The Occupational Safety and Health Administration (OSHA) has issued a National Emphasis Program (NEP) to ensure employees in high-hazard industries like healthcare are protected from contracting SARS-CoV-2.

The NEP augments OSHA’s efforts to respond to COVID-19-related “complaints, referrals, and severe incident reports by adding a component to target specific high-hazard industries or activities where this hazard is prevalent.” OSHA also is providing whistleblower protections to ensure workers who report unsafe conditions are protected from retaliation.1

“Particular attention for on-site inspections will be given to workplaces with a higher potential for COVID-19 exposures, such as hospitals, assisted living, nursing homes, and other healthcare and emergency response providers treating patients with COVID-19, as well as workplaces with high numbers of COVID-19-related complaints or known COVID-19 cases,” OSHA stated. “These include, but may not be limited to, correctional facilities, and workplaces in critical industries located in communities with increasing rates of COVID-19 transmission, and where workers are in close proximity.”

According to the general inspection procedures outlined in the document, OSHA visits may be programmed or unprogrammed, meaning inspectors could show up unannounced, particularly in response to a complaint or fatality.

“The [OSHA inspector] shall review the establishment’s injury and illness logs (OSHA 300 and OSHA 300A) for calendar years 2020 and 2021 to date to identify work-related cases of COVID-19,” according to the NEP. “[We] may choose to verify the employer’s assertions regarding workplace conditions or possible existence of worker exposures to SARS-CoV-2 by interviewing employee(s) at the site.”

The agency’s action is a direct response to a Jan. 21 executive order by President Biden to protect workers from COVID-19. It also raises the question of whether OSHA will issue a temporary standard or pursue official rulemaking on infectious disease protections for workers.

Community Acquisition

The somewhat controversial problem is that researchers are finding most of the COVID-19 infections in healthcare workers (HCWs) are acquired in the community.

Researchers conducted a cross-sectional study of 24,749 HCWs in three states, finding that contact with a known COVID-19 case in the community was the strongest risk factor associated infection. Also predictive of SARS-CoV-2 seropositivity was living in a ZIP code with higher prevalence of COVID-19. Remarkably, none of the assessed workplace factors were associated with seropositivity. But this was to some degree expected, as the hypothesis was that community exposure — not healthcare exposure — would be linked to seropositivity.2

“This cross-sectional study was conducted among volunteer [HCWs] at four large healthcare systems in three U.S. states,” the authors noted. “Sites shared de-identified data sets, including previously collected serology results, questionnaire results on community and workplace exposures at the time of serology, and three-digit residential ZIP code prefix of [HCWs].”

Cumulative incidence of COVID-19 per 10,000 in the community up to one week before serology testing ranged from 8.2 to 275.6. However, 81% of the HCWs reported no community contact with a person confirmed or suspected of having COVID-19. Seropositivity was 4.4% overall, representing 1,080 workers.

“In multivariable analysis, community COVID-19 contact and community COVID-19 cumulative incidence were associated with seropositivity,” the researchers concluded. “No assessed workplace factors were associated with seropositivity, including nurse job role, working in the emergency department, or workplace contact with patients with COVID-19.”

Of significance, the CDC participated in the study, which was conducted at four sites in the CDC Prevention Epicenters Program: Emory University in Atlanta, Rush University in Chicago, Johns Hopkins Medicine, and the University of Maryland Medical System. These academic institutions collaborate with each other and the CDC to perform cutting-edge infection prevention research, so they may have better compliance with PPE and other measures than, for example, small community and rural hospitals.

“In our study, there was no clear association between workplace contact with patients with COVID-19 and antibody positivity, consistent with some studies3,4 but conflicting with others,” they reported.

For example, researchers in seven hospitals in Denmark tested more than 25,000 healthcare workers and found an overall SARS-CoV-2 seropositivity rate of 3.4%. In contrast to the Epicenter study, the Danish researchers found a higher positivity rate among HCWs taking care of patients or working in the emergency department.5

“However, similar to our study, a large study6 of more than 40,000 [HCWs] in New York found no association between work location or direct patient care and seropositivity, but did not distinguish workplace and community exposures to individuals with known COVID-19,” the U.S. researchers noted.

‘That’s a Really Difficult Situation’

Hospital Employee Health asked study co-author Anthony D. Harris, MD, an epidemiologist at the University of Maryland, to comment on the study. The interview has been edited for length and clarity.

HEH: Your hypothesis was you would find the community as the prime source of infections. But were you surprised that no work factors were associated with seropositivity?

Harris: Yes, to be honest with you. You would think that reasonable hypothesis would be that healthcare workers who were exposed to patients with coronavirus or were working in higher-risk areas may have a slightly increased risk. But that’s why we think our results are really important. I’m a hospital epidemiologist, and our job is to protect healthcare workers. In the first three or four months [of the pandemic] when all of the stories were coming out that healthcare workers were seropositive, it was really scary. We were constantly modifying policies to protect the healthcare workers. I think what this study shows, at least in these academic centers, is that we probably had pretty good compliance with the things we know that matter — masks, eye coverings, and so on.

HEH: You thoroughly reviewed these findings?

Harris: The results were pretty robust. We had very strong epidemiological and statistical teams and a large number of healthcare workers. There was nothing to suggest that different aspects of the hospital were putting them at increased risk. We double- and triple-checked all the community findings with different [methods]. The healthcare workers who were getting it were driving in their cars unmasked with other healthcare workers, or they were letting their guard down at home — understandably. These results are really important to get out there, to alleviate the anxiety of healthcare workers with the basic message to keep doing what you’re doing and follow all of the guidance. In some ways, you are safer in the hospital than you are outside.

HEH: PPE use early on was not ideal, but that changed as the pandemic continued.

Harris: It’s a good point. Early on when there were massive PPE shortages — our healthcare workers were wearing surgical masks [instead of] N95s — I think that’s when problems were arising. A limitation of our study that we did acknowledge is that these policies in the participating facilities were changing throughout. It was really hard to tease out things [and conclude] “universal masking is what led to this,” or “proper compliance with N95s.” We couldn’t really tease out what worked and what didn’t. We could just say at these institutions that prioritized following the CDC guidance, we have fairly robust infection prevention practices. We did a lot of education and a lot of compliance monitoring. In these type of settings, healthcare workers were safe.

HEH: What are the implications for your study in situations where an HCW might think their COVID-19 infection was occupational? They could be eligible for workers’ compensation or benefits.

Harris: That’s a really difficult situation to comment on. That’s always the question, whether it is a healthcare worker or a patient: Where, exactly, did they get it from? Healthcare workers are not bubbled in the hospital. It’s really difficult to tell. From a similar point of view, if a patient gets it four days [after hospitalization], did they get it in the hospital? Did they come in with it? It’s hard to pinpoint.

Obviously, our goal and hope in our policies is that we protect healthcare workers in the hospital. If what we provide for them in the hospital — the PPE and the education — they then apply outside the hospital, that keeps them safer. But it’s really difficult to pinpoint definitively where a healthcare worker became infected.

I can tell you anecdotally that the hospital epidemiologists felt that in most of the outbreak situations, if healthcare workers were positive, it was often because of things like letting their guard down. We imply it [in the paper], but it is draining to wear PPE all the time. You assume among your colleagues that you are safe in instances like carpooling together without masks, or going into break rooms and sharing meals. We think that behavior leads to some seropositives. Now, there are cases with genetic sequencing where it looks like a healthcare worker, despite being fully masked and at least reporting full compliance, got it from a patient. There are instances of rare events where that might happen, but I think what our data show across 25,000 healthcare workers is that those are the exceptions and not the rule.

REFERENCES

  1. Occupational Safety and Health Administration. OSHA Direction: National Emphasis Program — coronavirus disease 2019 (COVID-19). March 12, 2021. https://www.osha.gov/sites/default/files/enforcement/directives/DIR_2021-01_CPL-03.pdf
  2. Jacob JT, Baker JM, Fridkin SK, et al. Risk factors associated with SARS-CoV-2 seropositivity among US health care personnel. JAMA Netw Open 2021;4:e211283.
  3. Steensels D, Oris E, Coninx L, et al. Hospital-wide SARS-CoV-2 antibody screening in 3056 staff in a tertiary center in Belgium. JAMA 2020;324:195-197.
  4. Hunter BR, Dbeibo L, Weaver CS, et al. Seroprevalence of severe acute respiratory coronavirus virus 2 (SARS-CoV-2) antibodies among healthcare workers with differing levels of coronavirus disease 2019 (COVID-19) patient exposure. Infect Control Hosp Epidemiol 2020;41:1441-1442.
  5. Jespersen S, Mikkelsen S, Greve T, et al. SARS-CoV-2 seroprevalence survey among 17,971 healthcare and administrative personnel at hospitals, pre-hospital services, and specialist practitioners in the Central Denmark Region. Clin Infect Dis 2020;ciaa1471. doi: 10.1093/cid/ciaa1471. [Online ahead of print].
  6. Moscola J, Sembajwe G, Jarrett M, et al; Northwell Health COVID-19 Research Consortium. Prevalence of SARS-CoV-2 antibodies in health care personnel in the New York City area. JAMA 2020;324:893-895.