Safely Returning America To Work Part Ii Industry-Specific Guidance

The world continues to face an unprecedented threat from the COVID-19 pandemic. Physical distancing has been identified as one of the methods of reducing transmission. As a result, businesses, schools, and institutes of education were closed due to such measures as well as restrictions on travel and social gatherings. Working from home, telework, and on-line meetings are now the norm. As businesses have reopened, they will be looking for guidance on how to work safely. Even those sectors that have continued to function will need guidance to ramp up functioning to new levels of normalcy. This document is intended to provide return-to-work guidance for both employers and the occupational and environmental medicine (OEM) physicians who will be supporting businesses to implement safe return-to-work strategies. TRANSMISSION While scientists race to develop effective, safe vaccines, and treatments to manage COVID-19, non-pharmacologic interventions (NPIs) serve as the bulwarks to reduce transmission of the SARS-CoV-2 virus. With wide social acceptance, NPIs can reduce the effective reproductive number of the virus and suppress the pandemic. NPIs include air ventilation/filtration, surface cleaning and sanitation, hand hygiene, avoiding touching the face, physical distancing, and a variety of other measures in the hierarchy of exposure control, including personal protective equipment (PPE). Respirators and face coverings are generally the least effective means of controlling most exposures. However, the opportunity for SARS-CoV-2 transmission in a wide variety of environments where other controls are challenging to optimize creates a critical role for the use of face coverings and respirators. The SARS-CoV-2 virus is frequently transmitted by the respiratory route. Viral containing particles in the air are often dispersed as either droplets or aerosol. Droplets are larger and heavier and fall to the ground relatively quickly in still air. Aerosols are smaller particles, remain suspended for longer times, and may be transmitted further. Evidence for droplet transmission is well-established as is that of aerosol transmission. Certain procedures such as intubation, bronchoscopy, or suctioning are likely to create many aerosol particles. However, aerosols may also be generated by singing or similar activities. Such activities may create smaller particles and, in addition, propel droplets or aerosols at high velocities so they will travel further. Published examples relate to local outbreaks following a choir practice in New York and an air conditioning system dissemination in China.1,2 In the United States (US), the Centers for Disease Control and Prevention (CDC) recommends following a “6-foot perimeter” distancing based upon the concept that droplets should fall to the ground within that distance. This is a somewhat arbitrary rule based upon the typical settling velocity for larger droplets in still air. This is not completely protective for two reasons. First, smaller particles or aerosols may be produced by the source or develop due to desiccation of larger particles. Second, droplets may be carried by convective air movement as well, remaining airborne longer and traveling further. These are affected by the airflow rates, direction, and the presence of turbulence. OSHA's Occupational Risk Pyramid Classification of worker exposure to SARS-CoV-2 using the Occupational Safety and Health Administration (OSHA) Occupational Risk Pyramid can help employer representatives determine and implement control measures. In the risk pyramid, OSHA classifies worker risk of occupational exposure to SARS-CoV-2. The level of risk depends on industry type, the need for contact within 6 ft. of individuals that are suspected of being infected or infected with the virus, or the need for repeated or extended contact with such individuals.3,4 Very high exposure risk refers to those with high potential for exposure to known or suspected sources of SARS-CoV-2 due to medical, laboratory, or postmortem procedures including health care workers (HCWs), laboratory personnel, and morgue workers. High exposure risk refers to jobs with high potential for exposure due to known or suspected sources such as health care delivery and support staff, medical transport workers and mortuary workers. Medium exposure risk refers to those that require frequent or close contact, within 6 ft. of those who are suspected to be infected with the virus but not known to be so. This includes workers who have frequent contact with travelers or with consumers in a community with high positivity rates. Lower exposure risk refers to those jobs not requiring contact with those infected with the virus or are suspected to be so, having minimal occupational contact with the public and other coworkers.3,4 The majority of workers fall into medium to lower exposure risk categories. ROLE OF OCCUPATIONAL AND ENVIRONMENTAL MEDICINE PHYSICIANS Occupational and environmental medicine (OEM) physicians have specialized training in epidemiology and public health and expertise in return-to-work practices, including the issues that pertain to testing protocols needed for communicable diseases and contact tracing. OEM physicians further have experience in organizational behavior and can additionally address fitness-for-duty determinations collaborating with other professionals as needed. OEM physicians collaborate with various professionals in diverse organizational settings to facilitate employees returning to work including public health officials, infection control practitioners, safety personnel as well as other occupational health professionals. Employers will need to look to expert professionals, including OEM physicians, for guidance regarding testing, contact tracing, and other return to work challenges.5 CDC and OSHA have made recommendations for employers regarding workplace considerations.6 Employers will need to develop and institute policies to facilitate the safety of employees. OEM physicians have various collaborative roles with other health and safety team members including human resources (HR), safety, industrial hygiene, infection control, and management. OEM physicians will have an important role and will advise in various return-to-work considerations. Policies for return to work after recovering from COVID-19 infection or exposure to an infected person must be established. Employers should put procedures in place and work with OEM professionals on what to do if an employee develops COVID-19 infection or tests positive for the virus, including quarantine and contact tracings. This should include how to handle surrounding privacy issues, stigma, and notifications. OEM physicians also have expertise in managing work-related illness and injuries as well as establishing work-related causation. Work-relatedness is established with a diagnosis by a treating physician, documented exposure, and evidence that the disease is related to the exposure. States vary on how this is applied during the COVID-19 pandemic. Some states have passed laws that there is a presumption of causation for certain workers. When the traditional workers’ compensation criteria are not met in a case, referral to an OEM physician for discussion of the work-relatedness is recommended. Role of Safety and Industrial Hygiene Industrial hygienists (also known as occupational health and safety science professionals) practice the science of anticipating, recognizing, evaluating, confirming, and controlling workplace conditions that may cause injury or illness to workers. The role of safety and occupational health professionals (OSH) professionals include anticipating, identifying, and evaluating hazardous conditions and practices as well as developing hazard control designs, methods, procedures, and programs. Further, both safety and industrial hygiene professionals have a role in implementing, administering, and advising others on hazard controls and subsequently to measure, audit, and evaluate the effectiveness of hazard controls and hazard control programs. Additional resources are available from the American Industrial Hygiene Association and the American Society of Safety Professionals.7,8 Reopening plans include determination of phases to re-populate facilities, preparing to implement basic infection prevention measures, developing policies and procedures for prompt identification and isolation of sick people as well as development, implementation, and communication about workplace flexibilities and protections including wellbeing and mental health services to be offered. Workplace controls are to be implemented based on short-term and long-term risk. OSH professionals should contact OEM professionals with questions pertaining to medical screening, contact tracing, workplace accommodations including as it pertains to high-risk vulnerable employees, and return-to-work evaluations. Hierarchy of Controls One way to categorize approach to exposures in the workplace is in terms of hierarchy of controls. This includes hazard elimination, substitution, engineering controls, administration, and PPE. Elimination/Substitution Hazard elimination in COVID-19 include ways to prevent exposure such as teleworking, postponing certain work, relocating, ensuring that only essential workers are on the job, health screening, and confining infected workers to home. Substitution could be thought of as permitting work alone in a spare room, solo workstation, or facilitating workers’ use of individual cars rather than collective transportation. Engineering Controls Buildings, Facilities, Operations, and Ventilation Core building infrastructure should be inspected including heating, ventilation, and air conditioning (HVAC), water system, plumbing, and new filters installed.9 Employers should consider designating separate entrances and exits for buildings and rooms, if possible, and provide unidirectional signage for traffic flow to ensure one-way pedestrian traffic flow along with frequent physical distancing reminders.9 Increments of acceptable physical distance on floors where lines might form (eg, entrance to building, restrooms, etc) should be designated. Areas of physical bottlenecks should be identified where physical distancing is more difficult and implement plans to alleviate bottlenecks (eg, restrooms, corridors, stairwells). Designating additional break rooms and lunchrooms to limit worker density and allow proper physical distancing should be considered.9 The workplace should be reconfigured taking physical distancing requirements into account, including occupancy limits, fitting workstations with Plexiglas if strict physical distancing cannot be maintained. Physical barriers can be installed such as plastic sneeze guards between workspaces that cannot conform to physical distancing guidelines. Consider using sensor technologies to monitor and govern physical distancing throughout a physical location.9 Plans should be developed for the safe restart of site assets and equipment including restart procedures, equipment maintenance audits, and preparation checks. Protocols should be developed for the use of confined spaces like elevators (eg, limited capacity of two or three individuals, and guiding workers on proper positioning in the elevators). Furniture should be removed from congregation-prone areas to discourage workers being too close to each other (eg, waiting/reception areas, dining/break rooms). Technology should be employed to monitor and govern physical distancing throughout the workplace. A formal assessment should be performed to determine areas that can be closed off that are not needed to do business, and close access to them, for example, gathering areas, and areas dedicated to certain workers. Motion-detection sensors should be installed in place of switches where possible to reduce touch points. Hands-free arm-pull or foot-operated door openers in restrooms and for other heavily trafficked doors should be installed. Signage for proper PPE usage, identification (eg, face shield for grinding operations versus plastic barrier for screening), should be prominently displayed.9 Further, processes for procurement and storage of hazardous materials (eg, hand sanitizer, cleaners, and disinfectants) should be implemented. Protocols should be established for proper disposal of face masks, gloves, and other disposable PPE worn during work shifts. Training programs should be developed, implemented, and monitored to ensure employees wear PPE properly. Procedures should be implemented for proper cleaning and disinfection of PPE if it is able to be reused.9 Administrative Controls Administrative controls include internal operating controls, the strategy for gradual reopening, management and worker education, training, de-densifying the workplace by staggering shifts, signage, communication strategies, the use of employee assistance program (EAP) services, virtual meetings, and travel restrictions. They also include alternating day schedule, starting with 25% capacity; telework for office workers, change shift start and end times to avoid shift congestion, change break, and lunch times to avoid lines, takeout food with touchless payment, individual water bottles, single serve coffee, and snacks. Also, reducing the number of workers in break or lunchrooms (ie, reducing number of chairs) and planning on minimum 36 square feet per person in spaces. Other options include using outdoor facilities or tents for extra break or lunch space and closing or reducing occupancy of meeting rooms and conducting virtual meetings whenever possible. Physical distancing should be observed when moving through the facility with one-way aisles or staircases and the number of individuals allowed in an elevator at one time should be limited. Visual cues and decals on floor in lines with 6 ft. of distance are helpful. Individual tools, workstations, electronics should be sanitized between use by others. The time for tasks where workers need to be within 6 ft. should be limited. Workers can be kept together in small teams to reduce exposures to large numbers of people on a site. Administrative controls further include screening for symptoms, temperature screening or using an attestation app as well as hand washing, use of sanitizer, respiratory hygiene, no contact greetings, and cloth face coverings. When and how should testing be offered and internal contact tracing are crucial considerations. Cleaning should be regular and enhanced after an exposure case. Accommodations should be made for high-risk workers and will require adequate communication with workers and leaders. Physical Distancing The CDC has developed guidelines for maintaining safe distancing in public that local health departments can use to help businesses implement and subsequently monitor for compliance.10 Even when lockdowns are relaxed, large public gatherings will remain on hold.11 Public areas need to ensure appropriate spacing, for example, limiting the number of customers in a business at any one time or the number of passengers in a subway car.11 Workplaces must be reorganized to minimize crowding by staggering shifts, limiting in-person meetings, appropriate spacing of seating arrangements, and resorting to telework as much as possible.11 Restaurants and retail stores need to actively plan and manage the spacing of customers, provide hand sanitizing facilities, and ensure appropriate ventilation to prevent viral particles from lingering in the air.11 Hygiene Practices Frequent handwashing and disinfecting should be adhered to according to local authorities. The correct number of sanitary facilities will be key, for example, hand washing and restroom facilities to facilitate good hygiene practices.12 Employees should be given sufficient time to wash their hands with soap and water for at least 20 seconds or use alcohol-based hand sanitizers.13 Good respiratory hygiene includes covering nose and mouth when coughing or sneezing and disposing of tissues.13 Encourage wearing a face mask whenever there is likely interaction between coworkers or the public. Consider allowing employees, where possible, to wear personal face coverings at work (check with applicable local and state requirements). Equipment, tools, and surfaces that are frequently handled must be cleaned and disinfected with standard products; door handles, mouse devices, keyboards, workbenches, handrails, screens, lockers, and forklifts are included. Site cleaning guidelines and frequency must be established, and cleaning chemical inventories maintained. The Environmental Protection Agency (EPA) provides a list of household disinfectants to kill the coronavirus SARS-CoV-2,14 and CDC also provides recommendations on environmental cleaning and disinfection.15 The frequency and intensity of cleaning and disinfecting should be increased in production areas, warehouses, offices as well as bathrooms, dining areas, and reception areas. Employees will need adequate training as well as supervision. Also, there should be a process in place for employees to report issues surrounding illness, hygiene, or physical distancing via telephone or email with prompt and appropriate feedback to the employee.12,13 Screening The Equal Employment Opportunity Commission (EEOC) has provided guidance allowing for employee testing consistent with it being a business necessity.16 Checking an employee's symptoms, including whether they have a fever, should be permitted during the pandemic, and EEOC should continue to allow this screening tool. While this is not a perfect solution because of the percentage of people who are asymptomatic, it is a helpful tool in determining if a person should not be at work. Guidance from EEOC and US Department of Health and Human Services (HHS) should be clear that temperature taking and symptom checking by a third-party provider retained by the employer, even if the third-party also is a medical provider, medical professional, or medical clinic, is not medical treatment and is not information protected by the Health Insurance Portability and Accountability Act (HIPPA). A recent study found that a self-reporting symptom application (app, COVID Symptom Study) was 80% successful in predicting who was likely to have COVID-19, with the loss of taste and smell being the top predictor of illness.17 The US Chamber developed a sample screening questionnaire that can also be used.18 In order for employees to return to a workplace, many organizations will institute screening (through self-assessments and temperature checks) to clear employees for entry into a building or site. If employers choose or are required to perform on-site temperature screens, they should be aware of the limitations, cautions, and requirements of testing. Temperature screening has not been shown to significantly impact the spread of COVID-19 based on current science. If it is used, it should be part of a larger education and pre-work screening effort which could include symptom screening and reminders of the importance of physical distancing, good hand hygiene, and face coverings. Organizations should consider certain actions such as providing written communication or webinars to inform employees how, when, and where screenings will be conducted and what will happen should an employee “fail” a temperature screening or provide a positive answer on a screening questionnaire. There should be careful attention to follow up steps for those who are instructed not to proceed to work as well as attention to all the concerns described above including how to keep information confidential; how to take temperature and maintain physical distance; how to proceed if an employee refuses to have their temperature taken and the return-to-work procedures if an employee does have an elevated temperature. Workplaces conducting symptom checking can also help identify areas of potential outbreaks and should share their results with public health officials. Employers should engage safety committees to help assist with creating guidelines. Employers are to ensure mechanisms are in place to track and understand completion and engagement metrics surrounding screening communications and training. Create guidelines for supervisors and managers in the event of a failed screening and ensure the employee has transportation and a place in which to self-isolate. A process should be established, including speaking points for communicating to employees who have been in contact with a symptomatic employee (eg, what steps occur as a result, self-quarantine, area closed for deep cleaning). Employers should adopt policies and practices that encourage employees to provide complete and accurate answers to questions concerning symptoms and potential COVID-19 exposures. Employers should be flexible with leave policies to ensure employees feel comfortable proactively sharing their symptoms and making decisions not to come to work at all. Any information maintained is subject to American with Disabilities Act (ADA) confidentiality requirements.18 Documentation of this information would represent a medical record and would also be subject to OSHA record keeping requirements (employment plus 30 years). HIPAA protects most health information from being shared publicly, including with employers. HHS has issued guidance during the pandemic to allow sharing of positive COVID-19 test to law enforcement, paramedics, other first responders, and public health entities. This guidance should be clearly extended to include employers as outlined by EEOC, for sharing of test results that constitute a potential direct threat, but not for sharing serology (blood test) results. Employers are responsible for providing safe workplaces to their employees and giving them access to this information will allow them to assist with contact tracing and containment. Personal Protective Equipment If used correctly, PPE such as masks and gloves can help reduce the spread of viruses.13 Gloves may be used but must be changed frequently and hands must be washed in between glove changes. Wearing gloves may allow bacteria to build up on the hands so handwashing is very important when gloves are removed to prevent subsequent contamination.13 Workers should avoid touching their eyes, nose, and mouth when wearing gloves.13 Wearing disposable gloves is not a substitute for handwashing, further removal of gloves could lead to contamination of hands.13 Wearing disposable gloves could give workers a false sense of security, which may result in staff not washing their hands as frequently as required.13 Hand sanitizers are an additional measure to handwashing but should not replace handwashing.13 Other PPE include face masks, hair nets, clean overalls, protective clothing, slip reduction work shoes and may be indicated for high-risk areas. Respirators and eye protection are recommended for two person tasks within 6 ft. and face shields should be added if cloth face coverings are worn instead of respirators. An N95 respirator with valve is appropriate if all workers performing similar tasks are wearing one. Medical Care/Physician-Prescribed Interventions Disease recognition and treatment (including testing) for individuals is a tertiary response/prevention and the hierarchy of controls contain primary and secondary prevention measures. On the other hand, preventing symptomatic people from entering the workplace and basing return to work on tests (if the predictive value improves in the future) could be either an engineering or administrative control. Exposure Controls The optimal methods for exposure control are source control and engineering controls as described above. Adequate area ventilation combined with attention to air flow direction and mixing efficiency is a central engineering control. This should be accompanied by adequate high efficiency particulate filtration and increasing the fresh (makeup) air. A filtration efficiency of at least MERV 13 is recommended by experts, and additional protection may be afforded by use of HEPA filters.19 Furthermore, ultraviolet germicidal irradiation (UVGI) has been suggested. Physical barriers to sneeze, cough, and spread from aerosol generating procedures should also be implemented. Use of respirators may also protect workers from inhaling and potentially being infected by viruses such as SARS-CoV-2. N95 respirators are commonly used for this purpose, but elastomeric dual cartridge respirators or powered air purifying respirators (PAPRs) may also be employed. N95 respirators are certified by the National Institute for Occupational Safety and Health (NIOSH)/National Personal Protection Laboratory. However, because of the pandemic induced shortage of N95 respirators, several that may be considered alternatives have appeared on the market. Some are inadequate and fraudulently labeled as N95 and approved by the National Personal Protective Technology Laboratory (NPPTL). In addition, the US Food and Drug Administration (FDA) has authorized use of devices called KN95, generally produced in China. The FDA emergency use authorization is for health care settings. Users should be sure that it is not a fraudulently labeled device. Wearing a facial covering that does not qualify as a respirator reduces the likelihood that an infected individual will emit viral particles in their area and as reviewed below and plays an important role as an NPI to mitigate transmission of COVID-19. DECISION-MAKING ABOUT USE OF RESPIRATORS AND FACIAL COVERINGS TO SIGNIFICANTLY REDUCE TRANSMISSION OF COVID-19 Although some employers have considerable experience with the choice and deployment of respirators for their workforce, many do not and even those with experience may not understand the use of respirators for management of infectious diseases. Decision-making should consider the following points: Is there a federal regulatory or state order? What are the occupational hazards and risks? Will the employer require or permit the use of a respirator or face covering? What device should be used? Regulatory Environment OSHA's Respiratory Protection Standard 29 CFR § 1910.134 outlines the requirements for a comprehensive respiratory protection program for when respirator use is appropriate. Description of the rules associated with respirator use is beyond the scope of this document. The key point here is that if employers require the use of a respirator (as opposed to a facial covering), including an N95, they must comply with the entirety of the 29 CFR § 1910.134. (OSHA has temporarily relaxed enforcement of some aspects of the Respiratory Protection Standard.20) The reader should note that the regulatory environment is dynamic and requires close attention to the latest information from OSHA and other pertinent regulatory agencies. The rule also requires that employers who provide respirators to employees for voluntary use or who permit employees to wear their own device must first determine that such use will not create a hazard. OSHA outlines the steps required to assure the safe use of respirators in these settings in its 1910.134 standard. The NIOSH Respirator Selection Logic provides guidance about the choice of the correct respirator for occupational respiratory hazards.21 However, this publication does not support the selection for protection from infectious diseases or terrorist agents. Instead, CDC provides guidance for the use of respirators and face masks for blocking transmission of infectious disease.22 States and municipalities have added to the regulatory environment with respect to face coverings and other NPIs during the COVID-19 pandemic. These mandates and recommendations have changed frequently. The reader is advised to consult a reliable source for the most up-to-date mandates specific to their site of operations.23 What Are the Hazards and Occupational Risks? The decision about respiratory protection should be based on an appropriate hazard and risk assessment. The hazard assessment describes the likelihood of a significant concentration of viral particles in the air. Several factors determine the concentration of particles: presence and number of infected individuals, the infected individual's actions that affect particle emissions (breathing, talking, singing, coughing, sneezing), behavior (use of face covering), and the duration spent in a particular environment. Indoor air is generally more hazardous than outdoor environments given the dilution inherent in outdoor air. Risk assessment should consider the number of people present, their susceptibility, their ventilation rate, their behavior (physical distancing, facial coverings, respirator, hand hygiene), their duration of exposure, and surface sanitation. Although the infectious dose of SARS-CoV-2 is not yet known, there is good reason to believe that risk will depend on both concentration and duration of exposure.3 Will the Employer Require or Permit the Use of a Respiratory or Face Covering? Some employers may decide to require or permit use of respirators or face coverings when not compelled by local orders or federal regulations. This decision should be based on the emerging science about blocking transmission with these devices. ACOEM's COVID-19 Resource Center is one site to find up-to-date evidence to inform decision-making.24 What Device Should be Used? PPE is designed to protect its user from exposure to hazardous agents. Very high-risk and some high-risk workers need PPE that includes respirators for protection from SARS-CoV-2. The choice of a respirator for this purpose should be guided by device availability, ability to manage use, the outcome of fit testing, and in some cases medical evaluation. Facial coverings that do not meet the specifications of a respirator include medical grade and non-medical grade face masks or facial coverings such