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Impact of COVID-19 on environmental services workers in healthcare settings: a scoping review

Published:September 14, 2022DOI:https://doi.org/10.1016/j.jhin.2022.09.001

      Summary

      Background

      In the wake of the coronavirus disease 2019 (COVID-19) pandemic, demand for deep cleaning and environmental services workers grew exponentially. Although there is extant literature examining the impact of the COVID-19 pandemic on healthcare workers, less emphasis has been placed on environmental services workers, who play an equally important front-line role.

      Aim

      To examine the impact of the COVID-19 pandemic on environmental services workers employed in healthcare settings.

      Methods

      Scoping review methodology. A search strategy was developed, in consultation with a medical information specialist, employing various combinations of the keywords [(environmental services worker OR health attendant OR housekeeping) AND (COVID OR coronavirus OR pandemic OR epidemic)]. Four bibliographical databases were searched from inception to 5th July 2022: OVID Medline, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Cochrane Database.

      Results

      In total, 24 studies were included in this review. The studies were generally cross-sectional in design. Seroprevalence studies highlighted significantly higher rates of COVID-19 among environmental services workers (housekeeping, cleaning and janitorial staff) compared with other clinical and non-clinical staff in the same institutions. In addition, based on qualitative interviews, environmental services workers experienced greater psychological stress working during the pandemic.

      Conclusions

      Environmental services workers were particularly vulnerable to increased work stress and COVID-19 during the pandemic. Health systems need to do more to support these workers. Further research could investigate specific policy and procedural changes to benefit this under-recognized group in the greater healthcare workforce.

      Keywords

      Introduction

      It is well recognized that regular disinfection, housekeeping and cleaning are essential for the daily operations of any healthcare facility. Environmental services workers are the unsung heroes who perform these arduous tasks, despite often long hours and limited renumeration [
      • Siganporia P.
      • Astrakianakis G.
      • Alamgir H.
      • Ostry A.
      • Nicol A.M.
      • Koehoorn M.
      Hospital support services and the impacts of outsourcing on occupational health and safety.
      ].
      During the coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), demand for deep cleaning and environmental services workers grew exponentially [
      • Tyan K.
      • Cohen P.A.
      Investing in our first line of defense: environmental services workers.
      ]. At the time of writing, there have been more than 555 million cases of COVID-19 and 6.3 million COVID-related deaths worldwide [
      Johns Hopkins Coronavirus Resource Center
      COVID-19 map.
      ]. Besides vaccines, the importance of hygiene and personal protective measures (e.g. mask wearing and disinfecting) in stemming the transmission of SARS-CoV-2 is critical, but adds to the burden of these workers [
      • Girum T.
      • Lentiro K.
      • Geremew M.
      • Migora B.
      • Shewamare S.
      • Shimbre M.S.
      Optimal strategies for COVID-19 prevention from global evidence achieved through social distancing, stay at home, travel restriction and lockdown: a systematic review.
      ]. Preliminary evidence showed that the virus could survive on surfaces for up to 3 days, although surface transmission is now thought to be a minor mode of transmission [
      • Katona P.
      • Kullar R.
      • Zhang K.
      Bringing transmission of SARS-CoV-2 to the surface: is there a role for fomites?.
      ].
      Although there is extant literature examining the impact of the COVID-19 pandemic on healthcare workers [
      • Tan B.Y.
      • Chew N.W.
      • Lee G.K.
      • Jing M.
      • Goh Y.
      • Yeo L.L.
      • et al.
      Psychological impact of the COVID-19 pandemic on health care workers in Singapore.
      ,
      • Chew N.W.
      • Lee G.K.
      • Tan B.Y.
      • Jing M.
      • Goh Y.
      • Ngiam N.J.
      • et al.
      A multinational, multicentre study on the psychological outcomes and associated physical symptoms amongst healthcare workers during COVID-19 outbreak.
      ], less emphasis has been placed on environmental services workers, who play an equally – if not more – important role, in the modus operandi of a well-functioning hospital. As such, this scoping review aimed to map the literature in this area and identify gaps for future research.

      Methods

      The protocol of this scoping review was guided by recommendations from Arksey and O'Malley's framework and the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) [
      • Arksey H.
      • O’Malley L.
      Scoping studies: towards a methodological framework.
      ,
      • Tricco A.C.
      • Lillie E.
      • Zarin W.
      • O’Brien K.K.
      • Colquhoun H.
      • Levac D.
      • et al.
      PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation.
      ]. A search strategy was developed, in consultation with a medical information specialist, employing various combinations of the keywords [(environmental services worker OR health attendant OR housekeeping) AND (COVID OR coronavirus OR pandemic OR epidemic)]. Four bibliographical databases were searched from inception to 5th July 2022: OVID Medline, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Cochrane Database. The full search strategy for the individual databases is available in Supplementary Material 1. Grey literature was not searched.
      The key research question was: what is the impact of the COVID-19 pandemic on environmental services workers in healthcare settings?
      All study designs (case series, randomized controlled trials and observational cohort studies) were included in the initial search for this scoping review. Studies needed to have data specifically pertaining to environmental services workers, housekeeping staff or sanitary workers etc. Overlapping data studies, reviews, commentaries, and letters without original data were excluded to improve the quality of the included literature. The full text was obtained for all articles of interest, and their reference lists were hand-searched to identify additional relevant papers. Conflicts were resolved by discussion and consensus amongst four study investigators (QXN, CYLY, CEY and YLL).
      Relevant quantitative and qualitative data were extracted by three study investigators (CYLY, CEY and YLL) and cross-checked by a fourth investigator (QXN) for accuracy.

      Results

      The study selection and abstraction processes are illustrated in Figure 1. The database search identified 1529 records, from which 127 duplicates were removed. A further 1357 articles were removed after title and abstract screening, and 21 articles were removed after full-text review. Finally, 24 articles were included in the scoping review [
      • Akinbami L.J.
      • Chan P.A.
      • Vuong N.
      • Sami S.
      • Lewis D.
      • Sheridan P.E.
      • et al.
      Severe acute respiratory syndrome coronavirus 2 seropositivity among healthcare personnel in hospitals and nursing homes, Rhode Island, USA.
      ,
      • Al-Kuwari M.G.
      • AbdulMalik M.A.
      • Al-Nuaimi A.A.
      • Abdulmajeed J.
      • Al-Romaihi H.E.
      • Semaan S.
      • et al.
      Epidemiology characteristics of COVID-19 infection amongst primary health care workers in Qatar: March–October 2020.
      ,
      • Baker J.M.
      • Nelson K.N.
      • Overton E.
      • Lopman B.A.
      • Lash T.L.
      • Photakis M.
      • et al.
      Quantification of occupational and community risk factors for SARS-CoV-2 seropositivity among health care workers in a large US health care system.
      ,
      • Barani S.
      • Jahan N.
      • Karuppiah M.
      • Chaudhuri S.
      • Raju M.
      • Ponnaiah M.
      • et al.
      Epidemiology of hospital-based COVID- 19 cluster in a tertiary care cancer hospital, Chennai, India 2020.
      ,
      • Barry M.
      • Robert A.A.
      • Temsah M.H.
      • Abdul Bari S.
      • Akhtar M.Y.
      • Al Nahdi F.
      • et al.
      COVID-19 community transmission among healthcare workers at a tertiary care cardiac center.
      ,
      • Cruz-Arenas E.
      • Cabrera-Ruiz E.
      • Laguna-Barcenas S.
      • Colin-Castro C.A.
      • Chavez T.
      • Franco-Cendejas R.
      • et al.
      Serological prevalence of SARS-CoV-2 infection and associated factors in healthcare workers in a "non-COVID" hospital in Mexico City.
      ,
      • Darvishian M.
      • Sharafkhah M.
      • Mohammadi Z.
      • Sadeghniiat-Haghighi K.
      • Abdollahi A.
      • Jafary M.
      • et al.
      SARS-CoV-2 seroprevalence among health care workers in major private and public hospitals with COVID-19 patient's referral in Tehran, Iran.
      ,
      • Das D.
      • Basu K.
      • Biswas L.
      • Bhattacharya S.
      • Sarkar P.
      • Pant N.
      • et al.
      Asymptomatic COVID-19 infection among healthcare workers in dedicated tertiary care facility of Kolkata, India.
      ,
      • Eyre D.W.
      • Lumley S.F.
      • O'Donnell D.
      • Campbell M.
      • Sims E.
      • Lawson E.
      • et al.
      Differential occupational risks to healthcare workers from SARS-CoV-2 observed during a prospective observational study.
      ,
      • Girgis S.A.
      • Halim M.
      • Habil I.S.
      • Hussein W.M.
      • Mossad I.M.
      • Abdel-Aziz A.
      • et al.
      Investigation of a COVID-19 outbreak in a university cardio-thoracic hospital in Cairo: exploration of the risk to healthcare workers and patients.
      ,
      • Goenka M.
      • Afzalpurkar S.
      • Goenka U.
      • Das S.S.
      • Mukherjee M.
      • Jajodia S.
      • et al.
      Seroprevalence of COVID-19 amongst health care workers in a tertiary care hospital of a metropolitan city from India.
      ,
      • Jacob J.T.
      • Baker J.M.
      • Fridkin S.K.
      • Lopman B.A.
      • Steinberg J.P.
      • Christenson R.H.
      • et al.
      Risk factors associated with SARS-CoV-2 seropositivity among us health care personnel.
      ,
      • Jordan S.R.
      • Daddato A.E.
      • Patel H.P.
      • Jones C.D.
      Forgotten frontline workers: environmental health service employees' perspectives on working during the COVID-19 pandemic.
      ,
      • Latha S.L.
      • Priscilla T.
      • Sudha Ty S.
      • Saritha C.
      • Alimchandani A.
      • Thangaraju P.
      Estimation of prevalence and comparing the levels of stress, anxiety, depression, and psychological impact before and after COVID-19 lockdown among front line health care workers.
      ,
      • Mishra B.
      • Behera B.
      • Singh A.K.
      • Mohapatra P.R.
      • Patro B.K.
      • Panigrahi M.K.
      • et al.
      Seroprevalence of SARS-CoV-2 antibodies among healthcare workers in a teaching hospital in Eastern India.
      ,
      • Musa S.
      • Abdel Alem S.
      • Amer K.
      • Elnagdy T.
      • Hassan W.A.
      • Ali M.A.
      • et al.
      Prevalence of SARS-CoV-2 infection and dynamics of antibodies response among previously undiagnosed healthcare workers in a university hospital: a prospective cohort study.
      ,
      • Oliveira M.S.
      • Lobo R.D.
      • Detta F.P.
      • Vieira-Junior J.M.
      • Castro T.L.S.
      • Zambelli D.B.
      • et al.
      SARS-CoV-2 seroprevalence and risk factors among health care workers: estimating the risk of COVID-19 dedicated units.
      ,
      • Pınarlık F.
      • Genç Z.
      • Kapmaz M.
      • Tekin S.
      • Ergönül Ö.
      Risk groups for SARS-CoV-2 infection among healthcare workers: community versus hospital transmission.
      ,
      • Rosser J.I.
      • Röltgen K.
      • Dymock M.
      • Shepard J.
      • Martin A.
      • Hogan C.A.
      • et al.
      Stanford Healthcare COVID-19 Workforce Response Group
      Severe acute respiratory coronavirus virus 2 (SARS-CoV-2) seroprevalence in healthcare personnel in northern California early in the coronavirus disease 2019 (COVID-19) pandemic.
      ,
      • Shepard J.
      • Kling S.M.
      • Lee G.
      • Wong F.
      • Frederick J.
      • Skhiri M.
      • et al.
      The prevalence of COVID-19 in healthcare personnel in an adult and pediatric academic medical center.
      ,
      • Shields A.
      • Faustini S.E.
      • Perez-Toledo M.
      • Jossi S.
      • Aldera E.
      • Allen J.D.
      • et al.
      SARS-CoV-2 seroprevalence and asymptomatic viral carriage in healthcare workers: a cross-sectional study.
      ,
      • Tamene A.
      • Habte A.
      • Endale F.
      • Gizachew A.
      A qualitative study of factors influencing unsafe work behaviors among environmental service workers: perspectives of workers, and safety managers: the case of government hospitals in Addis Ababa, Ethiopia.
      ,
      • Wattal C.
      • Oberoi J.K.
      • Goel N.
      • Datta S.
      • Raveendran R.
      • Rao B.K.
      • et al.
      A cross-sectional study of SARS-CoV-2 seroprevalence among asymptomatic healthcare workers in a tertiary healthcare centre: assessing the impact of PPE guidelines.
      ,
      • Zuñiga M.
      • Lagomarcino A.J.
      • Muñoz S.
      • Alonso A.P.
      • Rodriguez M.A.
      • O'Ryan M.L.
      A cross sectional study found differential risks for COVID-19 seropositivity amongst health care professionals in Chile.
      ]. The characteristics and salient findings of the included studies are summarized in Table I, Table II, Table III, grouped broadly as SARS-CoV-2 seropositivity studies, outbreak investigations and studies on mental health.
      Figure 1
      Figure 1PRISMA flowchart illustrating the study selection process.
      Table ICharacteristics of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) seropositivity studies included in this scoping review (arranged alphabetically)
      Author, yearCountryStudy designStudy population and sample size (N)Key findings
      Akinbami, 2021 [
      • Akinbami L.J.
      • Chan P.A.
      • Vuong N.
      • Sami S.
      • Lewis D.
      • Sheridan P.E.
      • et al.
      Severe acute respiratory syndrome coronavirus 2 seropositivity among healthcare personnel in hospitals and nursing homes, Rhode Island, USA.
      ]
      USACross-sectional studyEnvironmental services workers, N=114 (hospital) and N=69 (nursing home)Environmental services workers in the hospital and nursing home were at elevated risk of SARS-CoV-2 seropositivity, with 2.6% (95% CI 0.6–7.5%) and 13.0% (95% CI 6.1–23.3%) seropositive, respectively.
      Al-Kuwari, 2021 [
      • Al-Kuwari M.G.
      • AbdulMalik M.A.
      • Al-Nuaimi A.A.
      • Abdulmajeed J.
      • Al-Romaihi H.E.
      • Semaan S.
      • et al.
      Epidemiology characteristics of COVID-19 infection amongst primary health care workers in Qatar: March–October 2020.
      ]
      QatarCross-sectional studyHousekeeping staff, N=530Non-clinical staff including housekeeping staff had a higher attack rate (46.8%) and higher prevalence of RT-PCR positivity (47.1%, 248/526) than clinical staff (P<0.001).
      Baker, 2021 [
      • Baker J.M.
      • Nelson K.N.
      • Overton E.
      • Lopman B.A.
      • Lash T.L.
      • Photakis M.
      • et al.
      Quantification of occupational and community risk factors for SARS-CoV-2 seropositivity among health care workers in a large US health care system.
      ]
      USACross-sectional studyEnvironmental services workers, N=35Environmental services workers had a slightly higher likelihood of SARS-CoV-2 seropositivity, although with a wide CI (crude OR 1.6, 95% CI 0.4–4.6).
      Barry, 2021 [
      • Barani S.
      • Jahan N.
      • Karuppiah M.
      • Chaudhuri S.
      • Raju M.
      • Ponnaiah M.
      • et al.
      Epidemiology of hospital-based COVID- 19 cluster in a tertiary care cancer hospital, Chennai, India 2020.
      ]
      Saudi ArabiaRetrospective analysisHousekeeping staff, N=146Housekeeping staff had the highest infection rate (17.1%, 25/146) compared with other healthcare workers. Most infections appeared to have been acquired in the community.
      Cruz-Arenas, 2021 [
      • Barry M.
      • Robert A.A.
      • Temsah M.H.
      • Abdul Bari S.
      • Akhtar M.Y.
      • Al Nahdi F.
      • et al.
      COVID-19 community transmission among healthcare workers at a tertiary care cardiac center.
      ]
      MexicoCross-sectional studyJanitorial staff, N=11Security staff (62.5%, 5/8) and janitorial staff (45.4%, 5/11) had the highest IgG seroprevalence amongst all healthcare professionals working at a ‘non-COVID’ hospital.
      Darvishian, 2022 [
      • Cruz-Arenas E.
      • Cabrera-Ruiz E.
      • Laguna-Barcenas S.
      • Colin-Castro C.A.
      • Chavez T.
      • Franco-Cendejas R.
      • et al.
      Serological prevalence of SARS-CoV-2 infection and associated factors in healthcare workers in a "non-COVID" hospital in Mexico City.
      ]
      IranCross-sectional studyJanitors and building superintendents, N=349Janitors and building superintendents had the lowest prevalence of SARS-CoV-2-specific IgG or IgM antibodies (9.5%, 33/349).
      Das, 2022 [
      • Darvishian M.
      • Sharafkhah M.
      • Mohammadi Z.
      • Sadeghniiat-Haghighi K.
      • Abdollahi A.
      • Jafary M.
      • et al.
      SARS-CoV-2 seroprevalence among health care workers in major private and public hospitals with COVID-19 patient's referral in Tehran, Iran.
      ]
      IndiaCross-sectional studyWard boys and cleaners, N=97IgG seroprevalence was higher amongst ward boys and cleaners (29.9%, 29/97) compared with other healthcare workers in the hospital.
      Eyre, 2020 [
      • Das D.
      • Basu K.
      • Biswas L.
      • Bhattacharya S.
      • Sarkar P.
      • Pant N.
      • et al.
      Asymptomatic COVID-19 infection among healthcare workers in dedicated tertiary care facility of Kolkata, India.
      ]
      UKProspective cohort studyPorters and cleaners, N=323Over a 3-month period, porters and cleaners had higher seroprevalence (18.6%, 60/323) and greater risk of COVID-19 compared with other healthcare professionals (adjusted OR 2.06, 95% CI 1.34–3.15; P=0.001).
      Goenka, 2020 [
      • Eyre D.W.
      • Lumley S.F.
      • O'Donnell D.
      • Campbell M.
      • Sims E.
      • Lawson E.
      • et al.
      Differential occupational risks to healthcare workers from SARS-CoV-2 observed during a prospective observational study.
      ]
      IndiaCross-sectional studyHousekeeping staff, N=226Housekeeping staff had the highest SARS-CoV-2-specific IgG seroprevalence (26.1%, 59/226) and highest OR of seropositivity (adjusted OR 4.90, 95% CI 2.04–11.74; P<0.001).
      Jacob, 2021 [
      • Girgis S.A.
      • Halim M.
      • Habil I.S.
      • Hussein W.M.
      • Mossad I.M.
      • Abdel-Aziz A.
      • et al.
      Investigation of a COVID-19 outbreak in a university cardio-thoracic hospital in Cairo: exploration of the risk to healthcare workers and patients.
      ]
      USACross-sectional studyEnvironmental services workers, N=122Environmental services workers had slightly higher likelihood of seropositivity compared with other healthcare professionals (adjusted OR 1.5, 95% CI 0.8–3.1).
      Mishra, 2021 [
      • Goenka M.
      • Afzalpurkar S.
      • Goenka U.
      • Das S.S.
      • Mukherjee M.
      • Jajodia S.
      • et al.
      Seroprevalence of COVID-19 amongst health care workers in a tertiary care hospital of a metropolitan city from India.
      ]
      IndiaCross-sectional studyHousekeeping and sanitation staff, N=186Housekeeping and sanitation staff had higher seroprevalence (6.99%, 13/186) compared with other healthcare workers.
      Musa, 2021 [
      • Jacob J.T.
      • Baker J.M.
      • Fridkin S.K.
      • Lopman B.A.
      • Steinberg J.P.
      • Christenson R.H.
      • et al.
      Risk factors associated with SARS-CoV-2 seropositivity among us health care personnel.
      ]
      EgyptProspective cohort studyPatient transporters and cleaners, N=37Patient transporters and cleaners had higher seroprevalence (45.9%, 17/37) and higher likelihood of SARS-CoV-2 infection compared with other healthcare professionals (OR 5.94, 95% CI 2.08–16.96).
      Oliveira, 2021 [
      • Jordan S.R.
      • Daddato A.E.
      • Patel H.P.
      • Jones C.D.
      Forgotten frontline workers: environmental health service employees' perspectives on working during the COVID-19 pandemic.
      ]
      BrazilCross-sectional studyCleaners, N=93Among healthcare professionals working in a dedicated COVID-19 facility, cleaners were most likely to be infected with COVID-19 (crude OR 2.44, 95% CI 1.26–4.73; P=0.006) based on positive SARS-CoV-2 serology.
      Pınarlık, 2021 [
      • Latha S.L.
      • Priscilla T.
      • Sudha Ty S.
      • Saritha C.
      • Alimchandani A.
      • Thangaraju P.
      Estimation of prevalence and comparing the levels of stress, anxiety, depression, and psychological impact before and after COVID-19 lockdown among front line health care workers.
      ]
      TurkeyRetrospective analysisJanitorial staff, N=66On multi-variate analysis, being a janitorial staff worker was independently associated with increased risk of SARS-CoV-2 infection (adjusted OR 2.24, 95% CI 1.21–4.14; P=0.011). Most infections were likely acquired in the community.
      Rosser, 2021 [
      • Mishra B.
      • Behera B.
      • Singh A.K.
      • Mohapatra P.R.
      • Patro B.K.
      • Panigrahi M.K.
      • et al.
      Seroprevalence of SARS-CoV-2 antibodies among healthcare workers in a teaching hospital in Eastern India.
      ]
      USARetrospective analysisEnvironmental services, food service, patient transport staff, N=335On multi-variable regression analysis, environmental services, food service and patient transport staff had significantly higher likelihood of seropositivity (OR 2.64, 95% CI 1.33–4.80; P<0.001). This was not observed for other occupations in the academic medical health system.
      Shepard, 2021 [
      • Musa S.
      • Abdel Alem S.
      • Amer K.
      • Elnagdy T.
      • Hassan W.A.
      • Ali M.A.
      • et al.
      Prevalence of SARS-CoV-2 infection and dynamics of antibodies response among previously undiagnosed healthcare workers in a university hospital: a prospective cohort study.
      ]
      USARetrospective analysisEnvironmental services workers (56.12% females, average age 43.18 years), N=335At an academic medical centre, there was significantly higher prevalence of COVID-19 R T-PCR positivity among environmental services workers (5.96%) compared with clinicians (1.93%; P<0.0001) and nurses (1.46%; P<0.0001).
      Shields, 2020 [
      • Oliveira M.S.
      • Lobo R.D.
      • Detta F.P.
      • Vieira-Junior J.M.
      • Castro T.L.S.
      • Zambelli D.B.
      • et al.
      SARS-CoV-2 seroprevalence and risk factors among health care workers: estimating the risk of COVID-19 dedicated units.
      ]
      UKCross-sectional studyHousekeeping staff, N=29In a large hospital trust, the seroprevalence of SARS-CoV-2 antibodies was higher among housekeeping staff (34.5%, 10/29 tested positive) compared with other asymptomatic healthcare workers.
      Wattal, 2021 [
      • Pınarlık F.
      • Genç Z.
      • Kapmaz M.
      • Tekin S.
      • Ergönül Ö.
      Risk groups for SARS-CoV-2 infection among healthcare workers: community versus hospital transmission.
      ]
      IndiaCross-sectional studySanitary workers, N=203At a tertiary medical hospital, sanitary workers were at significantly higher risk of SARS-CoV-2 IgG seropositivity (OR 3.946; P<0.001) than other asymptomatic healthcare workers.
      Zuñiga, 2022 [
      • Rosser J.I.
      • Röltgen K.
      • Dymock M.
      • Shepard J.
      • Martin A.
      • Hogan C.A.
      • et al.
      Stanford Healthcare COVID-19 Workforce Response Group
      Severe acute respiratory coronavirus virus 2 (SARS-CoV-2) seroprevalence in healthcare personnel in northern California early in the coronavirus disease 2019 (COVID-19) pandemic.
      ]
      ChileCross-sectional studyJanitorial staff, N=8606In regions with low and medium SARS-CoV-2 seroprevalence, doctors, nurses, allied health professionals, and janitorial and other support staff were at increased risk of infection. The likelihood of seropositivity for janitorial staff in low and medium seroprevalence regions was OR 1.12 (95% CI 0.68–1.85) and OR 1.37 (95% CI 1.07–1.74), respectively.
      CI, confidence interval; COVID-19, coronavirus disease 2019; OR, odds ratio; PPE, personal protective equipment; RT-PCR, reverse transcription polymerase chain reaction; SARS-CoV-2, severe acute respiratory syndrome coronavirus-2.
      Table IICharacteristics of outbreak investigations included in this scoping review (arranged alphabetically)
      Author, yearCountryStudy designStudy population and sample size (N)Key findings
      Barani, 2021 [
      • Shepard J.
      • Kling S.M.
      • Lee G.
      • Wong F.
      • Frederick J.
      • Skhiri M.
      • et al.
      The prevalence of COVID-19 in healthcare personnel in an adult and pediatric academic medical center.
      ]
      IndiaOutbreak investigationHousekeeping staff, N=120In the wake of a COVID-19 cluster in a tertiary care cancer hospital, 2.5% of the housekeeping staff tested RT-PCR positive (3/120), and they showed the highest secondary attack rate (3.3 per 100 persons) among all healthcare workers.
      Girgis, 2022 [
      • Shields A.
      • Faustini S.E.
      • Perez-Toledo M.
      • Jossi S.
      • Aldera E.
      • Allen J.D.
      • et al.
      SARS-CoV-2 seroprevalence and asymptomatic viral carriage in healthcare workers: a cross-sectional study.
      ]
      EgyptOutbreak investigationHousekeeping staff, N=118In the wake of a hospital COVID-19 outbreak, 7.6% of the housekeeping staff were infected (9/118), and they had the highest risk of RT-PCR positivity (risk ratio 5.08, 95% CI 1.4–1.84) compared with other hospital staff.
      CI, confidence interval; COVID-19, coronavirus disease 2019; RT-PCR, reverse transcription polymerase chain reaction; SARS-CoV-2, severe acute respiratory syndrome coronavirus-2.
      Table IIICharacteristics of studies on mental health of environmental services workers (arranged alphabetically)
      Author, yearCountryStudy designStudy population and sample size (N)Key findings
      Jordan, 2022 [
      • Tamene A.
      • Habte A.
      • Endale F.
      • Gizachew A.
      A qualitative study of factors influencing unsafe work behaviors among environmental service workers: perspectives of workers, and safety managers: the case of government hospitals in Addis Ababa, Ethiopia.
      ]
      USAQualitative study; semi-structured telephone interviewsEnvironmental services workers (69% females; average age 51 years), N=16The COVID-19 pandemic worsened the existing stressors facing environmental services workers, and there is a need for more support (training, education and adequate PPE) and recognition for these front-line workers.
      Latha, 2022 [
      • Wattal C.
      • Oberoi J.K.
      • Goel N.
      • Datta S.
      • Raveendran R.
      • Rao B.K.
      • et al.
      A cross-sectional study of SARS-CoV-2 seroprevalence among asymptomatic healthcare workers in a tertiary healthcare centre: assessing the impact of PPE guidelines.
      ]
      IndiaCross-sectional studyHousekeeping staff, N=64Based on self-reported DASS-21 and IES-R scores, hospital housekeeping staff had high levels of depressive, anxiety and stress symptoms during and after lockdown. Housekeeping staff had the highest levels of anxiety, and this worsened after lockdown.
      Tamene, 2022 [
      • Zuñiga M.
      • Lagomarcino A.J.
      • Muñoz S.
      • Alonso A.P.
      • Rodriguez M.A.
      • O'Ryan M.L.
      A cross sectional study found differential risks for COVID-19 seropositivity amongst health care professionals in Chile.
      ]
      EthiopiaQualitative study; key informant interviews and one-on-one in-depth interviewsEnvironmental services workers, N=19There were concerns regarding a lack of sufficient and appropriately-sized PPE in the workplace; poor renumeration; increased work fatigue; and lack of experience and training dealing with potential hazards.
      DASS-21, Depression, Anxiety and Stress Scale 21; IES-R, Impact of Event Scale-revised; PPE, personal protective equipment.
      There were six studies from the USA [
      • Akinbami L.J.
      • Chan P.A.
      • Vuong N.
      • Sami S.
      • Lewis D.
      • Sheridan P.E.
      • et al.
      Severe acute respiratory syndrome coronavirus 2 seropositivity among healthcare personnel in hospitals and nursing homes, Rhode Island, USA.
      ,
      • Baker J.M.
      • Nelson K.N.
      • Overton E.
      • Lopman B.A.
      • Lash T.L.
      • Photakis M.
      • et al.
      Quantification of occupational and community risk factors for SARS-CoV-2 seropositivity among health care workers in a large US health care system.
      ,
      • Girgis S.A.
      • Halim M.
      • Habil I.S.
      • Hussein W.M.
      • Mossad I.M.
      • Abdel-Aziz A.
      • et al.
      Investigation of a COVID-19 outbreak in a university cardio-thoracic hospital in Cairo: exploration of the risk to healthcare workers and patients.
      ,
      • Mishra B.
      • Behera B.
      • Singh A.K.
      • Mohapatra P.R.
      • Patro B.K.
      • Panigrahi M.K.
      • et al.
      Seroprevalence of SARS-CoV-2 antibodies among healthcare workers in a teaching hospital in Eastern India.
      ,
      • Musa S.
      • Abdel Alem S.
      • Amer K.
      • Elnagdy T.
      • Hassan W.A.
      • Ali M.A.
      • et al.
      Prevalence of SARS-CoV-2 infection and dynamics of antibodies response among previously undiagnosed healthcare workers in a university hospital: a prospective cohort study.
      ,
      • Tamene A.
      • Habte A.
      • Endale F.
      • Gizachew A.
      A qualitative study of factors influencing unsafe work behaviors among environmental service workers: perspectives of workers, and safety managers: the case of government hospitals in Addis Ababa, Ethiopia.
      ], six studies from India [
      • Darvishian M.
      • Sharafkhah M.
      • Mohammadi Z.
      • Sadeghniiat-Haghighi K.
      • Abdollahi A.
      • Jafary M.
      • et al.
      SARS-CoV-2 seroprevalence among health care workers in major private and public hospitals with COVID-19 patient's referral in Tehran, Iran.
      ,
      • Eyre D.W.
      • Lumley S.F.
      • O'Donnell D.
      • Campbell M.
      • Sims E.
      • Lawson E.
      • et al.
      Differential occupational risks to healthcare workers from SARS-CoV-2 observed during a prospective observational study.
      ,
      • Goenka M.
      • Afzalpurkar S.
      • Goenka U.
      • Das S.S.
      • Mukherjee M.
      • Jajodia S.
      • et al.
      Seroprevalence of COVID-19 amongst health care workers in a tertiary care hospital of a metropolitan city from India.
      ,
      • Pınarlık F.
      • Genç Z.
      • Kapmaz M.
      • Tekin S.
      • Ergönül Ö.
      Risk groups for SARS-CoV-2 infection among healthcare workers: community versus hospital transmission.
      ,
      • Shepard J.
      • Kling S.M.
      • Lee G.
      • Wong F.
      • Frederick J.
      • Skhiri M.
      • et al.
      The prevalence of COVID-19 in healthcare personnel in an adult and pediatric academic medical center.
      ,
      • Wattal C.
      • Oberoi J.K.
      • Goel N.
      • Datta S.
      • Raveendran R.
      • Rao B.K.
      • et al.
      A cross-sectional study of SARS-CoV-2 seroprevalence among asymptomatic healthcare workers in a tertiary healthcare centre: assessing the impact of PPE guidelines.
      ], two studies from the UK [
      • Das D.
      • Basu K.
      • Biswas L.
      • Bhattacharya S.
      • Sarkar P.
      • Pant N.
      • et al.
      Asymptomatic COVID-19 infection among healthcare workers in dedicated tertiary care facility of Kolkata, India.
      ,
      • Oliveira M.S.
      • Lobo R.D.
      • Detta F.P.
      • Vieira-Junior J.M.
      • Castro T.L.S.
      • Zambelli D.B.
      • et al.
      SARS-CoV-2 seroprevalence and risk factors among health care workers: estimating the risk of COVID-19 dedicated units.
      ], two studies from Egypt [
      • Jacob J.T.
      • Baker J.M.
      • Fridkin S.K.
      • Lopman B.A.
      • Steinberg J.P.
      • Christenson R.H.
      • et al.
      Risk factors associated with SARS-CoV-2 seropositivity among us health care personnel.
      ,
      • Shields A.
      • Faustini S.E.
      • Perez-Toledo M.
      • Jossi S.
      • Aldera E.
      • Allen J.D.
      • et al.
      SARS-CoV-2 seroprevalence and asymptomatic viral carriage in healthcare workers: a cross-sectional study.
      ], and one study from each of Brazil [
      • Jordan S.R.
      • Daddato A.E.
      • Patel H.P.
      • Jones C.D.
      Forgotten frontline workers: environmental health service employees' perspectives on working during the COVID-19 pandemic.
      ], Chile [
      • Rosser J.I.
      • Röltgen K.
      • Dymock M.
      • Shepard J.
      • Martin A.
      • Hogan C.A.
      • et al.
      Stanford Healthcare COVID-19 Workforce Response Group
      Severe acute respiratory coronavirus virus 2 (SARS-CoV-2) seroprevalence in healthcare personnel in northern California early in the coronavirus disease 2019 (COVID-19) pandemic.
      ], Ethiopia [
      • Zuñiga M.
      • Lagomarcino A.J.
      • Muñoz S.
      • Alonso A.P.
      • Rodriguez M.A.
      • O'Ryan M.L.
      A cross sectional study found differential risks for COVID-19 seropositivity amongst health care professionals in Chile.
      ], Iran [
      • Cruz-Arenas E.
      • Cabrera-Ruiz E.
      • Laguna-Barcenas S.
      • Colin-Castro C.A.
      • Chavez T.
      • Franco-Cendejas R.
      • et al.
      Serological prevalence of SARS-CoV-2 infection and associated factors in healthcare workers in a "non-COVID" hospital in Mexico City.
      ], Mexico [
      • Barry M.
      • Robert A.A.
      • Temsah M.H.
      • Abdul Bari S.
      • Akhtar M.Y.
      • Al Nahdi F.
      • et al.
      COVID-19 community transmission among healthcare workers at a tertiary care cardiac center.
      ], Qatar [
      • Al-Kuwari M.G.
      • AbdulMalik M.A.
      • Al-Nuaimi A.A.
      • Abdulmajeed J.
      • Al-Romaihi H.E.
      • Semaan S.
      • et al.
      Epidemiology characteristics of COVID-19 infection amongst primary health care workers in Qatar: March–October 2020.
      ], Saudi Arabia [
      • Barani S.
      • Jahan N.
      • Karuppiah M.
      • Chaudhuri S.
      • Raju M.
      • Ponnaiah M.
      • et al.
      Epidemiology of hospital-based COVID- 19 cluster in a tertiary care cancer hospital, Chennai, India 2020.
      ] and Turkey [
      • Latha S.L.
      • Priscilla T.
      • Sudha Ty S.
      • Saritha C.
      • Alimchandani A.
      • Thangaraju P.
      Estimation of prevalence and comparing the levels of stress, anxiety, depression, and psychological impact before and after COVID-19 lockdown among front line health care workers.
      ].
      The seroprevalence studies, with the exception of a single study from Iran [
      • Cruz-Arenas E.
      • Cabrera-Ruiz E.
      • Laguna-Barcenas S.
      • Colin-Castro C.A.
      • Chavez T.
      • Franco-Cendejas R.
      • et al.
      Serological prevalence of SARS-CoV-2 infection and associated factors in healthcare workers in a "non-COVID" hospital in Mexico City.
      ], consistently reported that environmental services workers (housekeeping, cleaners and janitorial staff) were significantly more likely to have contracted COVID-19 compared with other healthcare workers in the same institutions [
      • Akinbami L.J.
      • Chan P.A.
      • Vuong N.
      • Sami S.
      • Lewis D.
      • Sheridan P.E.
      • et al.
      Severe acute respiratory syndrome coronavirus 2 seropositivity among healthcare personnel in hospitals and nursing homes, Rhode Island, USA.
      ,
      • Al-Kuwari M.G.
      • AbdulMalik M.A.
      • Al-Nuaimi A.A.
      • Abdulmajeed J.
      • Al-Romaihi H.E.
      • Semaan S.
      • et al.
      Epidemiology characteristics of COVID-19 infection amongst primary health care workers in Qatar: March–October 2020.
      ,
      • Baker J.M.
      • Nelson K.N.
      • Overton E.
      • Lopman B.A.
      • Lash T.L.
      • Photakis M.
      • et al.
      Quantification of occupational and community risk factors for SARS-CoV-2 seropositivity among health care workers in a large US health care system.
      ,
      • Barani S.
      • Jahan N.
      • Karuppiah M.
      • Chaudhuri S.
      • Raju M.
      • Ponnaiah M.
      • et al.
      Epidemiology of hospital-based COVID- 19 cluster in a tertiary care cancer hospital, Chennai, India 2020.
      ,
      • Barry M.
      • Robert A.A.
      • Temsah M.H.
      • Abdul Bari S.
      • Akhtar M.Y.
      • Al Nahdi F.
      • et al.
      COVID-19 community transmission among healthcare workers at a tertiary care cardiac center.
      ,
      • Darvishian M.
      • Sharafkhah M.
      • Mohammadi Z.
      • Sadeghniiat-Haghighi K.
      • Abdollahi A.
      • Jafary M.
      • et al.
      SARS-CoV-2 seroprevalence among health care workers in major private and public hospitals with COVID-19 patient's referral in Tehran, Iran.
      ,
      • Das D.
      • Basu K.
      • Biswas L.
      • Bhattacharya S.
      • Sarkar P.
      • Pant N.
      • et al.
      Asymptomatic COVID-19 infection among healthcare workers in dedicated tertiary care facility of Kolkata, India.
      ,
      • Eyre D.W.
      • Lumley S.F.
      • O'Donnell D.
      • Campbell M.
      • Sims E.
      • Lawson E.
      • et al.
      Differential occupational risks to healthcare workers from SARS-CoV-2 observed during a prospective observational study.
      ,
      • Girgis S.A.
      • Halim M.
      • Habil I.S.
      • Hussein W.M.
      • Mossad I.M.
      • Abdel-Aziz A.
      • et al.
      Investigation of a COVID-19 outbreak in a university cardio-thoracic hospital in Cairo: exploration of the risk to healthcare workers and patients.
      ,
      • Goenka M.
      • Afzalpurkar S.
      • Goenka U.
      • Das S.S.
      • Mukherjee M.
      • Jajodia S.
      • et al.
      Seroprevalence of COVID-19 amongst health care workers in a tertiary care hospital of a metropolitan city from India.
      ,
      • Jacob J.T.
      • Baker J.M.
      • Fridkin S.K.
      • Lopman B.A.
      • Steinberg J.P.
      • Christenson R.H.
      • et al.
      Risk factors associated with SARS-CoV-2 seropositivity among us health care personnel.
      ,
      • Jordan S.R.
      • Daddato A.E.
      • Patel H.P.
      • Jones C.D.
      Forgotten frontline workers: environmental health service employees' perspectives on working during the COVID-19 pandemic.
      ,
      • Latha S.L.
      • Priscilla T.
      • Sudha Ty S.
      • Saritha C.
      • Alimchandani A.
      • Thangaraju P.
      Estimation of prevalence and comparing the levels of stress, anxiety, depression, and psychological impact before and after COVID-19 lockdown among front line health care workers.
      ,
      • Mishra B.
      • Behera B.
      • Singh A.K.
      • Mohapatra P.R.
      • Patro B.K.
      • Panigrahi M.K.
      • et al.
      Seroprevalence of SARS-CoV-2 antibodies among healthcare workers in a teaching hospital in Eastern India.
      ,
      • Musa S.
      • Abdel Alem S.
      • Amer K.
      • Elnagdy T.
      • Hassan W.A.
      • Ali M.A.
      • et al.
      Prevalence of SARS-CoV-2 infection and dynamics of antibodies response among previously undiagnosed healthcare workers in a university hospital: a prospective cohort study.
      ,
      • Oliveira M.S.
      • Lobo R.D.
      • Detta F.P.
      • Vieira-Junior J.M.
      • Castro T.L.S.
      • Zambelli D.B.
      • et al.
      SARS-CoV-2 seroprevalence and risk factors among health care workers: estimating the risk of COVID-19 dedicated units.
      ,
      • Pınarlık F.
      • Genç Z.
      • Kapmaz M.
      • Tekin S.
      • Ergönül Ö.
      Risk groups for SARS-CoV-2 infection among healthcare workers: community versus hospital transmission.
      ,
      • Rosser J.I.
      • Röltgen K.
      • Dymock M.
      • Shepard J.
      • Martin A.
      • Hogan C.A.
      • et al.
      Stanford Healthcare COVID-19 Workforce Response Group
      Severe acute respiratory coronavirus virus 2 (SARS-CoV-2) seroprevalence in healthcare personnel in northern California early in the coronavirus disease 2019 (COVID-19) pandemic.
      ]. The quality of these cross-sectional studies was assessed using the Joanna Briggs Institute critical appraisal checklist for analytical cross-sectional study [
      Joanna Briggs Institute
      Checklist for analytical cross sectional studies.
      ] by consensus among three study investigators (QXN, CYLY and CEY). The studies had generally low-to-moderate risk of bias, with shortcomings in response rate reporting and sample size (further details in Supplementary Material 2).
      One cross-sectional, quantitative study looked at the levels of anxiety, depression and stress experienced by healthcare workers, including housekeeping staff, during and after a lockdown situation [
      • Wattal C.
      • Oberoi J.K.
      • Goel N.
      • Datta S.
      • Raveendran R.
      • Rao B.K.
      • et al.
      A cross-sectional study of SARS-CoV-2 seroprevalence among asymptomatic healthcare workers in a tertiary healthcare centre: assessing the impact of PPE guidelines.
      ]. Two qualitative studies conducted individual interviews with environmental services workers, and examined their thoughts, feelings and concerns during the pandemic [
      • Tamene A.
      • Habte A.
      • Endale F.
      • Gizachew A.
      A qualitative study of factors influencing unsafe work behaviors among environmental service workers: perspectives of workers, and safety managers: the case of government hospitals in Addis Ababa, Ethiopia.
      ,
      • Zuñiga M.
      • Lagomarcino A.J.
      • Muñoz S.
      • Alonso A.P.
      • Rodriguez M.A.
      • O'Ryan M.L.
      A cross sectional study found differential risks for COVID-19 seropositivity amongst health care professionals in Chile.
      ]. All of these studies found high levels of stress and anxiety among environmental services workers during the pandemic. Of note, compared with doctors and nurses, the prevalence of anxiety during and after lockdown was significantly higher among non-clinical workers (e.g. housekeeping and security staff), and this remained significant after adjustment for possible confounders [
      • Wattal C.
      • Oberoi J.K.
      • Goel N.
      • Datta S.
      • Raveendran R.
      • Rao B.K.
      • et al.
      A cross-sectional study of SARS-CoV-2 seroprevalence among asymptomatic healthcare workers in a tertiary healthcare centre: assessing the impact of PPE guidelines.
      ]. Based on self-reported Depression, Anxiety and Stress Scale 21 scores, the mean score for anxiety among housekeeping staff was 4.8 during lockdown and 7.2 after lockdown. In contrast, doctors had a lower mean anxiety score of 4.22 during lockdown and 5.6 after lockdown, and nurses had a lower mean anxiety score of 4.0 during lockdown and 7.0 after lockdown [
      • Wattal C.
      • Oberoi J.K.
      • Goel N.
      • Datta S.
      • Raveendran R.
      • Rao B.K.
      • et al.
      A cross-sectional study of SARS-CoV-2 seroprevalence among asymptomatic healthcare workers in a tertiary healthcare centre: assessing the impact of PPE guidelines.
      ]. These studies collectively highlighted a clear need for more support and recognition for these frontline workers [
      • Tamene A.
      • Habte A.
      • Endale F.
      • Gizachew A.
      A qualitative study of factors influencing unsafe work behaviors among environmental service workers: perspectives of workers, and safety managers: the case of government hospitals in Addis Ababa, Ethiopia.
      ,
      • Wattal C.
      • Oberoi J.K.
      • Goel N.
      • Datta S.
      • Raveendran R.
      • Rao B.K.
      • et al.
      A cross-sectional study of SARS-CoV-2 seroprevalence among asymptomatic healthcare workers in a tertiary healthcare centre: assessing the impact of PPE guidelines.
      ,
      • Zuñiga M.
      • Lagomarcino A.J.
      • Muñoz S.
      • Alonso A.P.
      • Rodriguez M.A.
      • O'Ryan M.L.
      A cross sectional study found differential risks for COVID-19 seropositivity amongst health care professionals in Chile.
      ]. Areas of deficit include psychological support, staff training, infection control education and adequate supplies of personal protective equipment (PPE).

      Discussion

      COVID-19 has been an unprecedented global pandemic of unparalleled scale, and has caused a serious strain for health systems and greatly increased the demands on healthcare workers. Based on the available studies, environmental services workers appeared to be particularly vulnerable to increased work stress and COVID-19 during the pandemic.
      Seroprevalence studies highlighted higher rates of COVID-19 among environmental services workers (housekeeping, cleaning and janitorial staff) compared with other clinical and non-clinical staff. In a prospective cohort study conducted in a teaching hospital in the UK over a 3-month period, porters and cleaners were found to have higher seroprevalence (18.6%, 60/323) and higher risk of COVID-19 compared with other healthcare professionals [adjusted odds ratio 2.06, 95% confidence interval (CI) 1.34–3.15, P=0.001] [
      • Das D.
      • Basu K.
      • Biswas L.
      • Bhattacharya S.
      • Sarkar P.
      • Pant N.
      • et al.
      Asymptomatic COVID-19 infection among healthcare workers in dedicated tertiary care facility of Kolkata, India.
      ]. Similarly, in a study conducted in the wake of a COVID-19 outbreak in a university cardiothoracic hospital in Cairo, Egypt, housekeeping staff were the most affected out of all hospital staff, with 7.6% (9/118) contracting COVID-19; these workers had the highest risk of reverse transcription polymerase chain reaction positivity (risk ratio 5.08, 95% CI 1.4–1.84) [
      • Shields A.
      • Faustini S.E.
      • Perez-Toledo M.
      • Jossi S.
      • Aldera E.
      • Allen J.D.
      • et al.
      SARS-CoV-2 seroprevalence and asymptomatic viral carriage in healthcare workers: a cross-sectional study.
      ].
      This difference could be due to a combination of knowledge, training and socio-economic factors. Although the studies did not control directly for income or education attainments, occupation is a surrogate for socio-economic status. As COVID-19 could be acquired in both healthcare (albeit less likely [
      • Barani S.
      • Jahan N.
      • Karuppiah M.
      • Chaudhuri S.
      • Raju M.
      • Ponnaiah M.
      • et al.
      Epidemiology of hospital-based COVID- 19 cluster in a tertiary care cancer hospital, Chennai, India 2020.
      ,
      • Latha S.L.
      • Priscilla T.
      • Sudha Ty S.
      • Saritha C.
      • Alimchandani A.
      • Thangaraju P.
      Estimation of prevalence and comparing the levels of stress, anxiety, depression, and psychological impact before and after COVID-19 lockdown among front line health care workers.
      ]) and community settings, environmental services workers could have poorer knowledge and compliance with PPE use, and they tend to gather frequently during mealtimes, as highlighted by a number of studies [
      • Al-Kuwari M.G.
      • AbdulMalik M.A.
      • Al-Nuaimi A.A.
      • Abdulmajeed J.
      • Al-Romaihi H.E.
      • Semaan S.
      • et al.
      Epidemiology characteristics of COVID-19 infection amongst primary health care workers in Qatar: March–October 2020.
      ,
      • Mishra B.
      • Behera B.
      • Singh A.K.
      • Mohapatra P.R.
      • Patro B.K.
      • Panigrahi M.K.
      • et al.
      Seroprevalence of SARS-CoV-2 antibodies among healthcare workers in a teaching hospital in Eastern India.
      ,
      • Shields A.
      • Faustini S.E.
      • Perez-Toledo M.
      • Jossi S.
      • Aldera E.
      • Allen J.D.
      • et al.
      SARS-CoV-2 seroprevalence and asymptomatic viral carriage in healthcare workers: a cross-sectional study.
      ]. Environmental services workers could also live in more crowded housing conditions that might expose them to SARS-CoV-2 [
      • Barani S.
      • Jahan N.
      • Karuppiah M.
      • Chaudhuri S.
      • Raju M.
      • Ponnaiah M.
      • et al.
      Epidemiology of hospital-based COVID- 19 cluster in a tertiary care cancer hospital, Chennai, India 2020.
      ]. Several international studies have found that COVID-19 further exacerbated income and socio-economic inequalities [
      • Silva J.
      • Ribeiro-Alves M.
      Social inequalities and the pandemic of COVID-19: the case of Rio de Janeiro.
      ,
      • Marí-Dell'Olmo M.
      • Gotsens M.
      • Pasarín M.I.
      • Rodríguez-Sanz M.
      • Artazcoz L.
      • Garcia de Olalla P.
      • et al.
      Socioeconomic inequalities in COVID-19 in a European urban area: two waves, two patterns.
      ,
      • Laajaj R.
      • Webb D.
      • Aristizabal D.
      • Behrentz E.
      • Bernal R.
      • Buitrago G.
      • et al.
      Understanding how socioeconomic inequalities drive inequalities in COVID-19 infections.
      ], and this could have adversely impacted the housing and living conditions of these employees. These have been identified as risk factors for SARS-CoV-2 transmission in other contexts. Workers living in dormitories and close quarters were particularly predisposed to COVID-19 outbreaks [
      • De Deyn M.L.
      • Ng Q.X.
      • Loke W.
      • Yeo W.S.
      A tale of two cities: a comparison of Hong Kong and Singapore's early strategies for the coronavirus disease 2019 (COVID-19).
      ].
      Environmental services workers are a vital part of the wider public health workforce as they positively impact the health and wellbeing of staff and patients through their work. Hence, due consideration and appreciation should be given to this population. Due to possibly increased staff turnover during the pandemic, infection control training should be provided (and reiterated) for these staff members. They should also be educated and receive reminders on potential sources of nosocomial and fomite transmission. In addition, across hospital systems, cost-cutting to hospital environmental services has been associated with an increased risk of nosocomial infections for these employees [
      • Litwin A.S.
      • Avgar A.C.
      • Becker E.R.
      Superbugs versus outsourced cleaners: employment arrangements and the spread of health care-associated infections.
      ]. As mentioned above, the majority of the infections were thought to have been acquired in the community, suggesting potential social inequalities which need to be addressed.
      For workers who have been infected and are returning to work, psychoneuroimmunity prevention measures (e.g. good ventilation in the workplace and availability of PPE) may also help with possible psychiatric symptoms and facilitate a smooth return to work [
      • Tan W.
      • Hao F.
      • McIntyre R.S.
      • Jiang L.
      • Jiang X.
      • Zhang L.
      • et al.
      Is returning to work during the COVID-19 pandemic stressful? A study on immediate mental health status and psychoneuroimmunity prevention measures of Chinese workforce.
      ].
      Apart from these physical needs and issues, the qualitative studies also indicated that environmental services workers experienced greater psychological stress working during the pandemic due to increased demands, fear of contagion of the virus and staff shortages [
      • Tamene A.
      • Habte A.
      • Endale F.
      • Gizachew A.
      A qualitative study of factors influencing unsafe work behaviors among environmental service workers: perspectives of workers, and safety managers: the case of government hospitals in Addis Ababa, Ethiopia.
      ]. Health systems can consider additional measures to support these workers, who are at times underappreciated and underprivileged [
      • Rocha M.R.A.
      • Marin M.J.S.
      • Macias-Seda J.
      Living, working conditions and mental health: a study with Brazilian and Spanish workers who work in hospital cleaning services.
      ]. They should be entitled to paid sick leave benefits to stay home if feeling unwell. Their work and stories could be elevated and recognized, and technology and innovation should be considered to complement their work and ease their burden.
      In conclusion, environmental services workers had increased work stress and heightened risk of COVID-19 during the pandemic compared with other healthcare staff. There is a paucity of studies focusing specifically on these employees, and addressing the impact of the COVID-19 pandemic on their lived experiences. Further research is needed to investigate policy and procedural changes to benefit this under-recognized group in the greater healthcare workforce.

      Author contributions

      QXN and JT conceived the original idea. QXN, CEY, CYLY and YLL carried out the study, investigation, and the relevant data analysis and interpretation. XX, KYF and JT contributed to the data analysis and interpretation. KYF and JT supervised the study. All authors contributed to the writing and proofreading of the final manuscript. The final manuscript was approved by all authors.

      Conflict of interest statement

      None declared.

      Funding sources

      This research did not receive any specific grant funding from agencies in the public, commercial or not-for-profit sectors.

      Ethical approval

      Not required.

      Appendix A. Supplementary data

      The following is the Supplementary data to this article:

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