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Safely Returning America to Work Part II Glenn S ACOEM GUIDANCE STATEMENT Safely Returning America to Work Part II Industry-Specific Guidance Tanisha K. Taylor, MD, MPH, MBA, Rupali Das, MD, MPH, Kathryn L. Mueller, MD, MPH, Glenn S. Pransky, MD, Philip Harber, MD, MPH, Robert K. McLellan, MD, MPH, Natalie P. Hartenbaum, MD, MPH, Amy J. Behrman, MD, Deborah R. Roy, MPH, RN, CSP, and Robert C. Blink, MD, MPH he world continues to face an unprec- critical role for the use of face coverings contact within 6 ft. of individuals that are T edented threat from the COVID-19 and respirators. suspected of being infected or infected with pandemic. Physical distancing has been The SARS-CoV-2 virus is frequently the virus, or the need for repeated or 3,4 06/05/2021 on BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= by http://journals.lww.com/joem from Downloaded transmitted by the respiratory route. Viral extended contact with such individuals. Downloaded identified as one of the methods of reducing transmission. As a result, businesses, containing particles in the air are often dis- Very high exposure risk refers to schools, and institutes of education were persed as either droplets or aerosol. Droplets those with high potential for exposure to from closed due to such measures as well as are larger and heavier and fall to the ground known or suspected sources of SARS-CoV- http://journals.lww.com/joem restrictions on travel and social gatherings. relatively quickly in still air. Aerosols are 2 due to medical, laboratory, or postmortem Working from home, telework, and on-line smaller particles, remain suspended for lon- procedures including health care workers meetings are now the norm. As businesses ger times, and may be transmitted further. (HCWs), laboratory personnel, and morgue have reopened, they will be looking for Evidence for droplet transmission is well- workers. High exposure risk refers to jobs guidance on how to work safely. Even those established as is that of aerosol transmission. with high potential for exposure due to by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= sectors that have continued to function will Certain procedures such as intubation, bron- known or suspected sources such as health need guidance to ramp up functioning to new choscopy, or suctioning are likely to create care delivery and support staff, medical levels of normalcy. This document is many aerosol particles. However, aerosols transport workers and mortuary workers. intended to provide return-to-work guidance may also be generated by singing or similar Medium exposure risk refers to those that for both employers and the occupational and activities. Such activities may create smaller require frequent or close contact, within environmental medicine (OEM) physicians particles and, in addition, propel droplets or 6 ft. of those who are suspected to be who will be supporting businesses to imple- aerosols at high velocities so they will travel infected with the virus but not known to ment safe return-to-work strategies. further. Published examples relate to local be so. This includes workers who have outbreaks following a choir practice in New frequent contact with travelers or with con- TRANSMISSION York and an air conditioning system dissem- sumers in a community with high positivity While scientists race to develop ination in China.1,2 rates. Lower exposure risk refers to those effective, safe vaccines, and treatments to In the United States (US), the Cen- jobs not requiring contact with those manage COVID-19, non-pharmacologic ters for Disease Control and Prevention infected with the virus or are suspected to interventions (NPIs) serve as the bulwarks (CDC) recommends following a ‘‘6-foot be so, having minimal occupational contact to reduce transmission of the SARS-CoV-2 perimeter’’ distancing based upon the con- with the public and other coworkers.3,4 The virus. With wide social acceptance, NPIs cept that droplets should fall to the ground majority of workers fall into medium to can reduce the effective reproductive num- within that distance. This is a somewhat lower exposure risk categories. ber of the virus and suppress the pandemic. arbitrary rule based upon the typical set- NPIs include air ventilation/filtration, sur- tling velocity for larger droplets in still air. ROLE OF OCCUPATIONAL AND face cleaning and sanitation, hand hygiene, This is not completely protective for two ENVIRONMENTAL MEDICINE reasons. First, smaller particles or aerosols avoiding touching the face, physical dis- PHYSICIANS tancing, and a variety of other measures in may be produced by the source or develop the hierarchy of exposure control, including due to desiccation of larger particles. Sec- Occupational and environmental personal protective equipment (PPE). Res- ond, droplets may be carried by convective medicine (OEM) physicians have special- ized training in epidemiology and public pirators and face coverings are generally air movement as well, remaining airborne health and expertise in return-to-work prac- on the least effective means of controlling longer and traveling further. These are 06/05/2021 most exposures. However, the opportunity affected by the airflow rates, direction, tices, including the issues that pertain to for SARS-CoV-2 transmission in a wide and the presence of turbulence. testing protocols needed for communicable variety of environments where other con- diseases and contact tracing. OEM physi- trols are challenging to optimize creates a cians further have experience in organiza- OSHA’s Occupational Risk tional behavior and can additionally Pyramid address fitness-for-duty determinations col- From the American College of Occupational and Classification of worker exposure to laborating with other professionals as Environmental Medicine, Elk Grove Village, SARS-CoV-2 using the Occupational Safety needed. OEM physicians collaborate with Illinois. and Health Administration (OSHA) Occu- various professionals in diverse organiza- The authors declare no conflicts of interest. Address correspondence to: Marianne Dreger, MA, pational Risk Pyramid can help employer tional settings to facilitate employees ACOEM, 25 Northwest Point Blvd., Suite 700, representatives determine and implement returning to work including public health Elk Grove Village, IL 60007 (mdreger@acoem. control measures. In the risk pyramid, officials, infection control practitioners, org). OSHA classifies worker risk of occupational safety personnel as well as other occupa- Copyright ß 2021 American College of Occupa- tional and Environmental Medicine exposure to SARS-CoV-2. The level of risk tional health professionals. Employers will DOI: 10.1097/JOM.0000000000002206 depends on industry type, the need for need to look to expert professionals, JOEM Volume 63, Number 6, June 2021 e373 Copyright © 2021 American College of Occupational and Environmental Medicine. Unauthorized reproduction of this article is prohibited Taylor et al JOEM Volume 63, Number 6, June 2021 including OEM physicians, for guidance Reopening plans include determina- workstations with Plexiglas if strict physi- regarding testing, contact tracing, and other tion of phases to re-populate facilities, pre- cal distancing cannot be maintained. Phys- return to work challenges.5 paring to implement basic infection ical barriers can be installed such as plastic CDC and OSHA have made recom- prevention measures, developing policies sneeze guards between workspaces that mendations for employers regarding work- and procedures for prompt identification cannot conform to physical distancing place considerations.6 Employers will need and isolation of sick people as well as guidelines. Consider using sensor technol- to develop and institute policies to facilitate development, implementation, and commu- ogies to monitor and govern physical dis- the safety of employees. OEM physicians nication about workplace flexibilities and tancing throughout a physical location.9 have various collaborative roles with other protections including wellbeing and mental Plans should be developed for the health and safety team members including health services to be offered. Workplace safe restart of site assets and equipment human resources (HR), safety, industrial controls are to be implemented based on including restart procedures, equipment hygiene, infection control, and manage- short-term and long-term risk. OSH profes- maintenance audits, and preparation ment. OEM physicians will have an impor- sionals should contact OEM professionals checks. Protocols should be developed for tant role and will advise in various return- with questions pertaining to medical the use of confined spaces like elevators to-work considerations. screening, contact tracing, workplace (eg, limited capacity of two or three indi- Policies for return to work after accommodations including as it pertains viduals, and guiding workers on proper recovering from COVID-19 infection or to high-risk vulnerable employees, and positioning in the elevators). Furniture exposure to an infected person must be return-to-work evaluations. should be removed from congregation- established. Employers should put proce- prone areas to discourage workers being dures in place and work with OEM profes- Hierarchy of Controls too close to each other (eg, waiting/recep- sionals on what to do if an employee One way to categorize approach to tion areas, dining/break rooms). Technol- develops COVID-19 infection or tests pos-
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