Prevention and Reduction of Transmission
Encouraging sick workers to stay home, and making it possible through paid sick leave, will continue to be a critical and effective strategy in preventing and reducing transmission of COVID-19 in the workplace. According to the Occupational Health and Safety Administration (OSHA), employers should “ensure that sick leave policies are flexible and consistent with public health guidance and that employees are aware of these policies.” The U.S. CDC cautions that it may be impractical to require workers to provide test results or a doctor’s note as these may not be available in a timely manner. Guidance on when recovered sick persons may return to work is addressed below.
Individual workers should be encouraged to wash their hands frequently or use alcohol-based hand rubs, practice respiratory etiquette including covering of coughs and sneezes, and use face coverings (cloth masks) when appropriate. Workers whose jobs necessitate use of personal protective equipment (PPE) including respirators and medical masks should continue to adhere to these requirements.
Employers who have not done so already may want to engage in a thorough workplace hazard assessment with COVID-19 transmission in mind in order to inform any new workplace controls.
The hierarchy of controls can guide employers to introduce measures that can make the biggest impact. Currently, the hazard (COVID-19) cannot be removed. However, sick leave policies are fundamentally important as a means of source reduction, and engagement with local public health authorities to support efforts to reduce the level of spread in the community will also reduce infectious sources. With this in mind, the following controls are recommended for workplaces in the context of COVID-19 transmission:
- Engineering controls can include changing seating and work arrangements to adhere to physical distancing guidelines and maintaining 6 feet between workers when possible. Special attention should be given to use of physical shields and barriers when physical distancing is not possible, such as in areas where workers interface with clients. Engineering controls can also include use of signs, tape and markers to remind workers about appropriate physical distancing. This is especially important in communal areas such as break rooms where additional steps, including removing communal equipment such as coffee machines or water coolers, may be necessary.
When possible, ventilation systems should be adjusted to increase the proportion of outdoor air used in air circulation and increase total airflow; in some situations it may be possible to consider opening windows to dilute indoor air and improve airflow.
- Administrative controls can include staggering shifts, support for virtual communication and meetings, allowing for continued work-from-home policies when feasible, adapting cleaning and disinfection practices, promoting or requiring additional hand hygiene including upon entry into the workplace, provision of training on safe practices to reduce transmission of COVID-19, minimizing nonessential travel for work, supporting safer means of commuting to the office such as walking and cycling, and other changes to work policy to minimize exposure to COVID-19.
- Additional guidance for various work settings, including office buildings, are available from the CDC here and from OSHA here.
Broadly, screening for COVID-19 refers to checking workers for symptoms by asking a series of questions or performing temperature checks prior to entry into the workplace. The purpose of screening is to identify persons who may be infected and to exclude them from the workplace until it is determined that they are not at risk of infecting others. The CDC considers screening in the workplace an “optional strategy” and in interim guidance to employers, currently recommends that employers consider conducting daily health screening checks of employees prior to entering a workplace and working with local health authorities and occupational health services when possible. This can promote maintaining worker privacy if screening occurs before arrival, reducing stigma, and improving access to next steps if a screen is positive.
Screening programs themselves pose challenges—they may result in crowding at entry points, risk additional exposure if not executed properly, could compromise privacy, and may result in a false sense of security. The CDC’s interim guidance and frequently asked questions for employers include additional strategies to optimize health check or screening programs.
Testing for active infection
There is a fundamental question that should be at the root of the decision any time a health care provider orders a test for an individual patient: How will the test results change the patient’s management? Some version of this question should also be part of the equation when approaching medical testing in the workplace. One way in which a test for COVID-19 can be relevant to decision-making in the workplace is assessing if an individual is fit to report for work, or if a worker may put others at risk if they have an active infection.
Testing for active infection is done by detection of viral genetic material using the RT-PCR or antigen test. The CDC does not currently recommend testing of persons without signs or symptoms of COVID-19 for active infection unless it is part of public health monitoring, sentinel surveillance, or some other plan designed by health officials.
One of the problems with relying on symptom screening alone for COVID-19 is that infected people may not always show signs or symptoms right away, or ever. Although prevention measures in the workplace can continue to mitigate risk from asymptomatic people, there are special workplace settings where the risk of transmission or health impact of transmission is higher due to the types of services provided, or if the clientele is especially vulnerable, such as in the health care setting. In New York state, the governor expanded the priority list for testing to include front line health care personnel even if they are asymptomatic, and has issued an executive order mandating testing for nursing home and adult care workers.
In contrast to screening, there is no current recommendation for testing in the workplace. There is some guidance to suggest that mandatory testing may be legal in certain settings with three conditions in mind according to the Equal Employment Opportunity Commission (EEOC). First, the test should be job-related and consistent with business necessity. The EEOC states that, “applying this standard to the current circumstances of the COVID-19 pandemic, employers may take steps to determine if employees entering the workplace have COVID-19 because an individual with the virus will pose a direct threat to the health of others.” It continues to say that administering tests for active infection would fall under this standard. If testing is to be carried out in keeping with the first condition, then the second condition states that the test to be used must be accurate and reliable. Finally, the third condition states that even in the setting of testing, employers should require, “to the greatest extent possible,” additional infection prevention and control measures such as those discussed above.
In specific work settings, after appropriate consideration of other factors such as the level of ongoing community transmission, the specific risk to other workers and clients, and how fully other preventive and control measures are being used, an employer may choose to approach the legal considerations for workplace testing and whether or not testing may be appropriate.
Testing for antibodies
Although testing for active infection may have a role in some work settings, there is currently no role for antibody (serologic) testing in the workplace, and this type of test cannot be mandated in the workplace. Antibody testing in general may give an individual information about past infection, as was discussed more thoroughly in a Data Insight from a prior issue of the Resolve to Save Lives COVID-19 Weekly Science Review. Antibody testing does not currently play a role in identifying workers who pose a hazard in the workplace and would not meet the standard set forth by the EEOC. In addition, antibody tests may not currently be reliable—a necessary condition for any testing offered in the workplace.
As test reliability improves, and as we learn more about what the presence of antibodies means, particularly whether or not it indicates protective immunity and for how long, it is possible that antibody tests may play a role in some workplace decisions in the future.
Returning to work after illness
The CDC currently states explicitly that “serologic test results should not be used to make decisions about returning persons to the workplace.” For non-health care workers, CDC does recommend two strategies to determine when a person who has been sick at home can end isolation and resume regular activities, including work. These are the symptom-based strategy and the test-based strategy. The symptom-based strategy requires that at least three days have passed since the resolution of symptoms, and that at least 10 days have passed since symptoms first appeared. The test-based strategy requires that the person’s symptoms have resolved, and that the person has had two consecutive negative PCR tests at least 24 hours apart. The CDC offers additional guidance for people who have tested positive but not been sick, and for those who have been sick and hospitalized. There is separate guidance for health care personnel seeking to return to work.
A recent article in the New England Journal of Medicine establishes a framework that individuals and their health care providers can use to determine their risk in the workplace and to counsel people on what protections may be necessary to keep them safe on the Job. If a worker is unsure of their occupational risk category, they may refer to the OSHA classification which designates very high/high, medium, and low categories depending on whether workers can expect to encounter known sources of COVID-19, frequent close contact (within 6 feet) with the general public in the setting of high community transmission, or frequent contact with travelers, or none of these.
Source: Larochelle M, NEJM
Unless it causes undue hardship, Employers should provide reasonable accommodation to employees whose preexisting illnesses, disorders or disabilities put them at greater risk from COVID-19, or where the stress and disruption of COVID-19 exacerbates their condition. Whether or not the employee requests reasonable accommodation, the employer should not take any adverse action against the employee solely because the person is at a higher risk for severe illness, whether because of age, disability, race, gender or other perceived attributes.
As workers start returning to offices in nonessential sectors, planning for COVID-19 is critical to ensure the health and safety of both the workforce and clientele. Different work settings already have policies and procedures in place to ensure the well-being of workers on the job, as well as those they work with and those they serve. During a pandemic where an invisible virus may spread from a person who is not showing any sign of infection and has the potential to expose dozens of coworkers and clients, a multi-tiered approach to workplace safety is necessary, as is outlined here.
This approach must include engineering controls such as physical barriers and improved air ventilation, administrative controls such as using virtual meetings and alternate workdays to reduce in-person contact among workers, and individual controls such as improved hygiene and use of face coverings. In addition, testing and screening of workers may be part of the approach in some settings. As the science of the pandemic continues to evolve, policies on testing and screening in the workplace should be guided by the best evidence currently available.