors
Not all risk factors for more severe symptoms with COVID-19 infection are modifiable.  Some however, such as weight and blood sugar, are.  Recently, Zhu et al. showed reduction in risk associated with better glycemic control.  The study enrolled diabetics hospitalized with COVID-19 infection in Wuhan, China5.  The hazard ratio for all cause mortality was 0.13 for low A1c (<8) patients relative to those with high A1c (>8).


  1. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-at-higher-risk.html
  2. Wu Z, McGoogan JM. Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72 314 Cases From the Chinese Center for Disease Control and Prevention [published online ahead of print, 2020 Feb 24]. JAMA. 2020.
  3. Rello, J., Storti, E., Belliato, M., & Serrano, R. (2020). Clinical phenotypes of SARS-CoV-2: Implications for clinicians and researchers. European Respiratory Journal.
  4. Richardson S, Hirsch JS, Narasimhan M, et al. Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area. JAMA. Published online April 22, 2020. doi:10.1001/jama.2020.6775
  5.  Zhu et al., 2020, Cell Metabolism 31, 1-10, June 02, 2020

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