Intended for healthcare professionals


Covid-19 in the workplace

BMJ 2020; 370 doi: (Published 21 September 2020) Cite this as: BMJ 2020;370:m3577

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  1. Raymond M Agius, emeritus professor of occupational and environmental medicine1,
  2. John F R Robertson, professor of surgery2,
  3. Denise Kendrick, professor of primary care research2,
  4. Herb F Sewell, emeritus professor of immunology2,
  5. Marcia Stewart, social care professional3,
  6. Martin McKee, professor of European public health4
  1. 1University of Manchester, Manchester, UK
  2. 2University of Nottingham, Nottingham, UK
  3. 3De Montfort University, Leicester, UK
  4. 4London School of Hygiene and Tropical Medicine, London, UK
  1. Correspondence to: R M Agius rmagius{at}

Reporting guidance should reflect risks to a wide range of workers

Faced with a novel lethal virus, employers have struggled to implement their legal duty to protect staff from harm in the workplace. There is no international case definition for attributing an occupational origin to covid-19 cases, and the World Health Organization has so far prepared a surveillance protocol only for healthcare workers.1 Employers are accountable, in the UK, to the Health and Safety Executive (HSE) and must notify it when there is “reasonable evidence” of a worker contracting covid-19 through occupational exposure.23 In general, HSE expects to be notified if it is “more likely than not that the person’s work was the source of exposure—as opposed to general societal exposure.” However, HSE also states that work with the general public—as opposed to work with people known to be infected—is not usually sufficient to trigger reporting.2

HSE has published a technical summary of the 8666 notifications of covid-19 in workers in England, Scotland, and Wales, including 125 deaths, from 10 April to 8 August.4 Data before 10 April 2020 are excluded because of a change in methods. The weekly number of notifications peaked at 1183 (including 23 deaths) in the week ending 2 May 2020, two weeks later than the peak of deaths among the general population, as reported by the Office for National Statistics (ONS).5

Missed cases

At least 3354 (39%) of the notified covid-19 cases were in people working in residential care and other social work, including 52 (42%) deaths. A further 3382 cases (39%) were among healthcare workers, including 50 (40%) deaths. As HSE acknowledges, these figures misjudge the true scale of the problem because of widespread under-reporting by employers. Misclassification further limits the comparison between sectors.4

The ONS statistical bulletins6 have shown that age standardised mortality rates for male security guards and related occupations were nearly four times higher than those for all men of working age, while for taxi, cab, bus, and coach drivers the age standardised mortalities were well over double. Although ONS analyses exclude many deaths subject to coroners’ inquests and do not yet take into account comorbidity, socioeconomic characteristics, or other factors such as ethnicity, they provide some comparative evidence on covid-19 deaths potentially associated with work. They are consistent with the conclusion that jobs with frequent and close public exposure (besides health and social care) carry a higher risk of covid-19.78 Such jobs should fall within the scope of future HSE reporting guidance and thus be subject to investigation.

Currently, HSE also intimates that if Public Health England (PHE) guidance on “effective control measures” 9 has been followed at work, cases of covid-19 among employees do not always need to be reported to HSE. Some have argued31011 that PHE’s guidance does not offer adequate protection as it is consistent with the view that aerosol transmission is unlikely.12 However, emerging evidence suggests the need to take precautions against aerosol transmission.1314

Acting on evidence

HSE should now encourage notification of covid-19 in health and social care workers who became infected despite having followed PHE’s guidance. Investigation of these cases would enable lessons to be learnt, such as whether the more precautionary European guidance on respiratory protective equipment should be used (wearing respirators rather than surgical masks) while managing people with suspected covid-19.15

As detailed in the HSE guidance,2 doctors have an important role in notifying employers in writing (ordinarily with the patient’s consent) of a diagnosis of covid-19. These reports should highlight the contribution of work related factors —for example, insufficient control measures. Moreover, some general practitioners who are employers have a legal duty as “responsible persons” to report to HSE, covid-19 attributed to occupational exposure in their employees.216 HSE has produced useful advice to help keep work safe during the covid-19 pandemic.17 Safety also relies on learning from experience, and HSE must act quickly to synthesise and disseminate what has been learnt to help prevent further death and disease among workers.

HSE should change its reporting guidance to reflect the risks in occupational sectors outside health and social care, and to consider whether current protective equipment and other control measures are adequate. The thousands of cases of covid-19 contracted at work warrant an urgent rapid review1819 of the national pandemic policy, followed by a full and wide ranging public inquiry.320


  • Competing interests: We have read and understood BMJ policy on declaration of interests and declare that MMcK is a member of the independent SAGE.

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