The continuing onslaught of COVID-19 is decimating the ranks of U.S. healthcare workers, leading to calls for the Occupational Safety and Health Administration (OSHA) to issue an infectious disease standard requiring employers to protect medical staff.
OSHA had an infectious disease standard in the legislative pipeline, but it fell into political limbo after the 2016 presidential election led to a new antiregulatory environment. The recently proposed Health and Economic Recovery Omnibus Emergency Solutions (HEROES) Act (H.R. 6800) would require OSHA to issue an emergency temporary standard to protect workers in hospitals, meatpacking plants, retail stores, and other workplaces during the pandemic. Although stuck in the Senate, the proposed law also would prohibit employers from retaliating against workers for sounding the alarm about unsafe conditions.
“There is no question that an OSHA infectious disease standard would prevent illnesses and deaths among healthcare workers,” says David Michaels, PhD, a professor of environmental and occupational health at George Washington University. “For the sake of the thousands of healthcare workers not yet sickened by COVID-19, I hope that Congress can overcome this shortsighted opposition and pass this important legislation.”
Michaels served as OSHA director during both terms of the Obama administration, shepherding the infectious disease standard and other regulations forward. Hospital groups have opposed OSHA regulations as burdensome, and the agency itself has said in recent congressional testimony that it currently has sufficient regulatory authority under its general duty clause to protect healthcare workers from COVID-19.
“The at least 400 deaths among nursing home and hospital workers are proof that just recommendations are not enough,” Michaels says. “We have to do better than that. To hear hospital administrators say we don’t need this standard is unfortunate and tragic.”
As originally proposed, the standard would include a Worker Infection Control Plan (WICP). Employers would have been required to create a WICP for those at risk of occupational exposures to infectious diseases during patient care and other duties. In a provision that seems particularly germane to the situation, the standard called for worker protections to be reviewed and updated to meet the threat of new and emerging infectious diseases.
As of Aug. 4, the Centers for Disease Control and Prevention (CDC) reported 123,738 COVID-19 infections in healthcare workers, with 598 deaths. However, the precise count is likely much worse, as the CDC data came from limited reports.1
Data were collected from 3,551,226 people, but healthcare personnel status was only available for 776,820, the CDC noted. Of the 123,738 cases, death status was only available for 84,388.1
“The CDC reporting is not mandatory. That is really the problem. You are not required to report any of this,” says Deborah Burger, RN, president of the California Nurses Association and co-president of National Nurses United (NNU). “We are calling for federal OSHA to pass an emergency temporary standard on infectious disease to mandate that our employers give us the highest level of protection.”
Burger is not optimistic about their chances. “It’s gotten attention, but it has become a political pawn,” she laments. “We can’t even get a consistent public health message that everyone should be wearing masks. I have been a nurse for over 45 years and I never thought that the federal government would play such a large role in politicizing a public safety issue.”
A new regulation likely is a nonstarter politically, but current Principal Deputy Assistant Secretary of Labor for Occupational Safety and Health Loren Sweatt, BA, MBA, said the agency can protect workers without creating a new standard.
“While extensive guidance is important as the rapidly changing dynamic of this pandemic continues, it is important to recognize OSHA also has existing standards that serve as the basis for its COVID-19 enforcement,” she said at a recent congressional hearing. “Those standards include rules regarding respiratory protection, personal protective equipment [PPE], eye and face protection, sanitation, and hazard communication.”
U.S. Rep. Alma Adams, D-NC, chair of the House Subcommittee on Workforce Protections, gave a withering assessment of OSHA at the hearing.
“OSHA, the agency that this nation has tasked to protect workers, has been largely invisible,” she said. “It has failed to develop the necessary tools it needs to combat this pandemic and it has failed to fully use the tools it has.”
In March, OSHA rejected Alma’s request for an emergency temporary standard “on the grounds that the healthcare industry fully understands the gravity of the situation and is taking the appropriate steps to protect its workers,” Alma said.
Depending on the outcome of this year’s election, an infectious disease standard could be back on the table. California’s state regulation on infectious diseases might form the basis of an eventual federal standard, Burger says. Creating a standard before the next pandemic hits could prevent worker protections from politicization.
“Healthcare worker safety would be a bit more insulated from the political arena,” Burger says. “There is no reason we have to lose doctors, nurses, and other healthcare workers in an infectious disease environment if we are given the proper equipment.”
The mixed messages from political and public health officials have given the pandemic response an “Orwellian” tone, she says. “I can’t even wrap my mind around how crazy this whole thing is.”
Although it has always been the case, the situation has revealed how voluntary guidelines from the CDC can be diluted or simply ignored if there is no regulation behind them.
“It’s voluntary — you can follow these, or not,” Burger says. “We know that the employers are going to do whatever they can to spend the least amount of money.”
The ‘Terrible Reality’
There certainly are exceptions to that harsh assessment, but the infections and deaths of healthcare workers on the frontlines are strongly linked to the lack of PPE, particularly N95 respirators, says Daniel Lucey, MD, a professor of infectious diseases at Georgetown University.
“Something needs to be done,” he says. “The very terrible reality is that the strategic national stockpile did not get replenished with masks and N95 respirators after the influenza pandemic of 2009-2010. Why not?”
Other public health measures took precedent, resulting in insufficient supplies and shifting CDC guidelines, dropping from N95 recommendation to masks, and the widely criticized last resort of “bandanas and scarves.”
“The proof is in the numbers — the 84,000 — they didn’t have the PPE,” he says. “What is the CDC’s role? To say it is OK to use something that doesn’t protect you — a surgical mask when you need an N95 — simply because we don’t have enough N95s? It has really damaged the faith of healthcare workers in the CDC, and there are still shortages now.”
After spending decades investigating pandemics and major outbreaks, Lucey’s grim take on the healthcare worker toll carries considerable weight.
“It is unlike anything I have ever seen,” he says. “It is an astonishing number of infections and deaths. It is going to continue to climb, hopefully not as quickly.” The healthcare workers who survived COVID-19 may still have health problems, both physical and mental, in the future, he notes.
The current situation does not bode well for the fall and winter, when there will likely be a “high tide” of COVID-19 cases during seasonal influenza, Lucey says.
“I think it is going to take some authority to make sure that we have enough tests, and it looks like it is not going to be the federal government,” he says. “The Trump administration has said it is up to the states.”
Healthcare worker flu vaccination also will be critical. Messaging to the public will emphasize the threat of a “double-barreled” viral season in 2020-21, says William Schaffner, MD, professor of preventive medicine at Vanderbilt University.
“With flu and COVID — not to mention RSV [respiratory syncytial virus] and all the other viruses — we fear a great surge of patients coming into the healthcare system,” Schaffner says. “At the moment, flu vaccine is the best intervention we have — not only to provide individual protection, but to mitigate the impact of a very substantial demand for medical care.”
‘We Are Expendable’
Will there be enough PPE to face such a surge? A recent NNU national survey of 23,000 nurses found the lack of PPE has become a chronic problem, leading to frequent reuse of equipment that was not designed to be reprocessed. The survey results included responses from union and nonunion nurses in all 50 states polled from April 15 to May 10. Overall, 87% of respondents reported reusing a single-use, disposable respirator or mask with a COVID-19 patient. In addition, 28% of respondents had to reuse “decontaminated” respirators with confirmed COVID-19 patients, a practice equipment manufacturers do not recommend, the NNU reports.2
The survey results revealed 27% of nurses providing care to confirmed COVID-19 patients reported they were exposed without appropriate PPE and then worked within the next two weeks. In addition, 84% of respondents had not been tested for the novel coronavirus. Of those nurses who have been tested, more than 500 reported a positive result, and another 500-plus were awaiting results when surveyed.
“How can we protect our patients form COVID-19 if we ourselves do not know whether or not we are positive?” Burger asks. “Nurses are fighting to get tested.”
One-third of survey respondents reported having to use their own sick leave, vacation, or paid time off to miss work or quarantine if they acquire or are exposed to COVID-19. The NNU argues illness caused by the novel coronavirus should be presumed to be occupationally acquired and covered by workers’ compensation. The nurse union is calling for states to pass bills ensuring nurses are protected with “presumptive eligibility” for COVID-19.
“Our employers won’t act to protect us on their own,” says Zenei Cortez, RN, co-president of the NNU. “They have totally disregarded the health and safety of nurses and the patients we [care for] every day. It was not a secret that a pandemic was coming. Nurses have been standing up and demanding infectious disease protections for years and years, during SARS, Ebola, and MERS.”
In addition to an OSHA emergency standard, the NNU is calling for implementation of the federal Defense Production Act to ramp up testing and PPE supplies.
“It’s been five months now and we haven’t gotten the adequate stores we need to provide care,” she says. “We are still in the first wave of this, and we are reopening.”
Certainly, some healthcare worker infections and deaths were a result of the shortage of PPE, she emphasizes.
“We know that because in Spain, where they used the correct PPE, they had four deaths of nurses,” she says. “We know when the proper equipment is used, there are fewer deaths.”
As CDC mask and respirator messages steadily weakened in the face of shortages, the message to nurses was “we are expendable,” Burger says.
- Centers for Disease Control and Prevention. Coronavirus disease 2019 (COVID-19): Cases in the U.S., Aug. 4, 2020. https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html
- National Nurses United. New survey of nurses provides frontline proof of widespread employer, government disregard for nurse and patient safety, mainly through lack of optimal PPE. May 20, 2020. https://www.nationalnursesunited.org/press/new-survey-results