COVID-19 Pandemic: What has work got to do with it?

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COVID-19 Pandemic: What has work got to do with it?
Pouran Faghri, M.D.1,4 – Marnie Dobson, Ph.D.2,4 – Paul Landsbergis, Ph.D.3,4 – Peter Schnall,
M.D.2,4
1University of California, Los Angeles, Los Angeles, CA, USA)
2University of California, Irvine, Irvine, CA, USA
3State University of New York – Downstate, New York, NY, USA
4Center for Social Epidemiology, Los Angeles, CA, USA
Corresponding Author:
Pouran Faghri, MD, MS FACSM
UCLA Fielding School of Public Health
650 Charles E. Young Drive South, 56-070 CHS
Los Angeles, CA 90095
Telephone: 310-206-5296
Pouran.Faghri@ucla.edu
Funding Sources: Center for Social Epidemiology (501c3)
Conflict of Interest: NONE
Address for Reprints (if different from Corresponding Author)
Acknowledgments, including all sources of support
Ethical Considerations & Disclosure(s) (e.g., IRB information, consent process, if applicable):
NA
Running Head Title (50 characters)
Work stress; essential workers; COVID-19

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Introduction
Since the start of the COVID-19 global pandemic more than 200 countries and territories have
experienced devastating public health, social and economic effects. Among those falling ill in
large numbers in the U.S. are workers in occupations or industries deemed “essential,” critical to
maintaining services to society during the pandemic. While definitions vary, “essential workers”
typically include workers in health care, food and agriculture, manufacturing, emergency
response, and transportation (1). Essential workers whose work cannot be done from home, or
those who work in close proximity to others (increasing the risk of exposure) also tend to have
lower incomes (2, 3). Some groups of essential workers are at increased risk of COVID-19 (4).
As well, African American and Latinx communities have been particularly hard hit by the
coronavirus, with a disproportionate number of infections and deaths (5-8). Black, Native
American & Hispanic/Latinx workers are more likely to be essential workers who work in
person and close to others and have lower incomes compared to white workers (2). Immigrant
workers are also more likely to be essential workers than native-born workers (9). One study
reported racial/ethnic disparities in job characteristics such as inability to work from home and
work in public safety, public utility, food or health care (10). African American and Latinx
workers are disproportionately represented in manufacturing, grocery(11), meatpacking (12) and
transit(13), which have also seen widespread workplace outbreaks of COVID-19.
In this paper, we examine two issues that impact on the magnitude and severity of the Covid-19
epidemic among workers - those work-related factors that increase the likelihood of exposure to
SARS-CoV-2 and to infection (differential exposure) among workers, including being an
essential worker, and work-related risk factors impacting the severity (differential vulnerability)
of COVID-19 illness. Stressful working (14) and low-income living conditions (15) increase the
risk of comorbid conditions, such as cardiovascular disease (CVD), hypertension and diabetes, as
well as impaired immune function, all of which increase the likelihood of severe illness if
exposed to SARS-CoV-2 (16-18).
Figure 1 provides a model of the overlapping and intersectional relationships between COVID19
and work that also helps to explain the disparities in exposure, infection and severe outcomes by
race-ethnicity and socioeconomic status (SES).
Insert Figure 1 here
Factors impacting the likelihood of SARS-CoV-2 exposure and infection among workers
Essential work is characterized by several features that increase the likelihood of infection.
Essential workers are less likely to work at home (e.g., in manufacturing, health care, as
warehouse workers, first responders) and that brings them in close contact with the public (e.g.,
grocery store workers, food service workers), as well as in close proximity with their coworkers
in indoor environments that may not be properly ventilated (e.g., meatpackers) nor where social
distancing is possible. This increases the likelihood that these workers are exposed to

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SARSCoV-2 (19). Other essential workers, such as health care workers and bus drivers, also
come into close contact with the public; drivers may not be protected (especially if they only
have cloth masks) as they work in close quarters with the public in crowded buses (13), while
health care workers, often with inadequate personal protective equipment (PPE), are face-to-face
with patients ill with COVID-19 and thus resulting in higher infection rates among these workers
(13, 20).
Additional factors impacting the likelihood of infection are race and ethnicity. African
Americans and Latinx people are among those at higher risk for contracting COVID-19 and have
higher rates of hospitalization and fatality (5-7, 10). This is due, in part, to greater socioeconomic
disadvantages and discrimination which increases the rate of comorbid conditions, reduce their
access to and the quality of health care (15, 17). In addition, African Americans and Latinx
people are more likely to be employed in essential in-person
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close-contact jobs (2). For
example, they are twice as likely as other workers to work in the animal slaughtering and
processing industries (locations of major COVID-19 outbreaks)(19). Racial/ethnic and SES
COVID-19 disparities, also result from workers of color and poorer workers being more likely to
live in densely populated areas where crowding increases the risk of exposure (5), to live in
households with workers who must work close to others, and households with at least two
generations of adults (2).
Factors impacting the severity of infection among workers
As occurs with other coronaviruses (severe acute respiratory syndrome coronavirus (SARS-
CoV) and Middle East respiratory syndrome coronavirus (MERS- CoV), COVID-19 can lead to
acute respiratory distress syndrome as a consequence of viral pneumonia. In addition,
uncontrolled COVID-19 has been shown to provoke an atypical immune response by triggering a
cytokine storm where pro-inflammatory cytokines and chemokines such as tumor necrosing
factor-a, IL-1 B and IL-6 are overproduced by the immune system causing multi-organ damage
(21, 22). It also causes coagulation abnormalities, including clotting and other thromboembolic
events, such as pulmonary embolism. Recent studies have shown that susceptibility to and the
outcome from COVID-19 are strongly associated with preexisting CVD and the relationship
between COVID-19 and CVD is bidirectional (23). COVID-19 has been shown to promote
cardiovascular damage, such as myocardial injury, arrhythmias, coronary heart disease and
venous thrombosis. It is therefore postulated that COVID-19 may also directly influence and
infect different heart muscle cells, such as cardiomyocytes, endothelial cells and pericytes
independent of respiratory issues, leading to major cardiovascular failure (24-26). The
preexistence of co-morbid conditions appear to enhance the ability of the virus to take root and
further damage the cardiovascular system.
We suggest that chronic exposure to stressors, including psychosocial workplace stressors,
interact with COVID-19 related sequalae. Stress also increase the body’s neural and endocrine
responses, a process named “allostasis.”(27) Another effect of chronic stress exposure is immune
function suppression which increases susceptibility to infection over time. Elevation of cortisol
is a natural hormonal response to acute stress, which increases the immune response and is
initially anti-inflammatory. However, chronic activation may lead to resistance and accumulation
of stress hormones and increase cytokine production which compromises the immune
response.(28)
1
In-person – work at the usual workplace as opposed to at home or remotely

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Over the past 40 years, research has identified a number of workplace psychosocial risk factors
that provoke the stress response and contribute to risk of illnesses, such as burnout, depression,
anxiety(29), elevated blood pressure (hypertension) and CVD (14). Workplace stressors, such as
high job psychological demands combined with low worker control over those demands (known
as “job strain”) elevate “allostatic load”(30). Low levels of coworker and supervisor support also
increase the risk of illness created by high job demands (31). Another work stressor (ERI or
effort-reward imbalance) is an imbalance between employee efforts and low rewards for those
efforts.(32) Overall, in addition to job strain and ERI, there are a substantial number (> 12) of
documented workplace stressors, including stressful organizational climate, harassment,
inflexible scheduling, job insecurity, long working hours, and work-life conflict contributing to
disease (33-35). The severity of COVID-19 is heightened in those with these comorbid health
conditions (24, 36, 37). Bus drivers, for example, are among the groups of essential workers in
which substantial elevations of blood pressure are associated with their work.
Chronic stress, including that caused by work stressors, will cause an increase in
proinflammatory cytokines and dysregulation of the immune system, which can lead to
activation of latent viruses. In adults, positive associations have been reported between chronic
work stressors and inflammatory markers such as C-reactive protein (CRP). High levels of CRP,
an indicator of elevated CVD risk, is associated with increased risk of SARS-CoV-2 infection
(21, 22, 38, 39). For example, caregivers experience longer healing time from wounds due to
lower lymphocyte accumulation, higher cytokines production, and lower antibody production
after vaccinations (25, 40).
Work stressors can affect individuals cumulatively throughout their working lives and the risk of
developing comorbid conditions increases substantially with age, in part due to chronic exposure
to workplace stressors (41). Also, as people age, the immune system weakens and the body’s
ability to regulate the cortisol response to both physical and psychological stressors decreases.
Some research suggests that older adults have difficulty terminating cortisol production in
response to stress (42, 43). At the cellular level, in some research chronic exposure to stressors
has also been linked to shortened telomere length in adults. The length of telomeres is directly
related to SES and poverty (44, 45), i.e., the lower the SES the shorter the telomeres.
Furthermore, low SES may lead to accelerated aging during stress exposure and lower immune
response significantly increasing the likelihood of manifest infection with SARS-CoV-2 and
severity of symptoms (46). In addition, the unhealthy behaviors promoted by work stressors
(lack of physical activity, unhealthy eating, alcohol and drug use, and lack of adequate sleep)
further contribute to development of chronic diseases, accelerated aging and lowered immunity
level (47).
The risk of a CVD event is increased up to 40% in those who are exposed to the abovementioned
work stressors compared to those who are not (33, 48). Work stressors also contribute to
increased risk of a second CVD event (49, 50) if returning to work and facing the same job
stressors as well as an increased likelihood of not returning to work at all. As a matter of fact, the
risk of a recurrent CVD cardiovascular event is increased by 65% in employees with “job strain”
or and other psychosocial work stressor risk factors (26, 51, 52). Workers who have suffered a
cardiovascular event or have comorbid conditions also are also more likely to take time off from
work due to their illnesses. How these factors impact on the ability of essential workers to
continue at work during the current pandemic requires further investigation.

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Racial and ethnic disparities in work exposures contribute to both the likelihood and severity of
infection, since workers of color are more likely to be working in essential jobs in-person and
close to others (2), and have work stress-related chronic conditions. Social and physical
distancing to reduce contacts between non-household members to reduce COVID-19
transmission to susceptible individuals, may be less effective in low-income neighborhoods.
Many low-income workers of color live in multi-generational households, with older family
members who are at higher risk of severe outcomes if exposed to the virus. These essential
workers face the dilemma of continuing to work and potentially exposing older family members
in the household (2). Prevention of COVID-19 among essential workers requires an examination
not only of those factors increasing exposure to the virus but also of the working conditions that
contribute to comorbidities and immune disruption.
Work stressors during COVID-19 pandemic:
Essential in-person work pays lower than median wages (2) and may also have higher than
average prevalence of work stressors. However, during the COVID-19 pandemic, it is clear that
stressors have increased in various essential occupations (and perhaps most occupations) due to
the threat of infection requiring constant vigilance to avoid infection and the adoption of new
demanding behavioral norms, such as mask wearing, social and physical distancing, and
isolation which may cause additional effects on mental health (23). Job insecurity is a
compelling work stressor during this pandemic, especially for essential and precarious workers.
Many workers have either lost their jobs, are afraid of losing their jobs, or fear being infected
and/or transmitting the infection to their households and family members (53, 54) . Additional
factors that contribute to work stress include struggles to manage work-life/family balance while
working either from home or at the workplace, managing children’s online education, having
childcare, and trying to learn new skills related to technology and communication. Job demands
have become heightened for some during the COVID-19 pandemic (55, 56). Workers who were
previously struggling with mental health issues are now experiencing heightened stressors, which
further increases their vulnerability. An increasing proportion of young people are reporting
suicidal ideation during the epidemic and many adults are reporting burnout (16, 57). Increasing
opioid fatalities have also been reported during the pandemic(58). Moreover, unhealthy
behaviors such as increased alcohol consumption, eating poorly, and exercising less, as a way of
coping with the stress of the pandemic, contribute to the development of chronic diseases, and
can further increase the severity of infection (17).
Conclusion and recommendations:
Essential in-person workers are at greater risk of SARS-CoV-2 infection due to their living and
working conditions bringing them into closer contact with those already infected, and at greater
risk of more severe infections when exposed to SARS-CoV-2 due to their higher rate of
comorbid conditions and immune system disruption possibly related to chronic exposure to work
stressors.
The first step in protecting essential workers and all other workers is to protect them from
becoming infected in the first place, an imperative that is still not being addressed adequately
during the pandemic. Providing personal protective equipment (PPE), including masks,
improved ventilation, and practicing social and physical distancing must be done at the
workplace and while going to and from work. Fortunately, some state occupational health

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agencies are now implementing new work environment regulations that provide for enforceable
workplace protections (59).
In addition to improved workplace safety and health, changes are needed that make it possible
for essential workers to properly protect themselves and practice social and physical distancing
in their homes and communities. Essential workers who earn lower incomes, have little paid sick
leave, and have little job security are less likely to be able to follow public health
recommendations, such as isolation or quarantining during this pandemic (5, 7). Many workers
are unable to quarantine when they get sick since it could jeopardize their jobs, income and
health care. These economic constraints contribute to the spread of the virus in workplaces and
communities. Examples of this were documented in meatpacking and farm worker virus
outbreaks, where some workers were reluctant to get tested or to stay at home if exposed because
of possible wage or job loss, and were also encouraged by management to work while exposed
or even while symptomatic (60, 61).
Essential workers would benefit from social policies that provide for paid family leave and fair
workers’ compensation benefits. Needed, most importantly, are protocols and enforceable
regulations that provide for safe workplaces and for adequate sick leave without penalty or fear
of job loss if they become ill. While the Congress passed the Family’s First Coronavirus Act and
the CARES Act that requires employers to pay for extended family leave or sick pay for their
employees, it does not apply to employers with over 500 employees. In addition, workers may
not know their rights or may be afraid to even get tested if it means they could not continue
working and providing for their families (62).
A second critical step to successfully protect all workers from COVID-19, in the absence of a
definitive medical treatment or a vaccine, is to address the work environment and its culture,
including psychosocial work stressors.
Occupational psychosocial risk factors predate the COVID-19 epidemic, but they contribute to
exposure, susceptibility to infection, and severity of illness during the pandemic. Workers of
color, who make up a larger percentage of essential in-person workers and have the highest rate
of COVID-19 infections and deaths, are made even more vulnerable due to the widespread
preexistence of comorbid conditions caused by stressful living and working conditions. This puts
them in a higher risk category (10) for serious disease after exposure. Reducing the presence of
comorbid conditions requires eliminating their social and occupational causes. Doing so will
reduce a workers' likelihood of co-morbid illnesses, such as diabetes, hypertension and CVD,
and thus reduce susceptibility to severe COVID-19 illness now and in future pandemics.
Finally, this pandemic underscores the deep inequities in this country that existed long before
SARS-CoV-2 and which have now been further highlighted. Addressing economic and social
inequities as well as unhealthy working conditions is paramount. Of course, many of these are
long-standing inequalities that will need to be remedied as we move ahead. What all workers
need right now is safe and healthy work, the ability to practice social and physical distancing,
access to affordable medical care, living wages, and to be treated with dignity and respect. As it
stands now, many workers are compelled to go to unhealthy workplaces and work even when ill,
which contributes to the continuing epidemic.

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Figure 1 legend
Figure 1. Socioeconomic status, race/ethnicity, working conditions and risk of SARS-CoV-2
infection and COVID-19 severity.
Note: “Differential exposure” refers to greater exposure to SARS-CoV-2 and risk of infection by
people experiencing lower socioeconomic working and living conditions, “essential workers”
and workers of color. “Differential vulnerability” refers to risk factors (resulting from living and
working conditions) that increase COVID-19 severity, if an individual is infected by SARSCoV-
2.

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'Figure 1- The contribution of social factors and working conditions to COVID-19 epidemic

Work
Essential work
+
low wages
+
psychosocial stressors
SARS
-
CoV
-
Exposure
2
COVID - 19
Illness
Severity
Sequelae
Differential Exposure
Physiological Impacts:
Inflammation
C
(
-
Reactive Protein,
ACE2 - renin -
angiotensin aldosterone system
Weakened Immune System
Increased cytokines
Lower lymphocytes
Non
-
Work
Living conditions
Multi
-
generational families
Public Transportation
“Pre
-
existing conditions”
Hypertension
Diabetes/metabolic syndrome
Obesity
Differential
Vulnerability
Government support for
worker rights, health
Race
Ethnicity
Low SES

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