Safely Returning America to Work Part II Glenn S

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3,4 The e373 3,4 PHYSICIANS Occupational and environmental Very high exposure risk refers to ENVIRONMENTAL MEDICINE ROLE OF OCCUPATIONAL AND contact within 6 ft.suspected of of being individuals infected or that infectedthe with are virus,extended or contact with such the individuals. need for repeated or various professionals intional diverse organiza- settingsreturning to to workofficials, including facilitate public infection health safety employees control personnel as practitioners, tional well health as professionals. Employers otherneed will occupa- to look to expert professionals, Medium exposure risk refersrequire to frequent those or that 6 ft. close of contact,infected those within with who thebe virus are so. but suspected not Thisfrequent contact known with to includes travelers to or workerssumers be with in con- a who community with have rates. high positivity Lower exposurejobs risk refers not toinfected those with requiring the virusbe contact or so, having are minimal suspected occupational withwith contact to the public those and other coworkers. medicine (OEM) physiciansized have special- training inhealth and epidemiology expertise in and return-to-work practices, public including thetesting protocols issues needed that for communicable diseases pertain and to contactcians tracing. further OEM have physi- experiencetional in organiza- behavioraddress fitness-for-duty determinations col- andlaborating can withneeded. OEM other additionally physicians collaborate professionals with as those with highknown potential or suspected for sources of exposure SARS-CoV- 2 due to to medical, laboratory, orprocedures postmortem including health(HCWs), laboratory care personnel, workers and morgue workers. High exposure riskwith refers high to jobs potentialknown or for suspected sources exposurecare such as due delivery health to andtransport workers support and staff, mortuary medical workers. majority of workerslower exposure fall risk into categories. medium to TATEMENT S 1,2 UIDANCE The SARS-CoV-2 virus is frequently In the United States (US), the Cen- Classification of worker exposure to and Robert C. Blink, MD, MPH ination in China. relatively quickly in stillsmaller particles, air. remain suspended Aerosols for lon- are ger times, and mayEvidence be for transmitted droplet further. transmissionestablished as is is that of well- aerosol transmission. Certain procedures such as intubation, bron- choscopy, or suctioning are likelymany to aerosol create particles.may However, also aerosols be generated byactivities. singing Such or activities may similar create smaller particles and, in addition, propel dropletsaerosols at or high velocities so they willfurther. travel Published examples relateoutbreaks following to a local choir practice inYork and New an air conditioning system dissem- critical role forand the respirators. use of face coverings transmitted by thecontaining respiratory particles route. in the Viral airpersed as are either often droplets or dis- aerosol. Droplets are larger and heavier and fall to the ground OSHA’s Occupational Risk Pyramid affected byand the the presence airflow of rates, turbulence. direction, SARS-CoV-2 using the Occupational Safety and Health Administration (OSHA)pational Occu- Risk Pyramidrepresentatives can determine help employer andcontrol implement measures.OSHA classifies In worker risk of occupational theexposure to SARS-CoV-2. risk The level ofdepends pyramid, risk on industry type, the need for ters for Disease(CDC) recommends Control following andperimeter’’ distancing a based Prevention upon ‘‘6-foot thecept con- that droplets shouldwithin fall to that the distance. ground arbitrary This rule is basedtling a upon velocity for somewhat the larger typicalThis droplets in set- is still not air. reasons. completely First, protective smaller particles formay or two be aerosols produced bydue the to source desiccation or of develop ond, larger droplets particles. may be Sec- carriedair by movement convective as well,longer remaining and airborne traveling further. These are Industry-Specific Guidance ACOEM G Safely Returning America to Work Part II Glenn S. Pransky, MD, Philip Harber, MD, MPH, Robert K. McLellan, MD, MPH, 2021 American College of Occupa- Natalie P. Hartenbaum, MD, MPH, Amy J. Behrman, MD, Deborah R. Roy, MPH, RN, CSP, Tanisha K. Taylor, MD, MPH, MBA, Rupali Das, MD, MPH, Kathryn L. Mueller, MD, MPH, TRANSMISSION ß Volume 63, Number 6, June 2021 While scientists race to develop he world continues toedented face an threat unprec- from the COVID-19 org). Environmental Medicine, ElkIllinois. Grove Village, ACOEM, 25 Northwest PointElk Blvd., Grove Suite Village, IL 700, 60007 (mdreger@acoem. tional and Environmental Medicine who will be supporting businesses toment imple- safe return-to-work strategies. guidance on how to work safely.sectors Even those that have continued toneed guidance function to ramp will up functioning to new levels ofintended to provide normalcy. return-to-work guidance Thisfor both employers and the document occupational and environmental medicine is (OEM) physicians identified as one of the methodstransmission. of reducing Asschools, and a institutesclosed of result, due education torestrictions were on businesses, such travel and measuresWorking social from gatherings. as home, telework, well andmeetings on-line as are now thehave norm. As reopened, businesses they will be looking for pandemic. Physical distancing has been Copyright JOEM From the American College of Occupational and The authors declare noAddress conflicts correspondence to: of Marianne interest. Dreger, MA, T DOI: 10.1097/JOM.0000000000002206 the hierarchy of exposure control, including personal protective equipment (PPE).pirators Res- and facethe coverings least aremost generally effective exposures. means However, thefor of opportunity SARS-CoV-2 controlling transmissionvariety in of environments atrols where wide are other challenging con- to optimize creates a to reduce transmission of thevirus. SARS-CoV-2 With widecan social reduce the acceptance, effective NPIs reproductiveber num- of the virus andNPIs suppress the include pandemic. air ventilation/filtration,face cleaning sur- and sanitation, handavoiding hygiene, touching thetancing, face, and a physical variety of dis- other measures in effective, safe vaccines, andmanage treatments to COVID-19,interventions (NPIs) non-pharmacologic serve as the bulwarks Copyright © 2021 American College of Occupational and Environmental Medicine. Unauthorized reproduction of this article is prohibited Copyright © 2021 American College of Occupational and Environmental Medicine.

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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- exposures in the workplace is in terms of ogy should be employed to monitor and itive for the virus, including quarantine and hierarchy of controls. This includes hazard govern physical distancing throughout the contact tracings. This should include how to elimination, substitution, engineering con- workplace. A formal assessment should be handle surrounding privacy issues, stigma, trols, administration, and PPE. performed to determine areas that can be and notifications. closed off that are not needed to do busi- OEM physicians also have expertise Elimination/Substitution ness, and close access to them, for example, in managing work-related illness and inju- Hazard elimination in COVID-19 gathering areas, and areas dedicated to ries as well as establishing work-related include ways to prevent exposure such as certain workers. causation. Work-relatedness is established teleworking, postponing certain work, relo- Motion-detection sensors should be with a diagnosis by a treating physician, cating, ensuring that only essential workers installed in place of switches where possi- documented exposure, and evidence that are on the job, health screening, and con- ble to reduce touch points. Hands-free arm- the disease is related to the exposure. States fining infected workers to home. Substitu- pull or foot-operated door openers in rest- vary on how this is applied during the tion could be thought of as permitting work rooms and for other heavily trafficked doors COVID-19 pandemic. Some states have alone in a spare room, solo workstation, or should be installed. Signage for proper PPE passed laws that there is a presumption of facilitating workers’ use of individual cars usage, identification (eg, face shield for causation for certain workers. When the rather than collective transportation. grinding operations versus plastic barrier traditional workers’ compensation criteria for screening), should be prominently dis- are not met in a case, referral to an OEM Engineering Controls played.9 Further, processes for procurement physician for discussion of the work-relat- and storage of hazardous materials (eg, edness is recommended. Buildings, Facilities, Operations, hand sanitizer, cleaners, and disinfectants) and Ventilation should be implemented. Protocols should Role of Safety and Industrial Core building infrastructure should be established for proper disposal of face Hygiene be inspected including heating, ventilation, masks, gloves, and other disposable PPE Industrial hygienists (also known as and air conditioning (HVAC), water sys- worn during work shifts. Training programs occupational health and safety science pro- tem, plumbing, and new filters installed.9 should be developed, implemented, and fessionals) practice the science of anticipat- Employers should consider designating monitored to ensure employees wear PPE ing, recognizing, evaluating, confirming, separate entrances and exits for buildings properly. Procedures should be imple- and controlling workplace conditions that and rooms, if possible, and provide unidi- mented for proper cleaning and disinfection may cause injury or illness to workers. The rectional signage for traffic flow to ensure of PPE if it is able to be reused.9 role of safety and occupational health pro- one-way pedestrian traffic flow along with fessionals (OSH) professionals include frequent physical distancing reminders.9 Administrative Controls anticipating, identifying, and evaluating Increments of acceptable physical distance Administrative controls include hazardous conditions and practices as well on floors where lines might form (eg, internal operating controls, the strategy as developing hazard control designs, meth- entrance to building, restrooms, etc) should for gradual reopening, management and ods, procedures, and programs. Further, be designated. Areas of physical bottle- worker education, training, de-densifying both safety and industrial hygiene profes- necks should be identified where physical the workplace by staggering shifts, signage, sionals have a role in implementing, admin- distancing is more difficult and implement communication strategies, the use of istering, and advising others on hazard plans to alleviate bottlenecks (eg, rest- employee assistance program (EAP) ser- controls and subsequently to measure, rooms, corridors, stairwells). Designating vices, virtual meetings, and travel restric- audit, and evaluate the effectiveness of additional break rooms and lunchrooms to tions. They also include alternating day hazard controls and hazard control pro- limit worker density and allow proper phys- schedule, starting with 25% capacity; tele- grams. Additional resources are available ical distancing should be considered.9 The work for office workers, change shift start from the American Industrial Hygiene workplace should be reconfigured taking and end times to avoid shift congestion, Association and the American Society of physical distancing requirements into change break, and lunch times to avoid Safety Professionals.7,8 account, including occupancy limits, fitting lines, takeout food with touchless payment,

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individual water bottles, single serve cof- good hygiene practices.12 Employees COVID-19, with the loss of taste and smell fee, and snacks. Also, reducing the number should be given sufficient time to wash being the top predictor of illness.17 The US of workers in break or lunchrooms (ie, their hands with soap and water for at least Chamber developed a sample screening reducing number of chairs) and planning 20 seconds or use alcohol-based hand san- questionnaire that can also be used.18 In on minimum 36 square feet per person in itizers.13 Good respiratory hygiene includes order for employees to return to a workspaces. Other options include using outdoor covering nose and mouth when coughing or place, many organizations will institute facilities or tents for extra break or lunch sneezing and disposing of tissues.13 screening (through self-assessments and space and closing or reducing occupancy of Encourage wearing a face mask whenever temperature checks) to clear employees meeting rooms and conducting virtual there is likely interaction between for entry into a building or site. If employ- meetings whenever possible. Physical dis- coworkers or the public. Consider allowing ers choose or are required to perform on- tancing should be observed when moving employees, where possible, to wear per- site temperature screens, they should be through the facility with one-way aisles or sonal face coverings at work (check with aware of the limitations, cautions, and staircases and the number of individuals applicable local and state requirements). requirements of testing. Temperature allowed in an elevator at one time should Equipment, tools, and surfaces that are screening has not been shown to signifi- be limited. Visual cues and decals on floor frequently handled must be cleaned and cantly impact the spread of COVID-19 in lines with 6 ft. of distance are helpful. disinfected with standard products; door based on current science. If it is used, it Individual tools, workstations, electronics handles, mouse devices, keyboards, work- should be part of a larger education and pre- should be sanitized between use by others. benches, handrails, screens, lockers, and work screening effort which could include The time for tasks where workers need to be forklifts are included. Site cleaning guide- symptom screening and reminders of the within 6 ft. should be limited. Workers can lines and frequency must be established, importance of physical distancing, good be kept together in small teams to reduce and cleaning chemical inventories main- hand hygiene, and face coverings. Orga- exposures to large numbers of people on tained. nizations should consider certain actions a site. The Environmental Protection such as providing written communication Administrative controls further Agency (EPA) provides a list of household or webinars to inform employees how, include screening for symptoms, tempera- disinfectants to kill the coronavirus SARS- when, and where screenings will be con- ture screening or using an attestation app as CoV-2,14 and CDC also provides recom- ducted and what will happen should an well as hand washing, use of sanitizer, mendations on environmental cleaning and employee ‘‘fail’’ a temperature screening respiratory hygiene, no contact greetings, disinfection.15 The frequency and intensity or provide a positive answer on a screening and cloth face coverings. When and how of cleaning and disinfecting should be questionnaire. There should be careful should testing be offered and internal con- increased in production areas, warehouses, attention to follow up steps for those who tact tracing are crucial considerations. offices as well as bathrooms, dining areas, are instructed not to proceed to work as well Cleaning should be regular and enhanced and reception areas. Employees will need as attention to all the concerns described after an exposure case. Accommodations adequate training as well as supervision. above including how to keep information should be made for high-risk workers and Also, there should be a process in place for confidential; how to take temperature and will require adequate communication with employees to report issues surrounding ill- maintain physical distance; how to proceed workers and leaders. ness, hygiene, or physical distancing via if an employee refuses to have their tem- telephone or email with prompt and appro- perature taken and the return-to-work pro- Physical Distancing priate feedback to the employee.12,13 cedures if an employee does have an The CDC has developed guidelines elevated temperature. Workplaces conduct- for maintaining safe distancing in public Screening ing symptom checking can also help iden- that local health departments can use to The Equal Employment Opportunity tify areas of potential outbreaks and should help businesses implement and subse- Commission (EEOC) has provided guid- share their results with public health quently monitor for compliance.10 Even ance allowing for employee testing consis- officials. when lockdowns are relaxed, large public tent with it being a business necessity.16 Employers should engage safety gatherings will remain on hold.11 Public Checking an employee’s symptoms, includ- committees to help assist with creating areas need to ensure appropriate spacing, ing whether they have a fever, should be guidelines. Employers are to ensure mech- for example, limiting the number of cus- permitted during the pandemic, and EEOC anisms are in place to track and understand tomers in a business at any one time or the should continue to allow this screening tool. completion and engagement metrics sur- number of passengers in a subway car.11 While this is not a perfect solution because rounding screening communications and Workplaces must be reorganized to mini- of the percentage of people who are asymp- training. Create guidelines for supervisors mize crowding by staggering shifts, limit- tomatic, it is a helpful tool in determining if and managers in the event of a failed ing in-person meetings, appropriate spacing a person should not be at work. Guidance screening and ensure the employee has of seating arrangements, and resorting to from EEOC and US Department of Health transportation and a place in which to telework as much as possible.11 Restaurants and Human Services (HHS) should be clear self-isolate. A process should be estab- and retail stores need to actively plan and that temperature taking and symptom lished, including speaking points for com- manage the spacing of customers, provide checking by a third-party provider retained municating to employees who have been in hand sanitizing facilities, and ensure appro- by the employer, even if the third-party also contact with a symptomatic employee (eg, priate ventilation to prevent viral particles is a medical provider, medical professional, what steps occur as a result, self-quarantine, from lingering in the air.11 or medical clinic, is not medical treatment area closed for deep cleaning). and is not information protected by the Employers should adopt policies and Hygiene Practices Health Insurance Portability and Account- practices that encourage employees to pro- Frequent handwashing and disinfect- ability Act (HIPPA). vide complete and accurate answers to ing should be adhered to according to local A recent study found that a self- questions concerning symptoms and poten- authorities. The correct number of sanitary reporting symptom application (app, tial COVID-19 exposures. Employers facilities will be key, for example, hand COVID Symptom Study) was 80% success- should be flexible with leave policies to washing and restroom facilities to facilitate ful in predicting who was likely to have ensure employees feel comfortable

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proactively sharing their symptoms and entering the workplace and basing return diseases. Decision-making should consider making decisions not to come to work at to work on tests (if the predictive value the following points: all. Any information maintained is subject improves in the future) could be either an to American with Disabilities Act (ADA) engineering or administrative control. Is there a federal regulatory or confidentiality requirements.18 Documen- state order? tation of this information would represent Exposure Controls What are the occupational hazards a medical record and would also be subject The optimal methods for exposure and risks? to OSHA record keeping requirements control are source control and engineering Will the employer require or permit the (employment plus 30 years). controls as described above. Adequate area use of a respirator or face covering? HIPAA protects most health infor- ventilation combined with attention to air What device should be used? mation from being shared publicly, includ- flow direction and mixing efficiency is a ing with employers. HHS has issued central engineering control. This should be Regulatory Environment guidance during the pandemic to allow accompanied by adequate high efficiency sharing of positive COVID-19 test to law particulate filtration and increasing the OSHA’s Respiratory Protection enforcement, paramedics, other first fresh (makeup) air. A filtration efficiency Standard 29 CFR § 1910.134 outlines the responders, and public health entities. This of at least MERV 13 is recommended by requirements for a comprehensive respira- guidance should be clearly extended to experts, and additional protection may be tory protection program for when respirator include employers as outlined by EEOC, afforded by use of HEPA filters.19 Further- use is appropriate. Description of the rules for sharing of test results that constitute a more, ultraviolet germicidal irradiation associated with respirator use is beyond the potential direct threat, but not for sharing (UVGI) has been suggested. Physical bar- scope of this document. The key point here serology (blood test) results. Employers are riers to sneeze, cough, and spread from is that if employers require the use of a responsible for providing safe workplaces aerosol generating procedures should also respirator (as opposed to a facial covering), to their employees and giving them access be implemented. including an N95, they must comply with to this information will allow them to assist Use of respirators may also protect the entirety of the 29 CFR § 1910.134. with contact tracing and containment. workers from inhaling and potentially (OSHA has temporarily relaxed enforcement of some aspects of the Respiratory being infected by viruses such as SARS- 20 Personal Protective Equipment CoV-2. N95 respirators are commonly used Protection Standard. ) The reader should If used correctly, PPE such as masks for this purpose, but elastomeric dual car- note that the regulatory environment is and gloves can help reduce the spread of dynamic and requires close attention to 13 tridge respirators or powered air purifying viruses. Gloves may be used but must be respirators (PAPRs) may also be employed. the latest information from OSHA and changed frequently and hands must be N95 respirators are certified by the National other pertinent regulatory agencies. The washed in between glove changes. Wearing Institute for Occupational Safety and rule also requires that employers who pro- gloves may allow bacteria to build up on the Health (NIOSH)/National Personal Protec- vide respirators to employees for voluntary hands so handwashing is very important tion Laboratory. However, because of the use or who permit employees to wear their when gloves are removed to prevent subse- own device must first determine that such 13 pandemic induced shortage of N95 respi- quent contamination. Workers should rators, several that may be considered alter- use will not create a hazard. OSHA outlines avoid touching their eyes, nose, and mouth the steps required to assure the safe use of 13 natives have appeared on the market. Some when wearing gloves. Wearing dispos- are inadequate and fraudulently labeled as respirators in these settings in its 1910.134 able gloves is not a substitute for handwash- N95 and approved by the National Personal standard. The NIOSH Respirator Selection ing, further removal of gloves could lead to Protective Technology Laboratory Logic provides guidance about the choice contamination of hands.13 Wearing dispos- of the correct respirator for occupational (NPPTL). In addition, the US Food and 21 able gloves could give workers a false sense Drug Administration (FDA) has authorized respiratory hazards. However, this publi- of security, which may result in staff not use of devices called KN95, generally pro- cation does not support the selection for washing their hands as frequently as protection from infectious diseases or ter- 13 duced in China. The FDA emergency use required. Hand sanitizers are an addi- authorization is for health care settings. rorist agents. Instead, CDC provides guid- tional measure to handwashing but should Users should be sure that it is not a fraudu- ance for the use of respirators and face not replace handwashing.13 Other PPE masks for blocking transmission of infec- lently labeled device. 22 include face masks, hair nets, clean over- Wearing a facial covering that does tious disease. alls, protective clothing, slip reduction not qualify as a respirator reduces the like- States and municipalities have added work shoes and may be indicated for lihood that an infected individual will emit to the regulatory environment with respect high-risk areas. Respirators and eye protec- viral particles in their area and as reviewed to face coverings and other NPIs during the tion are recommended for two person tasks below and plays an important role as an NPI COVID-19 pandemic. These mandates and within 6 ft. and face shields should be added to mitigate transmission of COVID-19. recommendations have changed frequently. if cloth face coverings are worn instead of The reader is advised to consult a reliable respirators. An N95 respirator with valve is DECISION-MAKING ABOUT USE source for the most up-to-date mandates specific to their site of operations.23 appropriate if all workers performing simi- OF RESPIRATORS AND FACIAL lar tasks are wearing one. COVERINGS TO SIGNIFICANTLY What Are the Hazards and Medical Care/Physician- REDUCE TRANSMISSION OF Occupational Risks? Prescribed Interventions COVID-19 The decision about respiratory pro- Disease recognition and treatment Although some employers have con- tection should be based on an appropriate (including testing) for individuals is a ter- siderable experience with the choice and hazard and risk assessment. The hazard tiary response/prevention and the hierarchy deployment of respirators for their work- assessment describes the likelihood of a of controls contain primary and secondary force, many do not and even those with significant concentration of viral particles prevention measures. On the other hand, experience may not understand the use of in the air. Several factors determine the preventing symptomatic people from respirators for management of infectious concentration of particles: presence and

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number of infected individuals, the infected fit, and breathability to optimize compli- effectively. However, due to the pandemic, individual’s actions that affect particle ance. For this reason, the most efficacious OSHA has relaxed the requirement for emissions (breathing, talking, singing, material may not always be the most effec- periodic retesting. OSHA has reduced the coughing, sneezing), behavior (use of face tive in the field. mandatory requirement for annual fit test- covering), and the duration spent in a par- Face shields and goggles have been ing, after an initial fit test as long as the ticular environment. Indoor air is generally employed in health care settings to provide employer demonstrates good faith efforts to more hazardous than outdoor environments additional droplet protection for a HCW comply with this requirement when possi- given the dilution inherent in outdoor air. wearing a respirator. Goggles only protect ble. Workers should also be properly Risk assessment should consider the num- the eyes, whereas a face shield offers trained to use the respirator. Simply provid- ber of people present, their susceptibility, broader protection. As a device to use ing a device without training is inadequate. their ventilation rate, their behavior (physi- instead of a respirator or non-medical face cal distancing, facial coverings, respirator, covering, the evidence of efficacy in pre- FIT TESTING hand hygiene), their duration of exposure, venting transmission of infectious diseases Fit testing procedures may require and surface sanitation. Although the infec- is mixed.30,31 At this point, the most appro- modification. CDC has suggested reducing tious dose of SARS-CoV-2 is not yet priate use of a face shield without a respi- the use of quantitative fit testing for filter- known, there is good reason to believe that rator is as an accommodation for those who ing face piece respirator users since this risk will depend on both concentration and cannot tolerate a face mask. If used, it leads to destruction of an otherwise needed duration of exposure.3 should be made of non-fogging material respirator. (However, the authors suggest that completely covers and wraps around that the sampling port might be carefully Will the Employer Require or the sides of the face and have a plugged, allowing continued use of the Permit the Use of a Respiratory comfortable headband. respirator). Use of respirators other than or Face Covering? filtering face piece respirators should be Some employers may decide to Use and Management of Face considered. Loose fitting PAPRs do not require or permit use of respirators or face Coverings require fit testing, and they are reusable. coverings when not compelled by local Although face coverings can serve as Also, elastomeric cartridge respirators, orders or federal regulations. This decision a key component of a suite of NPIs to such as dual cartridge half mask respirators, should be based on the emerging science reduce transmission of COVID-19, if man- are reusable and may be easily disinfected about blocking transmission with these aged improperly they may increase expo- between uses. devices. ACOEM’s COVID-19 Resource sure risk to their users or those around them. Center is one site to find up-to-date evi- Common mistakes while wearing include PRACTICAL APPROACHES dence to inform decision-making.24 failing to cover mouth, nose, and chin; The following practical aspects for touching the front of the mask; and leaving respiratory protection during the pandemic What Device Should be Used? large gaps along the sides by failing to should be considered: PPE is designed to protect its user tighten the straps. These and other details from exposure to hazardous agents. Very about how to properly don and doff, wear If respirators were used for required high-risk and some high-risk workers need for prolonged periods, and reuse are pro- exposure control before the pandemic, PPE that includes respirators for protection vided in an ACOEM publication designed they should continue to be used. from SARS-CoV-2. The choice of a respi- for employers.32 Particularly for N95 devices, which are rator for this purpose should be guided by in short supply, employers and workers device availability, ability to manage use, RESPIRATOR USE FOR OTHER should institute measures to reduce reli- the outcome of fit testing, and in some cases PURPOSES ance on such respirators, for example, medical evaluation. Facial coverings that In addition to respirator use for reduce the number of workers requiring do not meet the specifications of a respira- SARS-CoV-2, many worksites already use or use engineering controls. tor include medical grade and non-medical use respirators for protection against other For workers currently using N95 devi- grade face masks or facial coverings such as hazards such as silica or solvents. However, ces, whether in health care or elsewhere, cloth masks and face shields. Facial cover- because of shortage of certain respirators, alternative types should be considered. ings primarily block emission of viral par- methods to reduce reliance on respirators These include PAPRs and elastomeric ticles from their users rather than prevent should be considered. For example, reduc- respirators. exposure to viral particles in the air and as ing the number of workers in an exposed Workers newly assigned to a respirator such should not be considered PPE. area or use of enclosure may reduce reli- or a new type of respirator should have Increasingly robust evidence documents ance on respiratory protection. In general, fit testing performed. However, routine the value of widespread use of facial cover- respirator use for other purposes should annual repeat fit testing may be relaxed ings as an effective NPI in mitigating the continue as before the pandemic. The cur- on a temporary basis per CDC and spread of the pandemic.25–28 Because these rent pandemic does, however, impose sev- OSHA guidelines. types of face coverings do not fit tightly, eral special considerations. Careful attention to hand hygiene they cannot protect their user from expo- Respirators, particularly N95 filter- and doffing and donning is paramount. sure to fine viral aerosols. However, they ing face piece respirators, have inadequate The hands must be washed or treated with may have some role in protecting exposure supplies. Therefore, it may not be possible a hand sanitizer before performing the res- from droplets.28 to obtain them for workers who would pirator seal check. In addition, hands should Studies have evaluated the relative otherwise require them. In addition, HCWs be washed/sanitized before and after effectiveness of different materials for con- with significant potential exposure should removing the respirator. Providing hand structing non-medical grade masks.29 This be given very high priority for available sanitizer, training, and enforcement can evidence can be used to choose facial cov- N95 respirators, further reducing availabil- overcome challenges when there is limited erings to optimize their efficacy. Effective- ity for other workers. access to sinks. ness, however, depends not just on filtration Respirator users should undergo a fit Respirators that are meant to be sin- efficacy but also on factors such as comfort, test to ensure that the device will work gle use respirators (eg, N95) may be reused

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on a temporary basis. They should be dis- should include but are not limited to EAP spread. Communicate any changes to orga- infected between uses using one of several resources, ergonomics, home IT setup, nizational policy as a result of changes in accepted approaches (hydrogen peroxide social support and supervision, and community risk exposure clearly and con- vapor, ultraviolet treatment, or setting them performance measures. cisely to affected workers before and after aside for 5 days in a protected location). Employers should develop a plan to policy change. One paradigm proposed is Reused respirators should be carefully reintegrate employees who have recovered inclusion of vulnerable family members as inspected for damage before use. This dam- from COVID-19. Concerns for higher risk part of an at-risk unit instead of only the age may include deformation of the cup or populations and how to phase in high-risk employed individual. In this paradigm, the damage to the elasticity of the straps. employee profiles (eg, over 65 years old, community as a public health unit would be A specific individual who under- known medical conditions that are at higher factored into the equation for consideration stands procedures, regulatory requirements, risk) should be navigated following EEOC for exposure, return to work, and contact and disease transmission should be desig- guidance on protected classes. Resolve tracings. nated for each worksite. This is particularly potential liabilities (eg, work from home important in construction sites, where mul- flexibility vs return-to-work requirements, Workers’ Compensation tiple contractors and self-employed work- and access to professional development for As with all workers’ compensation ers may be present. work from home employees). Workers causation analyses, HCWs should remem- The conditions, availability of respi- should be cross trained to perform essential ber that they are providing a medical cau- rators, OSHA requirements and guidance, functions so the workplace can operate even sation conclusion. Depending on statutes or and knowledge are changing rapidly. if key workers are absent.9 case law in specific states, the legal result of Therefore, the respirator program should Virtual training should be used to a medical conclusion may defer from the be regularly re-evaluated. introduce employees to new protocols medical causation analysis. It is helpful if and patterns of behavior before they return the causation evaluator has knowledge of HR Employment, Legal, and to a physical workplace and ensure a the state laws and regulations, but final Human Resources method for acknowledgment that the train- interpretation of specific language is in Considerations/Communication ing has been completed prior to returning to the purview of the legal system. Thus, The ADA prohibits discrimination the workplace. Employees in any new orga- the medical facts in the case and the medi- against people with disabilities in transpor- nizational roles and responsibilities should cal reasoning should be clear to non-meditation, public accommodations, communi- be informed and trained as precautionary cal readers. The final analysis must state if cations, employment, and access to measures against reinfection. Cross-train- it is medically probable, more than 50% government programs and services. EEOC ing plans should also be developed for likely, that the work-related factors resulted enforces ADAwhen it comes to many of the potential fluctuation in the workforce (eg, in the disease and the resultant need employment provisions.16 EEOC states, employees out for quarantine periods) to for treatment. ‘‘the ADA and Rehabilitation Act rules ensure business continuity and communi- Clarifying the diagnosis can be dif- continue to apply, but they do not interfere cate appropriately to help employees under- ficult in many early cases. Nasal swab with or prevent employers from following stand why. A webpage should be created testing, which is recommended for diagno- the guidelines and suggestions made by the and updated regularly for employees dedi- sis and utilizes real-time polymerase chain CDC and other public health authorities cated to COVID-19 (eg, internal memos, reaction (RT-PCR), can have a high per- about steps employers should take regard- pay codes, EAP, and HR links).9 centage of false negative results. In a pooled ing the Coronavirus.’’ Another EEOC web- If using a phased approach, employ- analysis, the probability of a false negative site expands this to other public health ers should describe why certain groups or RT-PCR was 38% on the day of symptom guidance too, ‘‘The ADA and the Rehabili- individuals were chosen to return to work onset, decreasing to 20% 3 days later.34,35 tation Act do not interfere with employers and explain the rationale behind the crea- In addition, diagnostic testing may not be following advice from the CDC and other tion of new roles/positions within the orga- available for many workers, therefore it public health authorities on appropriate nization for handling the coronavirus. may be necessary to make a preliminary steps to take relating to the workplace.’’16 Outline the new responsibilities for existing diagnosis based on clinical criteria. Criteria During the pandemic, SARS-Cov-2 roles to ensure health and safety in the wake that will be used as reasonable evidence of a presents a direct threat to the health and of the pandemic and how employees are COVID-19 diagnosis should be developed safety of workplaces, and EEOC should expected to engage in the new roles. Con- in advance and applied uniformly for all acknowledge this for the duration of the vey in detail why certain protocol and cases where testing is not available within a pandemic declaration.16 This means design changes were adopted. Explain the reasonable time frame. Serology tests alone employers can prevent an employee with benefits of returning to a shared work envi- are currently not recommended for making a clear medical diagnosis of coronavirus ronment (eg, increased productivity and a diagnosis of COVID-19 and many state from coming to work until they are no innovation, access to shared equipment workers’ compensation systems will not longer contagious to others, as outlined in and network). accept serology results as supporting a recently released guidance from EEOC. diagnosis. Because the false positive ratings They would not be covered by the nondis- External Considerations for all serology testing are currently at least crimination provisions of the ADA. Monitor the number of confirmed 30%, it cannot be used as evidence of For example, the community is the COVID-19 cases in the community to disease, although it might contribute to a most common source of COVID compared assess potential interactions of employees finding already established by clinical find- with the workplace.33 Employers should be with confirmed cases to determine expo- ings. ACOEM states that ‘‘When using an prepared to address how and where sure risk. Determine organizationally how antibody test to confirm the diagnosis, it is employees can be tested when corporate community infection rates will impact self- critical to know which test was performed wide screening not available. Employers assessment of exposure risk (eg, very high, and the specificity and sensitivity of the should provide resources and information high, medium, low per OSHA guidelines) test, as many will have high rates of false for employees working at home temporar- and put a plan in place for triggering any positives and/or false negatives. It is also ily or possibly permanently. Such resources protocol changes based on local community important to look at when the test was

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performed in the course of illness as posi- care, and medical-legal expenses. Workers’ situations which may require formal eval- tive results are not reliably seen until compensation presumption laws may be uations to determine work-relatedness. 2 weeks into the illness. A clinical diagno- introduced with the goal of reducing dis- These include: (1) cases occurring in states sis can still be made based on the judgement putes and reducing delays in medical care. without presumptive rules; (2) cases of the clinician even in the absence of For example, in many states, cancer in claimed outside of the presumptive rules laboratory confirmation.’’35,36 firefighters is covered by a workers’ (eg, workers not directly covered); (3) those The easiest way to reflect on the compensation presumption. occurring among individuals who claim to conclusion is to consider what would have Presumptions flip the burden of have had COVID-19, but who tested nega- been the result if the patient had never proof and give the benefit of the doubt to tive for the virus by polymerase chain experienced the work-related exposure. If the plaintiff (or worker in this case). There reaction (PCR); and (4) those occurring the patient would have had the same medi- are two types of presumptions in workers’ in individuals who state they were ill and cal condition and needed the same medical compensation. A ‘‘rebuttable presumption’’ were not tested, or whose exposure at work treatment without the exposure, then one accepts that the illness or injury is related to is not clearly demonstrated. can safely say that this is not a workers’ work and removes the injured worker’s Physicians who suspect work-related compensation case. In some cases, it may need to prove work-relatedness. Instead, COVID-19 should do their due diligence to not be possible to say with 50% probability it requires the defendant (in this case the record a detailed occupational history that the worker sustained their condition employer) to disprove that the illness or describing timing of exposure relative to from work. For example, a grocery store injury is related to work from the outset. symptoms and diagnosis (incubation clerk who wears a mask at work tests Conclusive or non-rebuttable presumptions period), why the exposure is suspected to positive for COVID-19 and has related are legal presumptions that are deemed to be work-related, potential non-work- symptoms. Her community has seen a large be automatically conclusive and definitive, related contacts and exposures, and occu- increase in COVID-19 cases and not all her regardless of the evidence presented against pational and personal factors placing them customers wore masks. Her son recently it. Presumptions in general are rare. Con- at risk of exposure and adverse outcomes. came home from college, was not using any clusive or non-rebuttable presumptions are While physical distancing, use of face mask protection in the household, and extremely rare. masks, and other measures are recom- became symptomatic 5 days ago. The Since SARS-CoV-2 is easily trans- mended to prevent transmission of and patient was avoiding close contact with mitted and can be community-spread, exposure to SARS CoV-2, they cannot reli- the son, but he was not completely quar- direct attribution to a specific exposure is ably be used as sole measures of whether antined. In this case, it would be difficult to often difficult, and proving that COVID-19 exposure occurred at work. say exactly how the patient contracted is work-related can be resource-intensive. Limited data are available to date on COVID-19 since both exposures may have Many states and the federal government occupational COVID-19 claims. The Cali- logically resulted in infection. Thus, a med- have either passed laws or issued adminis- fornia Workers’ Compensation Institute ical examiner could conclude that it was trative orders granting the presumptions of (CWCI), a research organization represent- medically possible the patient contracted work-related causation of COVID-19 for ing workers’ compensation insurers and self- the disease from the workplace, but it was select occupations. All these states include insured organizations such as schools and not clearly medically probable. On the first responders and others specifically list public institutions, analyzed data in Califor- other hand, if the patient with the col- other occupations such as corrections offi- nia.38 As of May 1, 2020, 1077 COVID lege-age son was an emergency physician cers, military/national guard, nursing per- claims had been submitted to 16 insurers and had to intubate a COVID-19 patient sonnel, other HCWs, grocers, postal and 12 self-insured organizations in Califor- several days before becoming symptom- workers, etc.37 Most of the presumption nia. Less than a third (27.7%) had been atic, a clear high-risk exposure, it would laws expire on specific dates. The degree accepted as work-related, 36.9% were under be reasonable to conclude that she most and extent of coverage differs somewhat investigation at the time, and 35.5% were likely contracted the disease from work. among these states, with some limiting the denied. The most common reasons for denial The medical provider assessment extent and duration of coverage. were negative SARS-CoV-2 PCR test (70%) and discussion of both how the diagnosis While the specifics of COVID-19 and lack of work exposure (14.5%). Other is made and the likely possible source, presumption laws vary by state, typical reasons for claim denial included working including timing of exposure and resultant requirements for coverage include a posi- exclusively at home and lack of symptoms or symptoms, are the most important facts and tive SARS CoV-2 test and a diagnosis of a physician’s determination to support a an essential portion of the report in estab- COVID-19 made by a licensed physician diagnosis of COVID-19. Data from other lishing work-relatedness. Additionally, within a specified time-period after the last states are anecdotal. many states have introduced legal presump- day worked, and the worker’s assertion that The California Workers’ Compensa- tions specific to COVID-19 that would the illness is work-related. Some state laws tion Insurance Rating Board (WCIRB) pro- apply to specific types of workers only cover workers who are required by jected the costs of a rebuttable COVID and exposures. their employer to work outside their home. presumption in that state as $0.6 to $2 Workers’ compensation laws vary by In the absence of a conclusive pre- billion, with a mid-range estimate of $1.2 state and provide compensation for occu- sumption and unless work-relatedness is billion.39 The cost drivers were the severe pational diseases that arise out of and in the clearly demonstrated from the outset, cases which, although projected to be the course of employment. Many state statutes employers, or insurers are most likely going minority, were estimated to be extremely exclude ‘‘ordinary diseases of life,’’ such as to conduct independent investigations to expensive both for short-term in-hospital the common cold, from workers’ compen- determine work-relatedness to assess treatment as well as long-term health sation. Typically, the worker has the burden whether to accept a claim as work-related effects and disability. The accurate finan- of proving that an illness or injury arose out and therefore accept financial responsibil- cial costs of occupational COVID-19 of and in the course of employment. In ity. Cases which clearly meet the require- claims are likely to be available a year after many cases, uncertainty as to whether the ments of the presumption rules may not the start of the pandemic. disease is related to the work activity or require any further evaluation to determine In addition to financial costs, there exposure may lead to disputes, delays in work-relatedness. However, there are many are unquantifiable and significant social,

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emotional, and health costs to society. OEM childcare, etc. Employers must recognize Communication by a senior leader who physicians play a critical role by making that stress and mental distraction can pose demonstrates empathy, shares challenges, accurate diagnoses, risk assessments, and great hazards to worker safety and take honest and timely answers, and talks about risk attributions. Creating medical/legal extra precautions for workers performing problems as soon as they emerge is most reports, that clearly outline the facts and high-risk tasks. Workers should be provided effective. Address the ‘‘what ifs’’—contin- basis for the medical opinion of the physi- with education and opportunities to practice ually asking employees about their con- cian, will assist the efficient adjudication of ways of reducing stress, such as mindful- cerns to formulate the message is workers’ compensation claims. ness training, deep breathing, and exercise effective.43 (eg, yoga). Support and information should The following suggestions can be Connecting Employees to be provided for employees anxious about offered to employees to maintain their men- Mental Health Resources leaving the relative safety of quarantine. tal health during these stressful times: Employers have a unique ability and Employers should allow for flexible poli- Stress and mental health symptoms responsibility to manage their relationship cies as employees receive elective and rou- are common during this epidemic—you are with benefit providers, such as EAPs and tine medical care that may have been not unusual. Surveys show that many peo- health insurance plans to ensure workers postponed due to the pandemic. Allow ple are experiencing insomnia, change in have access to the help and support they for flexibility of employees to utilize paid eating habits, anxiety, or perhaps more need. Employers should encourage EAPs time off to spend time with family and symptoms or worsening of a mental health and health insurance plans to be very active loved ones they were physically separated condition. But that means that more of us in promoting their telephone and online from during quarantine to help restore their need to take positive steps to maintain our counseling services through various com- connection with others, reduce stress, and mental health. munications, and campaigns. As part of regain a sense of normalcy. Provide training Keep your focus on what you can EAP, counseling should be provided for for all leadership, supervisors, and employ- control and what you can do, not on things substance misuse, fatigue, family stress, ees on recognizing the signs of stress and over which you are powerless. Try to stay in and general mental health support. If how to create a culture of support and trust. the present, not projecting into the future. counseling cannot be provided by the com- Educate all leadership, supervisors, Meditation—even a short period of relaxa- pany, ensure policies allow for increased and employees on understanding the tion—is proven to improve calmness and need for off-site counseling. Having impacts of COVID-19 on stress levels, quell anxiety. Several sites have released employees know their employers are sup- mental health, and substance use. Recog- free meditation apps. porting them through these difficult times nize the signs of impairment, substance Take care of yourself physically by can make a significant difference for their misuse, or mental health distress. Employ- eating regular meals, exercise, get out- mental and physical health. Human resour- ees should be advised on how to engage in doors, and get the sleep you need. Do things ces teams and supervisors can help make mental health first aid and suicide preven- you enjoy, as much as you can. These all this difference a reality.9 tion efforts and how to refer employees to contribute to good mental health. Establish a mental health taskforce other resources and support. Recognize that Limit news and social media as much with management representation from all the stress and mental health effects may be online information is designed to engage functional areas and provide training on prolonged or delayed and allow for a long more than inform and greatly contributes to how to spot the signs of mental health issues period of transition over several months. anxiety. Obtain information from a trusted and approaches for handling or starting a Almost half of Americans said that site, such as CDC, or state health depart- conversation with an employee who is worry or stress related to the COVID pan- ment. Turn off news alerts; instead, set exhibiting symptoms and signs of mental demic has had a negative impact on their aside a specific time to read news from illness (consider having an identifier worn mental health—more so in lower-income credible sources, preferably not at night or used by every member of the taskforce so families.40 Contributing factors include job before bed. employees can easily identify who they can change, loss of income, isolation, and loss Stay connected with friends and fam- speak with should they want to do so). of support, altered family dynamics during ily, coworkers, and get the support you Employers should communicate frequently social isolation, negative stories on social need. Take advantage of video conferenc- to reassure employees from whom they can media and in the news, uncertainty and fear, ing tools that are temporarily free to do this get help for various problems and promote a and distrust of those in charge. Consequen- if you can. Loneliness is one of the most culture that normalizes seeking support. ces include insomnia, anxiety, eating dis- common problems faced by those who Consider using mobile and digital tools to orders, depression, substance abuse, post- work remotely. provide resources. Repeatedly share all the traumatic stress disorder (PTSD) activation, Share your feelings with trusted resources provided by your benefits pro- and adverse behaviors. Mental health ser- friends and colleagues by phone or video; viders and local community programs and vice utilization appears to be decreasing look for opportunities to help others who provide easy links to national support hot- while use of prescription psychotropic may be anxious or isolated. Both strategies lines.9 medications is increasing.41 can lower anxiety and other symptoms. Appropriate HR policies and resour- Employers can begin to address Practice effective parenting skills by ces should be adjusted and communicated; these problems through a multifaceted reassuring your children that they are safe. a confidential helpline or email address strategy. They can directly address fears Answer their questions and set an example should be provided for employees to get about the safety of return to work through by calm and reasonable behavior. Maintain help accessing personal resources and treat- effective communication, using principles their homework and exercise routines as ment privately. A confidential helpline for honed during past epidemics and crises.42 much as possible; avoid using screen time employees to raise job-related concerns Key messages include workers’ safety as for babysitting. CDC has good recommen- anonymously should be provided. Employ- the number one priority, describing a pro- dations for maintaining a normal home ers should be ready to provide assistance or active return to work (RTW) plan that is the life.44 links to local or national resources on com- result of consensus and expert input, Separate work from home as much as mon employee concerns, such as applying empowering employees to take actions if possible. If you work remotely from home, for unemployment, food insecurity, they feel something is unsafe. set aside specific hours and a specific

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location (if possible) for work, so your handwashing and regular cleaning and dis- clothing, slip reduction work shoes, and family knows when you will turn off work infection, and training employees on these may be indicated for high-risk areas of food emails and be present. Focus on the positive and other elements of the COVID-19 pre- premises producing ready-to-eat prepared aspects of working at home—no commute, vention plan.46 Policy, training, and signage and cooked foods. Workstations should be no dress code, perhaps a nicer office space, must be supported with enforcement of spaced out reducing the distance between you can eat what you want and when you physical distancing (such as verbal warn- workers, however, which may require want—this helps maintain a good attitude. ing, and corrective action). decreasing the speed of production lines Seek help if your anxiety interferes In terms of hygiene guidance there is and limiting the number of staff in food with your ability to function at home or at no evidence that food is a vector for trans- preparation areas at any given time.45 work, reach out to your EAP program, or mission of the disease and there is no Physical distancing must be imple- other mental health services. There are evidence of fecal-oral transmission even mented at 6 ft. between employees where more telemedicine options readily available though SARS-CoV-2 RNA has been iso- possible, and at least 3 ft. always. Physical now. lated from the stool samples of infected distancing should also be ensured at entran- Employers seeking to respond to patients.47 As with other potentially infec- ces and exits.12 In order to reduce the employee mental health issues are consid- tious agents, good hygiene practices includ- spread of the virus as much as possible, ering a continuum model, where the sever- ing appropriate sanitation measures should work hours or shifts should be staggered. ity of the problem is matched to the right be implemented to minimize transmis- Meetings and gatherings among employees level of service (see https://www.mental- sion.12,45 Handwashing after using the bath- should be avoided including during shift healthfirstaid.org/). Healthy, functioning room is an essential practice especially in changes. Cleaning should be thorough and adults receive preventive services such as food preparation.45 Transmission occurs on a regular basis. Changes to workplace reassurance and supportive communication via person-to-person contact with direct design will be important including use of from peers and managers using the strate- contact with respiratory droplets from an Plexiglas or other similar material to shield gies described above, as well as support infected individual whether from coughing employees from infecting each other others (see https://www.mindful.org/). or sneezing.45 It is possible that someone or customers. Those who are stressed and mildly affected could become infected from droplets reach- Access to workspaces and gathering might receive help from self-management ing their nose, mouth, or eyes; alternatively of staff should be limited if possible. Dining tools, managerial and peer support, and respiratory droplets too heavy to become services may be continued if physical dis- conversations with EAP providers and airborne may land on objects and surfaces, tancing can be maintained by arranging other professionals. Finally, those who which are in turn touched.45 The virus can tables according to requirements. Plexiglas are developing difficulties functioning remain viable up to 72 hours on stainless or similar materials must be installed if would ideally receive a more intensive steel or plastic.48 Therefore, someone may specified distance cannot be ensured. approach, including evaluation and fol- become infected by touching contaminated Breaks and meals should be adequately low-up. surfaces and then touching their face. spaced to ensure physical distancing. Con- It is extremely important to ade- tractors and temporary workers must be Industry-Specific Guidance— quately communicate to employees about made aware of the need to self-report or Special Considerations risks, symptoms, physical distancing, quar- notify contacts before entering facilities12 antine, and travel to reduce the spread of (resources are available for temporary Food Industry coronavirus.12,45 Employees should receive workers49). In retail aspects, the number The food industry is essential, over- regular reminders of the advice from fed- of customers must be limited and signs seeing production and distribution of food, eral and or public health authorities made placed for customers not to enter if they which may not have changed much during available on posters and handouts or that are ill. Queue control is important with the pandemic. Food workers/food handlers are downloadable.12 Specific precautions physical distancing advised inside and out- cannot work from home and it is essential should be available for everyone via bulle- side stores. Hand sanitizers, spray disinfec- that measures are implemented to protect tin boards.12,45 Information sessions are tants, and disposable paper towels are to be staff from spreading COVID-19 among recommended to familiarize employees placed at store entry points. Floor markings each other, maintain a healthy workforce with the new procedures. Retraining on should be used to facilitate compliance with and exclude infected food handlers from the food hygiene principles is recommended physical distancing especially in usually workplace.45 As it is critical to keep work- to reduce the risk of food surfaces and crowded areas such as counters.45 Regular ers in the food production and supply chains packaging materials becoming contami- announcements should be made to remind safe,45 employers must establish contin- nated with viral particles from food work- customers of physical distancing and regu- gency and continuity plans concerning ers.12,45 lar cleaning of hands. Introduce Plexiglas hygiene, cleaning, sanitation, suppliers, It has been established that infected barriers at counters and check out points as distribution, transportation, and fitness to persons may be asymptomatic and can be an additional level of protection. Use of work.12 General guidelines can be applied contagious highlighting the need for all contactless payment should be encouraged. at the company level.12 Minimum standards personnel working in the food industry Further, customers should be encouraged to are applied to food businesses during the regardless of their health status to practice bring their own shopping bags where pos- pandemic, which should be adopted and personal hygiene and use PPE.45 Gloves sible, and which should be cleaned between tailored as needed.12 Key food hygiene may be used by food workers but must use. High-touch points should be cleaned and sanitation practices at each stage of be changed frequently and hands must be and disinfected regularly, for example, food processing, manufacture, and market- washed in between glove changes.45 Food shopping carts, door handles, scales; other ing need to be ensured by food safety workers should avoid touching their eyes, items like ladles, tongs, and condiment authorities.45 nose, and mouth when wearing gloves.45 holders should be frequently sanitized. Key prevention practices include Hand sanitizers are an additional measure Doors should be kept open where possi- physical distancing to the maximum extent to handwashing but should not replace ble.45 Consumers should be advised to wash possible, use of face coverings by employ- handwashing.45 Other PPE include face fruits and vegetables with potable water ees and customers/clients, frequent masks, hair nets, clean overalls, protective before use.

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Maintaining good hygiene practices measures to minimize further spread.45 Stress the importance of practicing physical around open food displays is crucial, such Examples of contacts in the food industry distancing while taking public transporta- as salad bars, fresh produce displays, other include a worker who was face-to-face or tion to and from work. open food displays and bakery products. had physical contact or who was within All food contact surfaces and utensils 3 ft., working on the same team, cleaned General Office Settings/ should be washed and sanitized frequently. up any body fluids without adequate PPE Warehouses Unwrapped bakery products should not be (eg, gloves, overalls, protective clothing), openly displayed and should be removed or in the same household as the confirmed Guidance for General Office from self-service counter; instead, should case.45 Settings be placed in plastic, cellophane, or paper Recommended quarantining based Employers in office settings should packaging. Any loose baked products on CDC from the last point of exposure be preparing the workplace for operations should be displayed behind Plexiglas cab- to the confirmed case. Workers who had to occur during the pandemic (eg, enhanced inets and placed in bags using tongs when contact with a confirmed case should be disinfection measures), as well as focus on serving customers.45 asked to stay home for the recommended the indoor environmental quality (IEQ) of Staff cafeterias may need to remain duration from the last time they had contact the workspace as well as employee readi- open where there are no practical alterna- with the confirmed case and practice phys- ness and workforce management.51 For tives and frequent handwashing, and respi- ical distancing.45 If such individuals such businesses with indoor workplaces, ratory etiquette needs to be maintained. become ill within the isolation period and IEQ is a concern for buildings that have Physical distancing between workers test positive they too will become a con- been unoccupied and/or dormant for should be facilitated with seating arrange- firmed case and should be managed.45 A extended periods. Employers should also ments, staggering break, and lunch times to return-to-work policy for staff who have consider the comfort of employees as they reduce the number of workers in the cafe- become infected should be implemented. return to work because they may be in a teria at any given time. Non-essential phys- Confirmed cases can be released from iso- heightened state of concern. ical contact should be restricted. Notices lation once symptoms resolve.45 Employers should also consider and reminders should be visible and strate- Food businesses should follow pro- developing a team of professionals to mon- gically placed promoting hand hygiene and cedures per their local health departments. itor, assess, and implement new COVID-19 physical distancing, cleaning, and disin- Additional nondiscriminatory measures transmission risk mitigation strategies as fecting procedures.45 aligning with health authorities should be they become available and consider how Employees in the food sector should anticipated for pregnant workers, employ- they relate to IEQ. Aspects to reopening an be familiar with the symptoms of COVID- ees over 65 years of age or those who have office that should be emphasized during the 19 so symptoms can be recognized early immunosuppression, chronic health issues pandemic include workplace configuration, and minimize the risk of infecting such as hypertension, heart disease, or pul- conference rooms, lobby and common coworkers.45 This is imperative as an monary conditions who are at risk of areas, kitchens, ventilation, and enhanced infected worker who handles food could becoming critically ill.12 Recommenda- cleaning practices. introduce the virus into the food on which tions apply to all workers including tempo- Regarding general office space con- they are working, or onto adjacent surfa- rary workers and seasonal workers. figuration, reception seating areas could be ces.45 Workers or contractors should notify Drivers and suppliers must adhere to eliminated, or plastic partition installed at appropriate personnel immediately if they sanitary rules. If possible, truck drivers reception areas. Review floorplans and develop any symptoms such as fever, should remain in their vehicles and access reconfigure or remove furniture, seats, cough, shortness of breath before starting designated facilities. Drivers should be sup- and workstations to ensure recommended work or during work.12 Also, if contractors plied alcohol-based hand sanitizers, disin- physical distancing. Temporarily replace or workers had recent exposure, they should fectant and paper towels, and should use amenities frequently accessed such as water notify personnel. Temperature monitoring hand sanitizer before passing delivery coolers, and coffee makers replacing them including telethermographic systems such documents to staff on food premises. Dis- with alternatives. Vending machines should as infrared cameras as well as symptom posable containers and packaging should be be wiped down after each use if not turned screening are widely used.12,50 If a worker used to avoid the need for cleaning of any off. Reduce tasks requiring large number of develops symptoms suggestive of COVID- returns. Appropriate hygiene and sanitation people to be in one area. Virtual meeting 19 or is diagnosed with COVID-19 and is procedures should be implemented in the tools should be used in lieu of in-person onsite, the worker should practice good case of reusable containers.45 Surfaces meetings whenever possible.51 In-person respiratory hygiene, be moved to an area most likely contaminated with the virus meetings should be limited to 10 people away from other people, and with adequate include the steering wheel, door handles, or less and should be brief. Conference ventilation then sent home or directed to an mobile devices, and adherence to strict rooms should be disinfected daily as should appropriate medical facility immediately; hygiene standards is of paramount impor- surfaces and equipment touched in the con- calling ahead if need be. The area occupied tance to prevent cross-contamination. Driv- ference room. Kitchen areas and equipment by the ill individual needs thorough cleaners must further be aware of physical should be cleaned daily at a minimum. ing subsequently. If home, the employee distancing when picking up deliveries and Coffee machines, refrigerator, and ice should not come to work and can notify passing deliveries on to customers.45 machine handles should be cleaned at the appropriate personnel regarding illness via Use of individual rather than collec- beginning and end of each shift. Water telephone; recommendations for self-isola- tive transport should be facilitated where faucets that require workers to operate them tion and medical consultation should be possible to limit exposure. Employers may should be disinfected three times per day. followed as well as any close contacts facilitate safe travel arrangements if the Disposable silverware is preferred; if not followed. Surfaces touched by the infected company organizes transport service to available, silverware should be cleaned in a worker must be cleaned such as bathroom minimize infection risk by guaranteeing dishwasher. Congregating in kitchen areas surfaces, door handles, and telephones.45 physical distancing. This may be applicable should be discouraged. Notification of close contacts may be nec- in settings where employees provide hous- Multi-stall restrooms should be able essary, who can then take appropriate ing, for example, for temporary workers. to be opened without touching the handles

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if possible. Consider a key for single rest- operating controls, and access handles. substantially limit workplace infection risk. rooms so disinfection measures can be bet- Wipes should be disposed of in a waste Eye protection adds additional significant ter controlled. Signage should instruct bin after being placed in a refuse sack and protection. Aerosol generating procedures employees to wash hands before resuming tied. Supplier drivers should call to confirm continue to be associated with elevated work. Air dryers should be disconnected or arrival and directed to unloading area. transmission risk and require higher levels taped off.51 Unloading should be done without interac- of administrative control and PPE use for Adequate airflow into workspaces tion with team or customers.54 HCW safety.59,60 Specifically, HCWs who should be ensured. Restrooms should be perform these procedures must wear respi- under negative pressure and proper filtra- Health Care rators appropriate to airborne isolation tion should be used to help control SARS- HCWs and their employers have pathogens as well as eye protection. Gowns CoV-2 transmission. All HVAC intakes and necessarily led the way in developing suc- and gloves provide additional protection. returns should be cleaned and disinfected cessful strategies to mitigate workplace risk Close dynamic collaboration between daily. HVAC professionals and American and safe return to work because they were MCOH physicians, public health authori- Society of Heating, Refrigerating and Air- forced to do so while caring for COVID-19 ties, and hospital infection preventionists Conditioning Engineers provide updates patients and simultaneously maintaining can optimize staff safety. Indeed, improved that are useful.52 If fans are disabled or other critical functions throughout the pan- cross-disciplinary partnerships may be one removed, attention should be paid to heat demic. Some of these strategies are unique of the pandemic’s few developments. hazards.51 Additional guidance on general to health care, but many are applicable to In most US hospitals, the initial hor- office settings is available.53 other industries. Medical center occupa- rific shortages of PPE in general, and respi- tional health (MCOH) physicians play a ratory protection in particular,61 have Retail central role in maintaining workforce read- partially improved. At the time of writing, Special considerations in retail iness and workplace safety for HCWs dur- improved supply chains, stewardship poli- include limiting contact by using flexible ing this time of unprecedented risk. An cies to avoid inappropriate overuse of res- working hours and split shift teams to min- unintended consequence of their ongoing pirators in low-risk settings, increased use imize the risk of people gathering. Use efforts has been escalating recognition of of reusable respirators and eye protection, every other counter to allow optimal 6 ft. MCOH value and improved institutional and systematic implementation of steriliza- spacing. Contactless payment systems are resource allocation in many cases. tion and reuse protocols (for masks and N95 preferred—no cash. Credit card online pay- Infectious disease prevention, expo- respirators previously considered to be sin- ments are preferred with collection times sure management, medical clearances, and gle-use items) have alleviated scarcities to booked. Products to be picked up are to be care are core functions for MCOH in all some extent. Training and data-driven made ready ahead of collection. Collections eras. As we grappled with existential chal- improvements in administrative controls should be limited to two at a time, using lenges to HCWs’ well-being in the first half (such as pre-procedure testing, cohorting every other parking space depending on the of 2020, comparisons to prior epidemics infected patients, and isolating persons size of the site. One staff member should be were unavoidable. Increased risk of illness under investigation) have enhanced staff responsible for managing the flow. Custom- and death among physicians during epi- safety in patient care settings. ers should remain in their vehicles while demics has been recognized since antiquity Policies requiring HCWs to mask in preordered goods are retrieved; external (Thucydides), and is globally relevant at non-clinical settings, and interventions with customer queue should adhere to physical this time.55 Public events and compliance distancing and barriers to avoid potential distancing guidelines. Once goods have (or non-compliance) with non-pharmaceu- staff-to-staff transmission during meals and been left by their vehicle and the attendant tical interventions massively impacted meetings, are also crucial to control trans- is 6 ft. away, the customer may then exit HCWs’ experience during prior outbreaks, mission from asymptomatic coworkers. their vehicle and load merchandise them- with the devastating global influenza pan- Thermal and/or symptom screening before selves. A one-way system should be imple- demic of 1918 providing the most recent all shifts may also decrease the risk of mented to prevent people passing each parallel.56 A century later, geography, poli- transmission from infected HCWs to other.54 tics, travel, communications, public coworkers and patients, although data are Customer queue locations should actions, social inequities, and supply chain not robust for this intervention.62 have signs or tape demarcating 6 ft. inter- vulnerabilities are impacting HCWs during Over time, as occupational infection vals. A one-way system marking floor and the COVID-19 pandemic independent of control strategies have improved in the aisles with arrows should be implemented medical advances. context of essentially uncontrolled commu- to prevent people from passing each other. The epidemiology of COVID-19 nity spread in the United States, commu- There should be clear signage at point of infection, morbidity, and mortality among nity-acquired infections in HCWs have entry detailing new operating rules and HCWs is driven by occupational and non- become proportionally more common. procedures including where to stand while occupational factors, which can be modi- Managing household and community expo- collecting merchandise, and directional fied to improve outcomes. An array of sure and COVID-19 infections in HCWs signage to hand sanitizer. Plexiglas screens studies has shown that direct patient care are essential to maintaining a stable work- should be installed along the counter and can be associated with increased rates of force and preventing secondary workplace staff should be briefed on what to do if a HCW infection, hospitalization, and death transmission to other HCWs and patients. customer comes to the counter.54 in acute and ambulatory care settings.57,58 Health care employers must maintain Regarding receipt of supplier deliv- Fortunately, improved understanding of updated evidence-driven policies to guide eries during COVID-19, there should be transmission mechanisms and risk mitiga- quarantine and return-to-work protocols, separate material handling equipment for tion within the classic hierarchy of controls, and these policies must address non-occu- individual users if possible and company as described earlier in this guideline, has pational as well as occupational risks to sanitation rules for mechanical equipment greatly reduced workplace transmission. be effective. applied. Forklift should be wiped down Source control, defined as consistent mask- COVID-19 testing options for regularly with anti-bacterial wipes including of all HCWs at work and all visitors and HCWs continue to evolve, but the gold ing the truck, steering wheel, gear stick, patients (as clinically possible), can standard for diagnosis currently remains

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nucleic acid testing of nasal or oral secre- medical conditions that worsen COVID- influenza partially due to its spread among tions with RT-PCR. At the time of writing, 19 outcomes are common among HCWs, the immunologically naı¨ve.69 Influenza is rapid antigen testing still requires confir- including diabetes, obesity, immune-com- associated with tens of thousands of deaths matory RT-PCR in many cases, and anti- promise, and cardiovascular conditions. annually. The possibility of simultaneous body tests remain of unclear value for Pregnancy is also common in a health care COVID-19 and influenza epidemics pres- managing HCWs’ quarantines or treatment. workforce largely of women in their child- ent public health challenges. Interventions Ideally, HCWs test access should be bearing years and may be associated with such as face coverings mandates and phys- prompt, convenient, and free with timely more severe disease from COVID-19.64,65 ical distancing are expected to influence results available to HCWs and their MCOH In summary, occupational risks, community both infections; a decreased influenza inci- providers. Reagent shortages, restricted exposures, underlying medical conditions, dence was associated with the nonpharma- access and delayed turn-around times and demographic disparities combine to cologic interventions.69 Continued remain common in many parts of the coun- create ongoing hazards for HCWs despite enforcement of nonpharmacologic inter- try, although larger medical centers are risk mitigation. Employers should provide ventions is expected to decrease influenza likely to have in-house capability to guide accommodation for underlying conditions transmission. Influenza vaccination has quarantine management. Symptomatic that increase the risk of more severe disease consistently been lower than 50% and it HCWs should be quarantined pending within the context of their legal, ethical, and is particularly significant to minimize the RT-PCR testing. Asymptomatic exposed operational obligations. MCOH providers viral reservoir. National education cam- HCWs should have access to testing on a are central to these evaluations. paigns and community-based vaccinations voluntary basis following current CDC Infection and physical hazards are will prove crucial.69 guidance as it evolves. Surveillance testing not the only risks for HCWs in this pan- There is overlap of symptoms and it of asymptomatic HCWs is likely to become demic. Stress, burnout, and psychological may be difficult to tell the difference more common and should help control distress were critical issues for HCWs between them based on only symptoms.70 workplace transmission. before the COVID-19 pandemic.66 The Testing will be required to differentiate MCOH practices must utilize robust pandemic, with its associated physical, between the two. Both COVID-19 and data to manage COVID-19 exposures, fur- emotional, and ethical stressors for HCWs influenza have symptoms ranging from loughs, infections, and work restrictions. accentuates them all. Providing access to asymptomatic to fever, cough, shortness Rapidly accruing knowledge combined confidential psychological support services of breath, fatigue, body aches, sore throat, with ongoing uncertainties has led to is crucial to maintain resilience in headache, and runny nose; some individu- ever-changing guidance on quarantine HCWs,67,68 and manage crises including als may have vomiting and diarrhea.70 length, testing, and clearance criteria. suicidality. Every effort should be made Signs of COVID-19 that differ from influ- (Readers should consult current CDC, pub- to reduce stigma and encourage engage- enza include anosmia and ageusia. Individ- lic health, and infectious disease guidance ment with a range of behavioral uals with COVID-19 may take longer to rather than depending on any specific prior health resources. develop symptoms than if they have the reference for these criteria.) Robust and Health care employers and their flu.70 Influenza patients may develop symp- editable information technology (IT) tools MCOH staff must plan for long-term chal- toms from 1 to 4 days after being infected are essential to maintaining consistency, lenges with the COVID-19 pandemic, while the COVID-19 patient typically has managing individual cases, and tracking including immunizations. At the time of symptoms 5 days following infection. Both workforce status. Prior methodologies for writing, massive advances in medical can be spread before onset of symptoms—1 managing ordinary nosocomial infections understanding have not led to meaningful day for influenza and 2 days for COVID-19. and risks are likely to be inadequate to the control of community transmission. Case Both are spread by respiratory droplets and pandemic’s complexity. Stakeholders from rates and deaths continue to rise across the while spread in similar ways, COVID-19 is MCOH, infection prevention, human United States, and health care is increas- more contagious and noted to have super resources, and senior leadership should ingly stressed in many locations. MCOH spreaders. Both can cause severe compli- be included in IT selection and develop- providers must anticipate ever-changing cations including pneumonia and Acute ment to succeed in their linked but separate guidance and should strive to communicate Respiratory Distress Syndrome (ARDS) missions. Privacy must be maintained this effectively and reassuringly to their especially among those at high risk includ- appropriately within the context of contact HCWs. COVID-19 vaccines are arriving ing the elderly, and those with chronic tracing and public health reporting require- now for HCWs. MCOH providers are cen- medical conditions. Additional complica- ments. tral to providing safe, efficient, high-vol- tions associated with COVID-19 include When staffing shortages and pan- ume vaccination resources, building on blood clots and multisystem inflammatory demic-related workload become critical, their extensive experience with other syndrome. There are multiple influenza health care employers may need to imple- CDC-recommended vaccines for HCWs. vaccines made available annually to protect ment contingency or crisis staffing. This Seasonal influenza vaccine campaigns have against the viruses that circulate annually. implies that usual guidance to keep HCWs always been preparation for a pandemic. Vaccines for COVID-19 are currently in with known infections or high-risk expo- Now that it rages among us, we must con- various stages of development and clinical sures out of work may need to be disre- tinue working to protect our front-line trials and must be authorized for emergency garded. If possible, data should be HCWs and share any useful strategies with use by the FDA.70 maintained even in these extreme situations our colleagues in other industries. There are no specific symptoms that to help with future decision-making. specifically distinguish between early Differential morbidity and mortality Influenza in the COVID-19 Era COVID-19 illness and influenza.69 Distin- from COVID-19 among racial and ethnic While COVID-19 and influenza are guishing between the two viruses have minorities in the United States comprise a respiratory illnesses, the viral etiologies are implications for return-to-work guidance, particularly tragic aspect of the pandemic.63 different. With the COVID-19 pandemic, quarantine, and COVID-19 contact tracing. This disparity has been well documented in the influenza virus represents a second Coinfection with both SARS-CoV-2 and health care workplaces as well as commu- respiratory virus associated with morbidity influenza has occurred and a positive test nity outbreaks.57 In addition, chronic and mortality three-fold higher than result for one does not exclude the other.

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Diagnostic tests of both viruses may even- communication on issues of physical dis- Travel 69 tually be needed in a particular case. tancing, hand/respiratory hygiene, use of Many employees in the transporta- face covering, and other barriers. Screening tion industry will be performing duties COVID-19 in Long Term Care should be considered for and physical dis- away from their home terminal or base. Facilities tancing in any conveyances as well as in Considerations for these employees and The COVID-19 pandemic had a waiting or ticketing areas, employee break- others that may need to travel as part of major impact on nursing homes which rooms, restrooms, or maintenance facilities. their job or chose to travel for personal are considered high risk. Nursing home Appropriate cleaning protocols should be reasons would be similar.90,91 deaths account for 40% of US COVID-19 observed for any high contact/high touch The risks from travel should be care- deaths while nursing home residents are areas such as kiosks, turnstiles, benches, fully considered including the situation at less than 1% of the population.71 Numbers railings, handrails, garbage cans, door han- both origin and destination as many coun- are most likely underestimated, as only dles, payphones, restroom surfaces (fau- tries, states, and even some cities have about 80% of nursing homes reported, cets, toilets, counters), poles, handrails, specific limitations or requirements for and only federally regulated nursing homes seats, benches, grab bars, and exit buttons, travelers from certain areas.92–98 Travelers were represented and not assisted-living or after identification of an employee of should not only consider the infection rate facilities.71 Many nursing home worker passenger infected with SARS-CoV-2. at their destination but also be certain that deaths went unnoticed by the federal Equipment and supplies should not be they have a plan should they become ill or agency responsible for protecting work- shared and if necessary, thoroughly cleaned need to quarantine after an exposure.99,100 ers.72 Many deaths went unreported with between users. To the extent possible, ven- Some areas may be experiencing limita- nursing home operators claiming they were tilation should be optimized, whether tions in hospital or ICU bed capacity which unable to determine whether someone through enhanced HVAC systems or open- may make travel riskier. Plans should be in became ill at work or contracted the disease ing windows, doors, etc. place should the individual become ill or elsewhere despite major outbreaks among For delivery drivers some consider- exposed while away from home. Those at both residents and employees at the facili- ations might include: higher risk of more severe illness should ties.72 OSHA issued guidance that gives consider carefully whether the need to employers permission to not report deaths Limiting time spent outside cab, travel outweighs the risk.101 International to the agency if a ‘‘reasonable and good Using paperless, electronic invoicing travel can present unexpected challenges if faith inquiry cannot determine whether it is when available, borders close, rules change, or if the trav- more likely than not’’ that an employee’s Contacting facilities in advance—mak- eler becomes ill while abroad. Some impor- COVID-19 infection was linked to expo- ing an appointment for unloading of tant questions to consider include: sure at work.72 cargo, OSHA, as well as state worker safety Identifying rest areas or hotels which are Do I need to quarantine before I arrive? programs approved by the agency, has only following proper protocols in advance, Do I need to quarantine when I return? physically investigated a fraction of nursing Packing supplies—food and water to Do I need a COVID-19 test? 72 home employee deaths. All federally limit stops, and Do I need to wear a face covering? funded nursing homes were directed to Keeping truck well ventilated. What is opened/closed? Restaurants/ regularly test all residents and staff, but bars—indoors or only outdoors? follow-through has been uneven across Guidance for different transportation Will I need to have my temperature the states. Some experts suggest that rou- modes can be found through the CDC web- checked? 74–83 tine, repeat testing of staff is the key to site or other industry-specific sites. For all travel, the same core princi- controlling COVID-19 in nursing homes, as It is important that the risk of fatigue ples to minimize spread of SARS-CoV-2 asymptomatic spread from staff to residents is considered in any transportation opera- should be followed: likely introduces the virus into facilities. tion. For some administrations in Depart- Nursing homes that followed federal guide- ment of Transportation, such as the Federal Physical distancing (proper spacing and lines did not have as poor an outcome as Motor Carrier Safety Administration avoiding crowds), 71 those that did not. (FMCSA) and Federal Railroad Adminis- Hand washing or use of alcohol-based The Centers for Medicare & Medic- tration (FRA), relief from hours of duty hand sanitizers (especially after touch- aid Services (CMS) supplied adult care requirements were available during the ing high touch items), facilities with rapid POC test kits as most early stages of the pandemic through emer- Wearing a face covering or appropriate nursing homes were ill-equipped to regu- gency declaration. For FMCSA, relief con- (PPE) (and using them properly), larly screen employees and residents. There tinues to be an option through the end of the Symptom monitoring, and 84 were concerns that employees often worked year for certain operations. However, Avoiding contact with those who are ill. while symptomatic and were subsequently operators are still required to have suffi- found to be positive.73 Without widespread cient rest and if rest is needed, the employer For anyone traveling, whether for testing, outbreaks often begin with asymp- must ensure the employee has a rest oppor- business or personal, it is important to be tomatic staff who unknowingly introduce tunity. There are several excellent sources certain that rest stops, overnight accommo- the virus from the community.71 of information on addressing fatigue during dations, client locations, restaurants are COVID including through CDC or the available and are following appropriate Transportation and Travel National Safety Council (NSC).85–87 steps. Ensure that there is a plan should For employers in the transportation Discretion of enforcement for sev- employees or customers become ill or are industry, the primary principles for return- eral other DOT requirements such as con- exposed to someone with COVID-19 and ing to work safely are no different than for trolled substance and alcohol testing and those traveling should have a plan if they other operations, needing to protect both medical examination requirements were become ill while away from home. Differ- the employees and the customers, in this announced.74–77,88,89 Check applicable ent modes of travel carry different risk.102– setting, passengers. Ensuring adequate transportation modes administration web- 104 The safest is probably driving a personal appropriate supplies and education and site to confirm status. vehicle and while studies suggest that

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certain modes of transportation are safe, the face covering or an N95 mask if the number of people at any one time. Further, there would still be other potential risks. individual is high risk.101 This is also true if good ventilation should be ensured, for There may be several other potential expo- the ability to physically distance is difficult, example, keeping the windows open and sures to the virus such as those associated especially if indoors. Similarly, provisions facing away from each other to help reduce with the method of getting to and from the of hand sanitizer, disinfecting wipes which the risk of transmission. The vehicle should station or airport (taxi/ride share, public meet EPA criteria, information on how to be cleaned regularly using gloves and transportation),78–82,102–104 lines for tick- obtain health care should they become ill approved cleaning products with particular eting or boarding, gathering in waiting (even more important if international), cur- emphasis on handles and other areas where areas, or indoor eating settings and accom- rent information on requirements on quar- passengers may touch surfaces. Parking modations.105 CDC is now specifically rec- antine, testing, reporting, and other local arrangements should be considered for ommending the use of face covering during steps to limit COVID-19 spread as well as additional vehicles. any public mode of transportation convey- general information on precautions they Where public transportation is the ance both at the hub and during convey- can take. only option for workers, consideration ance,106 and a face shield might be Other items to bring include a ther- should be given to changing and staggering considered in addition to the face covering mometer, forms for symptom logging, an site hours to reduce congestion on public in some settings. adequate supply of usual medications to transportation as well as avoidance of pub- For any setting, barriers between permit the duration of quarantine if neces- lic transportation during peak times. Work- individuals, avoidance of shared items, sary, contact information for the employer’s ers should be reminded that face coverings using online reservation/check-in pro- occupational health representative, emer- are mandatory on all types of public trans- cesses, cashless payment or ticketing meth- gency contact, and health care provider port.54 When traveling at work or between ods, keyless entries, and enhancing information in the event this is required site locations, workers should travel alone. ventilation by opening doors or windows by health care providers. If food or bever- If workers have no option but to share a should be used when feasible. Avoiding age may be limited at the destination, food vehicle, then available guidance on Work- restaurants, travel, or other activities during and water should be packed. ing Safely during COVID-19 in a vehicle peak hours will limit exposure to crowds. In addition to any local requirement, should be followed.110 Vehicles should be And of course, continued hand washing (or upon returning from travel, passengers, shared with the minimum number of people use of alcohol-based hand sanitizer if soap especially if participating in activities con- at a time, good ventilation should be main- and water not available), physical distanc- sidered high risk,101 or are a high-risk tained, and vehicles should be regularly ing, and wearing a face covering. individual or lives or cares for someone cleaned. There are several travel-related who is, should monitor their health and if Non-essential visitors should be dis- activities which are considered higher required or recommended, quarantine. continued, the number of access points risk91: Testing may be considered, but in general should be changed to reduce congestion should not be used as a replacement for and contact. Where loading and offloading Being in an area that is experiencing quarantine.109 arrangements on site will allow it, drivers high levels of COVID-19, including des- should remain in their vehicles. Workers tinations with a Level 3 Travel Health Construction should be reminded not to attend work if Notice, General recommendations for the they have symptoms of COVID-19. Off- Going to a large social gathering like a construction industry especially where loading areas should be isolated where wedding, funeral, or party, 6 ft. physical distancing cannot be adhered ideally, the driver is the only person in Attending a mass gathering, to include keeping activity time as short as the area. Steering wheel, gear stick, crane Being in crowds, and possible, using back-to-back or side-to-side controller, access handles and devices Traveling on a cruise ship or river working rather than face to face whenever should be wiped with anti-bacterial wipes boat.107,108 possible and reducing the number of people after each delivery. Where manual off-load CDC provides examples of risk lev- each person has contact with by using fixed is required, either the driver does it on his els from lowest to highest for transporta- teams or partnering. Workers in teams own or they remain in the cab while the tion, lodgings, food, and camping. For should not be changed if possible. Increas- customer completes the off-load. Two-per- example, outdoor dining is lower risk than ing the frequency of handwashing and sur- son lifts are only permitted on products indoor dining and a long walk may be face cleaning remain crucial though not where physical distancing can be main- preferable to exercise in a gym. In all unique to the construction industry.54 tained.54 Additional guidance on construc- situations, risks are lower when limiting Staff should be reminded not to tion is available.54 exposure to those outside the immediate touch their faces and not rush or cut cor- household, whether in vehicles obtaining ners—safety should be at the forefront of Marine and Offshore Industries food or lodging and risk is lower if physical their minds. Managers are to walk the The American Bureau of Shipping distance is maintained and if everyone is branch to ensure proper physical distancing (ABS) has created guidance in response to wearing a face covering. While activities is being maintained. Desks should be the current pandemic to assist marine and may be permitted in some areas, this does cleared of any items other than keyboard, offshore industry in protecting their work- not mean that they are without risk. In some computer, screen, and phone for ease of force while continuing crucial operations. business or even personal travel situations, cleaning and all other items should be Such guidance provide response to expo- certain steps might be considered such as placed in a box under the desk or in a sure cases through isolation, contact trac- pre-travel quarantine and/or testing for drawer.54 Staff should also be reminded ing, quarantine, cleaning, and groups that will be traveling to remote to stay safe once they have left work. disembarking. Mitigation of exposure risks locations and able to stay within a specific Wherever possible workers should travel by cleaning, disinfecting, screening, and ‘‘bubble.’’ to site alone using their own transport. If physical distancing. Commercial vessels Individuals should also bring ade- workers have no option but to share trans- must comply with guidance from port quate supplies such as face covering (pos- port, journeys should be shared with the authorities to help control the spread of sibly a face shield) to be used in addition to same individuals and with the minimum SARS-CoV-2 prior to arrival. If there is a

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suspected case of COVID-19 on board, the with contact tracing if a confirmed COVID- are monitoring the availability of PPE for port health authority at the next port of call 19 is identified following disembarka- essential workers. The Federal Emergency should be notified.111 tion.111 Management Agency (FEMA) released Due to close quarters on vessels and An outbreak management plan information about information about distri- other maritime and offshore assets as well should be developed by all assets if an bution of cloth masks. FEMA later issued a as the nature of transmission of the virus, exposure is suspected.111 Contacts should temporary final rule that extended the PPE rapid spread is possible.111 Given the range be identified and isolated before disem- allocation.115 of symptoms and disease severity, assets barking. Clinical management of suspected Guidelines for optimizing PPE with suspected cases should take immediate case(s) is important as are procedures to including reducing, reusing, or repurposing measures to limit spread starting with iso- clean and disinfect potentially contami- PPE in accordance with CDC’s PPE opti- lation. Isolation on board vessels is critical nated areas including isolation cabins. Con- mizing strategy for use when PPE supplies in preventing potential spread to personnel, tact of the suspected case(s) must be are stressed.116 Usage of PPE should be adversely impacting onboard medical managed. Procedures for PLFs, continued reduced by modifying normal operations resources, operations as well as the ability service provisions for suspected cases, pro- and procedures. Reuse can be accomplished to disembark. Ill personnel may not be able vision of PPE, and disembarkation policies by decontamination procedures. Alterna- to obtain adequate medical attention while must be clarified. All staff should have tive types or sources of PPE can be repur- on board.111 knowledge of the outbreak management posed including NIOSH-approved Further, early detection, prevention, plan and understanding of responsibilities. respirators in lieu of N-95 for activities and control of COVID-19 is important to for which respiratory protection is required prevent transmission.111 All asset managers Energy/Utilities per CDC. are to have a plan in place to minimize the According to the Department of Decisions about testing remain at the risk of exposure. Due to the potential for Energy (DOE), the department has been discretion of state and local health depart- asymptomatic spread, physical distancing in Phase 2 since June 29, and there is ments or individual providers. New guid- measures that minimize unnecessary expo- currently no specific date for the start of ance includes screening of asymptomatic sure are recommended. Prevention man- Phase 3.112 Energy sector companies are individuals if prioritized by state or local agement plans include specific cargo- encouraged to assess the risk within the plans. Energy industry suppliers and infra- handling procedures, personnel rotation supply chain including the effects on indus- structure operators are identifying essential and shift-change procedures, port call and try service providers. Protective measures employees for prioritized COVID-19 test- liberty policies based on the prevalence of for access to homes and businesses in spe- ing.113 CISA provided guidance across the disease in a specific geographical area, cific areas should follow CDC and OSHA critical infrastructure sectors including access-control measures for visitors, con- guidance. Non-essential work orders at energy prioritizing testing for asymptom- tractors, and pilots. Areas overlapping with businesses or customers’ homes that require atic personnel performing essential jobs in other industries include identification of workers to enter may be deferred wherever support of operations centers and control high-risk areas to focus cleaning and dis- possible to conserve PPE for essential rooms.117 infecting efforts including regarding emergency work protecting the health and CDC provided testing strategies in accommodations, physical distances, selec- safety of personnel.113 high-density critical infrastructure work- tion, provision, education, and use of PPE The Cybersecurity and Infrastructure places after case identification.118 Early as well as hand and respiratory hygiene. Security Agency (CISA) and Department of identification of asymptomatic individuals Work practices may need to be adjusted to Homeland Security (DHS) industry list of include initial and regular testing of every- avoid exposure as it pertains to meetings, essential critical infrastructure workers one residing or working in such settings as meal preparation, service, work teams, and included electricity, petroleum, natural well as testing of new entrants or upon re- work shift adjustment.111 gas, and propane workers.114 Important entering following a prolonged absence. Special considerations are given to areas for governors to consider include Some energy companies have imple- embarkation and disembarkation especially critical infrastructure workers needing pri- mented sequestration protocols for essen- regarding personnel coming on board ority access to PPE, testing, and supplies. tial personnel to ensure uninterrupted including crew, passengers, and offshore Critical energy infrastructure employees operation of energy functions. Protocols workers.111 The World Health Organization should be identified and credentialed in include assessing the minimum number (WHO) advises asset owners to implement the event of a shelter in place order. Further, of essential workers and setting expecta- pre-boarding screening to identify potential waivers may be needed for fuel carrier tions about duration. Also, creating sepa- contacts; probable and confirmed cases standards and commercial driver’s licenses rate living quarters, individually assigned should not be allowed to board the asset. needed to move critical utility cleaning equipment, physical separation between All crew and passengers boarding marine supplies. Reliance on energy is a shared workstations, testing workers prior to and offshore assets should be provided with area of interdependence among all critical sequestration, and requiring appropriate general information on COVID-19 and pre- infrastructure sectors, making energy reli- PPE use.113 ventive measures. Crew members should ability a critical need for national safety and Wellness checks are implemented not come into direct contact with shore security.113 based on CDC guidance throughout work gangways and ladders. Gangway watch In cases where access is restricted, shifts of essential workers including symp- should wear appropriate PPE. WHO regional coordinators and state emergency tom and thermal screen to monitor for advises that until the end of the COVID- operating centers (SEOCs) have clear pro- symptoms of COVID-19.119 CDC further 19 pandemic, all crew and passengers on tocols on how essential personnel can issued guidance for critical infrastructure board marine and offshore assets should access restricted areas. DOE performed a workers who may have had exposure. complete a passenger/crew locator form thorough review of PPE inventories and Workers who were exposed but remain (PLF). This form should be kept on board other supplies including at labs, plants, asymptomatic should pre-screen and be the asset for at least 1 month after the and sites. DOE supports the safety and monitored regularly. They should also wear passenger or crew member has disem- security of the energy sector workforce a mask, physically distance, and disinfect barked. PLF helps local health authorities ensuring the energy system. Energy sectors workspaces.120 Contact tracing is utilized

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