Prevalence of occupational hand eczema among healthcare workers and its associated risk factors in a tertiary hospital in Sarawak during Covid-19 pandemic

   Abstract 


Background: Occupational hand eczema (OHE) is common among healthcare workers (HCWs), especially during the coronavirus disease 2019 (COVID-19) pandemic. Aims: Our study aimed to determine the prevalence of OHE among HCWs and to identify its associated risk factors. Methods: We conducted a cross-sectional study. A self-administered questionnaire study was done. It was followed by a clinical assessment of subjects with skin changes on their hands to determine the likely cause and its severity. Descriptive analysis and inferential analysis were performed to determine the prevalence of OHE and its associated risk factors. Results: A total of 1004 HCWs with a mean age of 34.58 years old were recruited. Of these, 50.1% were nurses, another 24.6% were doctors. A 1-year prevalence of 42.3% and a point prevalence of 16.5% were reported. Dry skin (n = 368, 86.6%) and itching (n = 274, 64.5%) were the common symptoms. Risk factors that were significantly associated with OHE were atopic eczema, allergic rhinitis, frequent hand washing and caring for children under four years old, whereas HCWs who frequently use alcoholic disinfectant and moisturizer hand cream showed lower odds of OHE. No significant association was found between age, gender, profession, involvement in COVID-19 care, number or duration of glove usage and occurrence of hand eczema. Conclusions: We report a high prevalence of OHE among HCWs during the current COVID-19 pandemic. Education and effective preventive measures are paramount to prevent and improve occupational dermatosis.

Keywords: Covid-19, hand eczema, healthcare workers, occupational, prevalence, risk factors


How to cite this article:
Teo HG, Lim TH, Bujang MA, Kiing JW, Muniandy P. Prevalence of occupational hand eczema among healthcare workers and its associated risk factors in a tertiary hospital in Sarawak during Covid-19 pandemic. Indian J Dermatol 2023;68:121
How to cite this URL:
Teo HG, Lim TH, Bujang MA, Kiing JW, Muniandy P. Prevalence of occupational hand eczema among healthcare workers and its associated risk factors in a tertiary hospital in Sarawak during Covid-19 pandemic. Indian J Dermatol [serial online] 2023 [cited 2023 Apr 1];68:121. Available from: 
https://www.e-ijd.org/text.asp?2023/68/1/121/373062    Introduction Top

Occupational skin disease is defined as a pathological skin condition in which occupational exposure is the major causal or contributory factor.[1] Contact eczema constitutes 95% of all occupational skin diseases.[2] Healthcare workers (HCWs) contribute to more than one-quarter of the occupational contact eczema cases.[3] Hand eczema comprises up to ≥80% of all occupational contact eczema.[4] Previous studies prior to the coronavirus disease 2019 (COVID-19) pandemic showed that the prevalence of occupational hand eczema (OHE) among HCWs ranged from 12% to 26.2%.[5],[6],[7],[8],[9] During the COVID-19 pandemic, there is an emergence of severe skin diseases and exacerbation of pre-existing dermatoses.[10] As a result, occupational hand eczema has become a major concern, especially among HCWs.[11],[12] To our best knowledge, there is limited published data on the prevalence and risk factors of OHE among HCWs in the era of COVID-19 pandemic. Our study aim is to provide new data on the prevalence of OHE among HCWs during the COVID-19 pandemic and determine its associated risk factors.

   Methods Top

This was a single-centre study conducted in a cross-sectional design from 1 May 2021 to 31 January 2022, at a tertiary hospital. We went to different departments in the hospital and approached all staff on duty. We invited those who worked with patient care direct or indirectly for at least 12 months to participate in the study. Informed consent was obtained from all the subjects, and a self-administered questionnaire was given. Respondents with self-reported skin changes of the hands during the past 12 months were assessed by dermatologists. During the assessment, a detailed history of skin changes on both hands followed by a clinical examination was done to determine the likelihood of occupational hand eczema and its severity using the Hand Eczema Severity Index (HECSI). HCWs who were diagnosed with non-occupational related dermatoses (i.e., psoriasis, urticaria due to food allergy, atopic eczema) were excluded from the study. Ethical approval was obtained from the Medical Research and Ethics Committee (MREC) prior to the conduct of the study.

Questionnaire

The questionnaires were adapted from the Nordic Occupational Skin Questionnaire 2002 (NOSQ-2002) English version.[13] Content validity was conducted by two subject matter experts in a similar field. The questionnaires were modified to target any self-reported skin changes (i.e. dryness, redness or itchiness) of the hands during the last 12 months. Further questions on onset, severity, factors associated with the skin changes on hands and the impacts on their work and daily activities were obtained. Forward and backward translations were conducted to produce a Malay version to address OHE among HCWs in the local settings. Face validity was conducted among five respondents, and there were no significant difficulties in understanding the questions among the subjects. Subsequently, the pilot study was conducted among 15 HCWs prior to the actual study, and the agreement test results were excellent. Intraclass correlation coefficient (ICC) of 0.605–0.762 was obtained for two questions of quantitative measurements. The remaining questions had a Kappa coefficient of 0.548 to 1.

Sample size

Previous studies reported the prevalence of occupational contact eczema was between 12% and 50%.[5],[6],[7],[8],[9],[11] Based on a 95.0% confidence interval, this study needs a minimum required sample size of 384 participants to be able to detect the estimated prevalence of 50.0% with a margin of error of 5.0%.

Statistical analyses

Descriptive analysis and inferential analysis were performed. Frequencies and percentages were used for the prevalence of occupational hand eczema, and categorical variables and means with standard deviations were used for continuous variables. A univariate analysis followed by a multivariate analysis was conducted to test the association between variables with OHE using logistic regression analysis. P values of <0.05 were considered significant, and odds ratios (OR) with a 95% confidence interval (CI) were used to establish the strength of associations. Analysis was performed using SPSS version 25.0.

   Results Top

We approached a total of 1026 HCWs who fulfilled the inclusion and exclusion criteria during the study period and 1014 (98.8%) HCWs were recruited. Up to 435 HCWs reported skin changes on their hands during the last 12 months. Of these, 425 were diagnosed with occupational hand eczema after assessment by dermatologists. The remaining ten HCWs were diagnosed with non-occupational related dermatoses (i.e., psoriasis, atopic eczema, urticaria due to food allergies and irritant contact dermatitis due to detergent at home), and they were excluded from the study. Thus, we included a total of 1004 HCWs in our study. Their socio-demographic and employment characteristics were summarized in [Table 1].

Table 1: Socio-demographic, working-related characteristic and univariate analysis (n=1004)

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Socio-demographic and work-related characteristics

The age of our study subjects ranged from 21 to 60 years old with a mean of 34.58. There were more females (n = 811,80.8%) than males (n = 193, 19.2%) with a ratio of 4:1. Only 2.8% (n = 28) of the subjects were active smokers. Half of the respondents were nursing staff, and another 247 (24.6%) were doctors. Up to 419 (41.7%) of the respondents were ever involved in the screening or management of COVID-19 patients. This includes managing patients at severe acute respiratory infection (SARI) wards/COVID wards/fever clinic or SARI zone at the emergency department. More than half (n = 606, 60.4%) of the respondents worked between 41 and 60 hours a week on average, in the past 12 months.

Prevalence of OHE

In our study, 425 respondents reported hand eczema symptoms during the past 12 months. Of these, 166 reported hand eczema symptoms during the study recruitment. Therefore, the 1-year prevalence and point prevalence of OHE were 42.3% and 16.5%, respectively. Dry skin (n = 368, 86.6%) and itching (n = 274, 64.5%) were common symptoms. Other symptoms included redness (n = 211, 49.6%), fissure or cracks (n = 192, 45.2%), pain (n = 83, 19.5%), papules (n = 76, 17.9%), vesicles (n = 65, 15.3%) and weeping or crusts (n = 63, 14.8%). Up to 90.4% (n = 384) of the HCWs with OHE experienced an improvement in their hand lesions when they were away from work. Despite the high prevalence of OHE among our study population, 96.9% (n = 412) of them did not request medical sick leave due to hand eczema.

Impacts of OHE on quality of life (QoL)

The mean score using a numerical rating scale (NRS) of 0–10 for the self-reported severity of OHE at its worst during the past 12 months was reported as high as 4.63 (SD 2.41) [Table 2]. During clinical examination, the mean score for HECSI was 2.08 (SD 3.61). In regard to QoL, 32.9% (n = 140), 14.4% (n = 61) and 9.4% (n = 40) of the respondents reported slight, moderate and large effects on their occupational work, respectively. Similarly, 32.5% (n = 138), 12.7% (n = 54) and 8% (n = 34) reported slight, moderate and large effects on their daily housework activities. The OHE had at least mild effects in 19.3–35.5% of the subjects in terms of hobbies or sports activities, sleep, social activities, close personal relations and mood.

Table 2: Clinical characteristics of skin changes and its impacts on quality of life (n=425)

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Risk factors for OHE

Univariate analysis was summarized in [Table 1], [Table 3] and [Table 4]. Our study did not show any association between OHE and gender, age, body mass index and smoker status. There was no statistically significant difference between educational level, departments, professions and OHE as well. In our study, it is shown that involvement in COVID screening or management did not increase the odds of OHE.

Table 4: Exposure at workplace and outside work and univariate logistic regression

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Respondents with a history of atopic eczema (OR 3.54, 95% CL: 2.43–5.17) or allergic rhinitis (OR 1.59, 95% CL: 1.18–2.15) showed significant association with OHE under multivariate logistic regression. Under the same model, asthma and a history of allergy to food or drug did not significantly associate with the occurrence of OHE [Table 3] and [Table 5].

Table 5: Risk factors associated with occupational hand eczema among healthcare workers: Multivariate logistic regression

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In multivariate analysis [Table 5], a dose-dependent association was found between OHE and the frequency of handwashing. Conversely, alcohol disinfectants use 6–10 times (OR 0.53, P = 0.002), 11–20 times (OR 0.56, P = 0.009) and ≥20 times (OR 0.49, P = 0.003) per day showed lower odds to have OHE compared to alcohol disinfectants use of 0–5 times per day. HCWs who had concomitant use of moisturizer hand cream had higher odds of OHE (OR 2.84, 95% CL: 2.11-3.84) than those who never used them. Glove usage, duration of glove usage and number of gloves used at work were not significantly associated with OHE in our study cohort. For exposures outside the workplace, taking care of children under four years old for <½ hour (OR 3.06, P = 0.049) and ½-2 hours (OR 3.44, P = 0.002) daily was associated with a higher risk of OHE. However, there was no association found between food preparation and cleaning or washing with OHE.

   Discussion Top

To our best knowledge, this is the first large-scale prevalence study in which all respondents with symptoms of HE were examined by dermatologists to exclude non-occupational-related hand dermatoses. From the previous validation studies, self-reported hand eczema has high specificity (>90%) but with lower sensitivity (<70%).[14],[15],[16],[17],[18] On the other hand, a symptom-based diagnosis has higher sensitivity with low specificity, but it was found to be inconsistent.[15],[19] The previous study done by Smit et al. concluded that a symptom-based questionnaire can be used to determine the prevalence of hand eczema in the study population provided that clinical examination was done on respondents with a positive diagnosis.[15]

Our study found a high prevalence of OHE among HCWs. This finding is in contrast with earlier studies done prior to the COVID-19 pandemic, which reported a 1-year prevalence of 12–26.2% among HCWs.[5],[6],[7],[8],[9] This indicates a high level of compliance to regular hand hygiene among HCWs as a measure to combat the COVID-19 pandemic. Studies done during the COVID-19 pandemic reported a wide range of prevalence, in part owing to different study methods and possibly different exposures.[11],[20],[22],[23],[24] A study on self-reported HE done by Hamnerius et al. reported a 1-year prevalence of 29% among Swedish HCWs during the pandemic.[24] Guertler et al. reported a high prevalence of symptoms associated with HE (90.4%) among the HCWs in Germany, but HE was underreported (14.9%).[21]

Most of our study population had mild HE on clinical examination with a HECSI score of 0–11. Our data may underestimate the severity of HE as many of the HCWs had their episodes of HE during the earlier stage of the COVID-19 pandemic and were self-treated or resolved after necessary measures. In the current study, 23.8% and 20.7% of HCWs with OHE reported moderate to large effects on their occupational work and daily housework activities, respectively. The productivity of these HCWs will be affected leading to suboptimal patient cares. However, only 18.4% of the affected HCWs visited a doctor for the treatment of their hand eczema. This could be due to their busy schedule, especially during the COVID-19 pandemic. Underreported self-diagnosed HE among HCWs, mild OHE which was resolved with proper hand hygiene and prevention, and self-treatment with over-the-counter topical steroids and moisturizers are among the factors.

In the current study, we found no significant difference regarding the prevalence of OHE between HCWs involved in COVID-19 and non-COVID-19 patients' care. In multivariate analysis, no association was found between OHE and the departments or occupations of the HCWs as well. This is likely due to an increase in hand hygiene and wet work among all HCWs regardless of their professions and working units as part of the measures to reduce the transmission of COVID-19 infection.[25]

Atopic dermatitis (AD) is strongly associated with OHE (OR: 3.54, 95% CI: 2.43–5.17) among HCWs. This association is not new, and several studies had found a similar association.[5],[6],[8],[24] This showed the need for effective education and management in AD patients, focusing on the prevention of OHE. In our study, HCWs with allergic rhinitis had higher odds of OHE (OR 1.59, 95% CI: 1.18–2.15) compared to those without. This can be explained by higher odds of AD among HCWs with allergic rhinitis (OR 3.26, 95% CI: 2.34–4.54) in our study populations.

In the current study, hand washing is strongly associated with the occurrence of OHE among HCWs in a dose-dependent pattern. Our finding is in accordance with studies conducted among HCWs in earlier studies in Sweden and Brunei.[6],[9],[24] For example, a cross-sectional study that was done in Sweden showed that frequent hand washing with soap was associated with increased odds of HE.[6] Repetitive hand washing predisposes to constant wet and dry cycles, disrupting the protective layer of the skin that makes it less pliable and more prone to contact dermatitis among HCWs.[26] In our study, HCWs who used alcohol disinfectants more than 5 times a day had lower odds of hand eczema compared to those who use 0–5 times per day. This is different from other studies done by Hamnerius et al. in which no significant association between HE and alcohol disinfectant use could be ascertained.[6],[24] Alcohol disinfectants had been shown to have a lower risk of irritants and better skin tolerance compared to hand washing with soaps.[27] Hand washing had been recommended to be replaced with disinfectant use whenever possible.[6] Change of the alcohol disinfectants containing emollients in our hospital during the pandemic can be a protective factor for HCWs who used the alcohol disinfectant frequently. Pederson et al. reported a lower risk of skin irritation with the use of glycerol-containing alcohol disinfectants.[28] Nonetheless, there is a lack of data on the types of alcohol disinfectants used in our study. Further studies are needed to clarify the exact effects of alcohol disinfectants with or without emollients. In the current study, no significant association was found between the number or duration of glove usage and OHE. Earlier studies on OHE also showed conflicting results regarding glove exposure and the risk of HE.[5],[24],[29]

For exposures outside the workplace, HCWs involved in caring for kids under four years old for ≤2 hours per day showed higher odds of OHE compared to those who were not involved. Wet works associated with diaper changes, bathing, and cleaning play an important role in these subgroups of HCWs. Proper education and emollients will be helpful to reduce the risk of OHE among those who involve in childcare. HCWs who used moisturizer hand cream concomitantly during the study period had higher odds (OR 2.8, 95% CI: 2.1–3.8) of OHE compared to those who never used it. The causal effect of this relationship can't be determined as no data on the timing of moisturizer hand cream usage either prior to or after the onset of OHE. Those with OHE are more likely to use moisturizer hand cream to alleviate the symptoms associated with OHE such as dryness, itching and papules.

Limitations

Cross-sectional studies using questionnaires tend to have recall bias. Another limitation was HCWs with HE were more likely to respond to the questionnaire and recruited to the study. This led to a selection bias, and our study may overestimate the true prevalence of OHE.

   Conclusion Top

Our study reported a 1-year prevalence of OHE of 42.3% and a point prevalence of 16.5% among HCWs during the COVID-19 pandemic. Atopic dermatitis, allergic rhinitis, frequent hand washing and taking care of children under 4 years old are associated with a higher risk of OHE, while the use of alcohol disinfectants reduced the risk of OHE. Education and effective preventive measures are paramount to reducing the prevalence of OHE among HCWs during the COVID-19 pandemic.

Acknowledgement

We would like to thank the Director General of Health Malaysia for his permission to conduct the study and for publication. We would like to thank all doctors and staff in the dermatology clinic at Sarawak General Hospital for helping during the conduct of the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 

   References Top
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]

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