Research and Information on COVID-19: Social Determinants of Health

The Social Determinants of Health and the COVID-19 Pandemic

In Canada, it is widely recognized that the conditions in which people are born, grow, work, live, and age (i.e., the social determinants of health) account for the disproportionate health risks and health inequities across a population[1]. While COVID-19 has affected the entire world, the health risks, burdens, experiences, and outcomes are not equal for everyone.

A wealth of historical literature points to respiratory infection disparities in vulnerable populations because of differential exposure to influenza virus, differential susceptibility to disease, and differential access to health care. Research out of Ontario found that during the 2009 H1N1 pandemic, higher hospitalization rates were observed in people with lower education, of indigenous ethnicity, and who were living in deprived neighbourhoods (American Journal of Public Health).

This section shares some key research findings and resources on the social determinants of health as it relates to COVID-19. The information and research provided are not exhaustive and members are encouraged to engage in additional research and due diligence as required. Members wishing to share additional items for posting are invited to do so by emailing gotnews@oha.com. This resource will be updated as more information becomes available, and members are encouraged to visit regularly.

Disclaimer: This resource has been created for general information purposes only. The OHA assumes no responsibility or liability for any harm, damage or other losses, direct or indirect, resulting from any reliance on the use or the misuse of any information contained in this resource. Facts, figures and resources mentioned in the referenced resources have not been validated by the OHA.

[1] Raphael, D., Bryant, T., Mikkonen, J. & Raphael, A. (2020). Social determinants of health: The Canadian facts, 2nd Edition. Accessed online, January 2021 https://thecanadianfacts.org/The_Canadian_Facts-2nd_ed.pdf


Race and Ethnicity

Highlights

  • There is increasing evidence that COVID-19 is disproportionately affecting Black and racialized communities in Canada, the United States and the United Kingdom.
  • Racial differences are likely multifactorial and may reflect underlying racial differences in housing and working conditions, gaps in education, income and wealth, rates of underlying health conditions, access to care, etc.  
  • The lack of race- and ethnicity-based data in the health sector has made it difficult to measure health inequalities and to identify inequities rooted in racism and discrimination. 
  • Advocates and experts are calling for the collection of race-based data to inform pandemic recovery efforts and to address structural inequalities.

United States

  • This Morbidity and Mortality Weekly Report (June 2020) by the CDC, reported an overrepresentation of Black/African American among hospitalized patients based on data from end of January until end of May 2020.
  • An analysis of COVID-19 patients at Sutter Health, a large integrated health care system in northern California, showed that compared with non-Hispanic White patients, African Americans had 2.7 times the odds of hospitalization, after controlling for sociodemographic and clinical factors, as well as income (Health Affairs, May 2020).

  • The United States is seeing a heightened risk of death from COVID-19 among the Asian American population (Health Affairs, July 2020). 

  • The CDC 's Health Equity Considerations and Racial and Ethnic Minority Groups includes resources re: data on COVID-19 and race and ethnicity. It also offers information on factors that contribute to increased risk and what can be done to support communities that are disproportionately impacted by COVID-19.

  • Emory University maintains a COVID-19 Health Equity Interactive Dashboard. The National Health Equity Report compares COVID-19 cases, deaths and vaccination by race & ethnicity among other variables. Hispanic Americans and African Americans are two disproportionately under-vaccinated populations in the United States.

Canada

In early spring 2020, as research emerged showing that COVID-19 was having a disproportionate impact on racialized populations in the United States, several advocacy groups and news agencies in Canada highlighted data gaps in the health sector and the importance of collecting race, ethnicity and socio-demographic data related to COVID-19.

  • Read about it here:

    • Morrison, A. (2020, April 8). Outcry over racial data grows as coronavirus kills black Americans at disproportionate rate. Globe and Mail
    • Alliance for Healthier Communities (April 10, 2020). Letter to Premier Ford, Deputy Premier Elliott and Dr. Williams regarding the need to collect and use socio-demographic and race-based data
    • Pinto, A., & Hapsari, A. (2020, April 14). Collecting data on race during the COVID-19 pandemic to identify inequities. The Upstream Lab
    • McKenzie, K., Boozary, A. & Robertson, A. (2020, April 15). We need data to protect those most vulnerable to the coronavirus. Toronto Star
    • Hall, C. (2020, May 30). This expert is alarmed by Canada's failure to collect race-based pandemic data. CBC
  • In May 2020, Manitoba became the first province to track sociodemographic data related to COVID-19. Quebec and Ontario followed (Ontario Government News Release, June 15, 2020).
  • On May 29th, 2020, the Canadian Institute for Health Information (CIHI) proposed an interim race data collection standard. In July 2020, CIHI released a broader discussion document with greater details on measuring racial health inequalities in Canada.

In the absence of race, ethnicity and sociodemographic data for Canadians with COVID-19, in May 2020, a research team at the University of Western Ontario leveraged Public Health Agency of Canada COVID-19 data and census data to assess how racial and socioeconomic factors have shaped COVID-19 infection and death rates. Some notable findings include:

  • COVID-19 infection rates are higher in health regions with a higher percentage of Black residents.
  • COVID-19 infection rates are higher in health regions with a higher percentage of foreign-born residents.
  • COVID-19 death rates are higher in communities with higher proportions of adults aged 65 years and older (Choi, Denice, Haan & Zajacova, 2020). 

IC/ES maintains a COVID-19 dashboard that provides an overview of the sociodemographic and clinical characteristics of Ontarians who were tested and confirmed positive for COVID-19.

  • In May 2020, IC/ES released a report describing the sociodemographic and clinical characteristics of those who had been tested for COVID-19 in Ontario up until April 30th, 2020. Some notable findings include:
    • Ontarians who tested positive for COVID-19 were more likely to live in marginalized neighbourhoods with a greater concentration of immigrants and visible minorities. 
    • Those who live in neighbourhoods with a higher concentration of visible minorities were less likely to be tested for COVID-19, but more likely to be among those who tested positive.    
  • A September 2020 IC/ES report analyzed COVID-19 testing and test result data among immigrants and refugees and Canadian-born counterparts between January 15 and June 13, 2020. Some notable findings include:
    • Immigrants, refugees and newcomers accounted for 43.5% of all COVID-19 cases, despite only making up over 25% of the population in Ontario.
    • Testing rates were lower in most immigrant, refugee and newcomer populations, in comparison to Canadian-born and long-term residents.
    • The rate of positive cases is significantly higher than Canadian-born or long-term residents.  
  • An April 2021 IC/ES report found that COVID-19 vaccination rates were consistently lower in immigrants, refugees, and recent OHIP registrants than in Canadian-born/long-term residents in all age groups (and particularly in those aged 70 and above) and across all neighbourhood risk groups. It was also found that in those under 65 years of age, vaccine coverage had increased most in those living in neighbourhoods with high COVID-19 risk.

Sociodemographic Data and Reports in Ontario:

The Ontario Health Report: Tracking COVID-19 Through Race-Based Data (August 2021), developed in partnership with the Wellesley Institute, analyzed data on confirmed COVID-19 cases since June 26th, 2020, when race-based data collection began, until April 21, 2021. The analysis found:

  • White Ontarians had the lowest rates of COVID-19 infection. In comparison to white Ontarians, racial groupings had:
    • 1.2- to 7.1-fold higher age-standardized per capita rate of infection
    • 1.7- to 9.1-fold higher age-standardized per capita rate of COVID-19-related hospitalization
    • 2.1- to 10.4-fold higher age-standardized per capita rate of COVID-19-related critical illness (ICU admission)
    • 1.7- to 7.6-fold higher age-standardized per capita rate of death following COVID-19 infection
  • Recommendations from the Report:
    • Ontario's health and public health systems standardize the collection of sociodemographic data through health care registration and renewal
    • The health system apply anti-racist approaches to identify systemic causes of health inequities
    • The health system use race-based data to inform recovery efforts and address structural inequities 

Toronto Public Health

  • Report: COVID-19 and the Social Determinants of Health: What do we know? Are some populations disproportionately affected by COVID-19 in Toronto (July 2020)
  • According to the Toronto Public Health, COVID-19: Ethno-Racial Identity and Income Dashboard as of May 31st, 2021:
    • The majority (73%) of reported COVID-19 cases in the City of Toronto identified with a racialized group, which is higher than the proportion of the total population of Toronto who identified as belonging to a racialized group.
    • Sixty seven percent (67%) of people who were hospitalized due to COVID-19 identified as belonging to a racialized group, and after age-standardization, this increased to 75%.
    • Racialized groups over-represented in reported COVID-19 cases and hospitalization include: Arab, Middle Easter, or West Asian people; Black people; Latin American people; South Asian or Indo-Caribbean people; Southeast Asian people
    • Ethno-racial groups under-represented in reported COVID-19 cases and hospitalizations include: East Asian people; White people

Ottawa Public Health

  • Report: COVID-19 and Racial Identity in Ottawa (November 2020) based on data from February to August 2020, showed:
    • Racialized populations (particularly those who identify as Black) are over-represented among people with COVID-19 in Ottawa
    • Among people with COVID-19, most of those who are racialized are not born in Canada; they identify as Middle Eastern, Black and South Asian and appear to have immigrated within the last five years.

Peel Public Health           

  • Report: COVID-19 and the social determinants of health: race and occupation (August 2020)
  • Race-based data available from the COVID-19 in Peel dashboard shows that between April 13, 2020 and July 31, 2021:
    • Visible minorities are over-represented in Peels' COVID-19 cases (represent 63% of Peel's population but make up 83% of COVID-19 cases)
    • Race groups that were overrepresented among COVID-19 cases compared to their respective share of the Peel population were: South Asian, Black, Middle Eastern and Latino.

How has COVID-19 Impacted Indigenous Communities in Canada?

  • A September 2020 CMAJ article explores COVID-19 and the decolonization of Indigenous public health. It reports that Indigenous communities in Canada have had a lower rate of COVID-19 and a lower case-fatality rate in comparison to non-Indigenous communities despite structural inequities and social determinants that are often related to worse health outcomes. This is significantly different from the outcomes during the H1N1 pandemic.
  • Health Canada (March 2021): What we heard: Indigenous Peoples and COVID-19 – this report, led by the Waakebiness-Bryce Institute for Indigenous Health (WBIIH) and the Dalla Lana School of Public Health, University of Toronto, complements the Chief Public Health Office of Canada's Report on the State of Public Health in Canada. It summarizes the key themes provided by engagements with Indigenous communities and organizations.  
  • In April 2021, a Toronto Star article reported, based on exclusively acquired data, that Indigenous people in Toronto have been hospitalized with COVID-19 at 3x the rate of the city's general population. The rate of COVID-19 for Indigenous people in Toronto is also 23% higher than the city's general population.
  • Find the most current epidemiological summary of COVID-19 cases in First Nations communities across Canada here.

United Kingdom (UK)

  • This cross-sectional study conducted by The Oxford Royal College of General Practitioners (RCGP) Research and Surveillance Centre in the UK showed that the adjusted odds ratio of contracting COVID-19 among Black adults between January and April 2020 was 4.75 higher compared to White adults (Lancet).
  • Data from England collected between January 2020 and March 31, 2021, shows (Office for National Statistics):
    • During the first wave of the pandemic, people from all ethnic minority groups (except for women in the Chinese or "White Other" ethnic groups) had higher rates of COVID-19 death in comparison to the White British population.

    • The rate of COVID-19 mortality was highest for the Black African group, followed by the Bangladeshi, Black Caribbean, and Pakistani ethnic groups.

    • In the second wave of the pandemic, the differences in COVID-19 mortality compared with the White British population increased for people of Bangladeshi and Pakistani ethnic backgrounds; the Bangladeshi group had the highest rates, 5.0 and 4.1 times greater than for White British males and females respectively.

    • Although the Black Caribbean and Black African populations maintained an elevated risk in the second wave, the relative risk compared to the White British population was reduced in comparison to the first wave.

  • In September 2020, the Scientific Advisory Group for Emergencies (SAGE) submitted a report to the UK government entitled, Drivers of the higher COVID-19 incidence, morbidity and mortality among minority ethnic groups. It summarizes the available epidemiological evidence of ethnic inequalities in COVID-19 and explores explanations for the observed differences. The group uses a conceptual model that highlights possible pathways from exposure to the virus, through infection to the development of severe disease.
  • The REal-time Assessment of Community Transmission-2 (REACT-2) national study evaluated the prevalence of IgG antibodies for SARS-CoV-2 infection among 100,000 adults aged 18+ living in England (Nature, Feb 2021). Some notable results include:
    • The highest prevalence by ethnic group was found in people of Black and Asian ethnicities. Black ethnicity was associated with a three-fold increase in odds of being antibody positive (and reduced to an odds ratio of 2.0 after adjusting for covariates).
    • The results of this study suggest that the different frequency of infection drives differences in mortality rates between ethnic groups.
    • This is counter to the thinking that increased risk of hospitalization and mortality from COVID-19 among certain ethnic groups is due largely to comorbidities or other biological factors.

Additional Research and Resources: COVID-19 and Race/Ethnicity

 

Housing

Highlights

  • "Housing has become the front line defence against the coronavirus. Home has rarely been more of a life or death situation."  Leilani Farha, Former UN Special Rapporteur on the right to adequate housing  
  • Poor housing conditions, such as overcrowding, incomplete kitchen or plumbing facilities or high cost burden, have been associated with an increased rate of COVID-19 infection. 
  • People experiencing homelessness, or with a recent history of homelessness, are especially vulnerable to SARS-CoV-2 infection and its complications. 
  • In Canada, and many countries around the world, long-term care and retirement home residents and staff have been disproportionately affected by COVID-19.

  • Poor housing conditions can limit the ability to practice or put in place COVID-19 prevention strategies like hygiene measures, self-isolation, or self-quarantine. COVID-19 outbreaks have occurred in many shared and congregate housing settings such as correctional facilities, homeless shelters, and long-term care facilities (CDC, December 2020).
  • This study reviewed over 3000 US counties and found that those with a higher percentage of households with poor housing conditions had a higher incidence of, and mortality associated with, COVID-19. Poor housing conditions included overcrowding, incomplete kitchen facilities, incomplete plumbing facilities or a household that was severely cost burdened (PLOS ONE, November 2020).
  • In July 2020, the City of Toronto found that in areas with the highest rates of household crowding, COVID-19 case counts were significantly higher in comparison to areas with the lowest rates of household crowding (568 per 100,000 vs. 144 per 100,000). In response, the City of Toronto created isolation centres to support people who are unable to safely and effectively isolate at home.
  • This paper explored the impact of eviction moratoriums on COVID-19 incidence and mortality. It found that in states that ended eviction moratoriums, COVID-19 incidence and mortality increased, offering further evidence for the use of eviction moratoriums to prevent the spread of COVID-19 (American Journal of Epidemiology, July 2021).

People Experiencing Homelessness

  • People who sleep in homeless shelters or who are dependent on drop-in centres are at greater risk for contracting COVID-19. Oftentimes, sleeping arrangements are crowded, bathrooms and common spaces are shared and overall, it is difficult for this population to follow public health advice around physical distancing, isolation, quarantine and hand hygiene. People experiencing homelessness often have underlying chronic conditions, which increases the likelihood that they will experience severe disease and require hospitalization (Lancet Commentary, May 2020).   
  • A May 2020 study investigating an outbreak at three affiliated homeless shelters in King County, Washington found that 35 of 195 (18%) residents and eight of 38 (21%) staff members tested positive for COVID-19.

  • A CDC report on the incidence of COVID-19 in homeless shelters in four US cities (Seattle, San Francisco, Boston, Atlanta) found that 25% of 1,192 residents tested were positive for the virus. Of the 313 staff tested, 33 (11%) were positive (May 2020).

  • The Boston Health Care for the Homeless Program (BHCHP) assessed the prevalence of COVID-19 among the population of a large shelter in Boston. Of the 408 residents, 36% tested positive for the virus. A large proportion (87.8%) of those who tested positive were asymptomatic at the time of testing (research letter, April 27, 2020, JAMA).

  • Based on data between January 23 and July 31, 2020, people experiencing homelessness in Ontario were more likely to be tested, test positive, be hospitalized, be admitted to the intensive care unit and die of COVID-19 in comparison to community-dwelling individuals (CMAJ).

  • Public Health Ontario: Health Protection Actions for People Experiencing Homelessness During the COVID-19 Pandemic. This environmental scan identifies actions being taken over the course of the COVID-19 pandemic to meet the basic health and social needs of people experiencing homelessness (March 2021).

Long-term Care Facilities and Retirement Homes

  • Internationally, a large proportion of COVID-19 deaths have been among long-term care (LTC) residents.  The International Long-Term Care Policy Network (ILPN) documents the impact of COVID-19 on this population and offers a number of resources to support community and institutional long-term care responses.
  • A paper examining the association between crowding in long-term care homes and the incidence of COVID-19 across over 600 long-term care facilities in Ontario found that about one quarter of residents live in 4-bed rooms and residents in highly crowded homes were twice as likely to become infected and die of COVID-19. Simulation analyses suggest that 20-30% of COVID-19 infections and deaths in Ontario LTC homes could have been prevented if all 4-bed rooms had been modified to 2-bed rooms prior to the pandemic (JAMA, 2020).

  • In March 2021, CIHI released, Long-term care and COVID-19: The First 6 months, which considers the impact of COVID-19 on residents and staff during the first wave (March 1 to August 31, 2020) and some early comparisons with the second wave (September 1, 2020 to February 15, 2021) of the COVID-19 pandemic. Some key findings reported:

    • In comparison to the first wave, there were more outbreaks, infections, and deaths in LTC and retirement homes during the second wave of the pandemic.
    • During the first wave, LTC residents received less medical care than in previous years. There were also more deaths than usual.
    • To date, recommendations from provincial and national inquiries on COVID-19 in long-term care facilities are similar and highlight the structural issues in the sector. Some of these include the need for more staff, better infection prevention and control practices, improved inspection and enforcement of standards, and improved infrastructure to prevent crowding and infection spread.
  • In this March 2021 science brief, the COVID-19 Ontario Science Table evaluated the early impact of Ontario's COVID-19 vaccine rollout on long-term care home residents and health care workers. Eight weeks after the start of vaccination, it was evident that vaccines had substantially reduced infections, hospitalizations and deaths among health care workers and residents.
  • The National Advisory Committee on Immunization (NACI) has recommended boosters of the COVID-19 vaccine for all long-term care residents and older adults living in congregate settings (Government of Canada, September 28, 2021).

    On October 1st, 2021, the Ontario government announced mandatory vaccines for all long-term care home staff, support workers, students and volunteers by November 15th, 2021 (Ontario Newsroom).

Additional Information: Housing and COVID-19

 

Income and Socioeconomic Status

Highlights

  • People who are socially and economically disadvantaged are particularly vulnerable to COVID-19.
  • There is increasing evidence that low-income populations have disproportionately high rates of COVID-19 infection, hospitalization and mortality in the Canada, the United States, and the United Kingdom.

  • For people of low socioeconomic status (SES), there are several factors that increase their exposure to COVID-19. For example, economically disadvantaged people:

    • are more likely to live in overcrowded housing, which make it more difficult to practice physical distancing.
    • are often employed in occupations where working from home if not possible.
    • are more likely to have unstable work conditions and incomes.
    • tend to access health care at a more advanced stage of disease, which leads to poorer health outcomes.
    • are at higher risk for conditions such as hypertension and diabetes, which are risk factors for death from COVID-19 (Public Health, June 2020)

Canada

  • In Canada, as of November 2020, people from the least affluent neighbourhoods had the greatest number and percentage of COVID-19 hospitalizations and emergency department visits:
  • Similar patterns can be observed from Toronto Public Health data. Data as of February 28th, 2021, showed that a higher proportion of COVID-19 cases in people living in households considered to be "low income" in comparison to higher income households.

International

  • In the United States, data as of May 5th, 2020 show a substantially unequal burden of COVID-19 outcomes by county. COVID-19 death rates per 100,000 person-years were the following:
    • 143 vs. 83 in high versus low poverty counties
    • 124 vs. 48 in counties in the top versus bottom quintile for household crowding
    • 128 vs. 26 for counties in the top versus bottom quintile for the percentage of persons who are people of colour (Journal of Public Health Management and Practice)
  • In England, data as of July 31st, 2020 show the age-standardized mortality rate of COVID-19 deaths was more than double in the most deprived areas compared to the least deprived areas (3.1 vs. 1.4 deaths per 100,000) (Office for National Statistics). 


Occupation

Highlights

  • Early in the pandemic, Canadian workers in the bottom of the earnings distribution lost many more working hours than workers in the top of the earnings distribution. However, some low-income workers are working more because of the COVID-19 economic shutdown.
  • Workers in low-paid occupations are working in jobs that increase their risk of contracting COVID-19; this is particularly true for women, immigrants and racialized workers.
  • Outside of jobs in health care, workers with a Bachelor's degree or more face significantly lower occupational exposure risks. 
  • Paid sick leave can support essential workers in following public health measures, which in turn can reduce transmission and illness among essential workers

  • Across Canada, and around the world, public health measures to "flatten the curve" have included requirements to close non-essential businesses (ILO-OECD, 2020).

  • Public-facing sectors such as retail trade, tourism and hospitality, recreation, and food services have been significantly impacted by such closures (St. Denis, 2020).  

  • Based on March and April 2020 data from Statistics Canada's Labour Force Survey, workers in the bottom of the earnings distribution lost many more working hours than workers in the top of the earnings distribution. However, the analysis also found that some low-income workers are working more as a result of the COVID-19 economic shutdown (Canadian Labour Economics Forum- Working Paper Series- Spring/Summer 2020).

  • The October 2020 Statistics Canada report, COVID-19 in Canada: A six-month update on social and economic impacts showed that:

    • In comparison to Canadian-born workers, immigrants and visible minorities were more likely to have lost their jobs in March and April 2020, mostly because they were new to the job markets and more likely to have lower-paying jobs.
    • People that were able to work from home fared better during the pandemic.
    • Youth, less-educated workers, women, recent immigrants and temporary employees were most affected by the pandemic.
  • Research on the sociodemographic determinants of occupational risks of exposure to COVID-19 in Canada, published in July 2020, showed that:
    • Some occupations place workers at greater risk of exposure because of the need to be physically close to others and the frequency of exposure to diseases/infections (of all sorts).
    • Based on Canadian 2016 Census data, about 45% of Canadian workers are in occupations that require performing activities in close physical proximity to others (at arm's length or closer). Whereas about 8% of Canadian workers are in occupations with a regular frequency of exposure to diseases/infections (e.g., food processing, health care, etc.).
    • Women seem to have a higher occupational risk of exposure to COVID-19 in comparison to men. This is largely driven by the fact that women are over-represented in occupations that have significantly higher average risk scores (e.g., health care).
    • Outside of jobs in health care, workers with a Bachelor's degree or more face significantly lower occupational exposure risks.
    • Older workers (65 years or more), a group vulnerable to COVID‐19, tend to work in occupations with activities requiring a lower level of physical proximity than their younger colleagues, with little differences in the frequency of exposure to diseases/ infections.
    • When compared to those not working in low‐income occupations, low-income workers are more likely to have occupations where they need to be physically close to others and where they are exposed to infections/diseases. This pattern is particularly apparent among women, immigrant, and visible minority workers (St. Denis, 2020).  
  • At the beginning of the pandemic, health care workers across Canada tested positive for COVID-19 more often than the general population. This February 2021 CIHI report re: COVID-19 cases and deaths in health care workers in Canada shows that while health care worker cases increased in the 6 months prior to the report, in almost all provinces, growth was slower when compared with growth in cases in non-health care workers.
  • Meat and poultry processing plants emerged as a common outbreak site in Canada and the United States. This CDC Morbidity and Mortality Weekly Report (May 8th, 2020) reviews factors influencing the risk for infection. Some of these include: difficulty maintaining physical distancing and adhering to face coverings; difficulty adhering to cleaning and disinfection guidance; the fact that many workers live in crowded, multigenerational homes and often share transportation to and from work.
  • In Peel Region, between March 5th, 2020 and July 31st, 2021 occupation groups with the highest proportion of COVID-19 cases included trades, transport and equipment operators and related occupations, sales and service occupations and business, finance and administration occupations (Peel Public Health).

Paid sick leave can help reduce the spread of COVID-19

  • The Ontario Science Table's research brief on the Benefits of Paid Sick Leave During the COVID-19 Pandemic, reviews the evidence suggesting that paid sick leave is related to a reduction of COVID-19 transmission and illness among essential workers. Providing workers with paid sick leave can support them in following public health measures including when they need time off because of illness, an exposure, to self-isolate, to get tested, to get vaccinated or when their workplaces close because of an outbreak. The brief proposes a model for a paid sick leave program in Ontario (May 4th, 2021).

Additional Research and Resources: COVID-19 and Occupation

  • The Research, Analysis and Evaluation (RAEB) Branch of the Ontario government produced an evidence synthesis briefing note on the impact of providing workers with paid sick leave benefits during the COVID-19 pandemic (February 2021).