This chapter is based on a presentation given by Amber Mitchell, Dr. Robert Harrison, and Jonathan Rosen. It is the seventh in the “Essentials of Pandemic Response” series based on AIHA's 2021 ebook. 

During AIHce EXP 2021, Kevin Hedges, CIH, past president of Workplace Health Without Borders, introduced a presentation covering workplace controls and training programs for protecting essential workers from COVID-19. This session, titled “Preventing SARS-CoV-2 Among Essential Workers,” was presented by Amber Mitchell, DrPH, MPH, CPH; Dr. Robert Harrison, MD, MPH; and Jonathan Rosen, CIH, FAIHA. It was the third and final part of the “Key Topics in Addressing the COVID-19 Pandemic” series of presentations and was preceded by “The Varied International Experience” and “Scientific Issues and the Hierarchy of Controls,” which were covered in the Feb. 22 and March 17 SynergistNOW posts, respectively.

Reducing Essential Workers’ Exposures

“As we’re talking about reducing the burden of worker exposure and thinking about workplaces as essentially the intersection between public health and occupational health,” said Mitchell, the president and executive director of International Safety Center Inc., “then workplaces may be the only location where people are getting any type of health information.” Mitchell suggested that practicing occupational and environmental health and safety during a pandemic is about building “a structural culture of empathy in the workplace,” involving the use of workplace health and safety discussions as opportunities to provide workers with information about protecting themselves from exposure to infectious diseases.

Mitchell drew from healthcare worker safety advocate Paul O’Neill’s three key questions for gauging how workers feel about their work setting:

1. “Am I treated with dignity and respect, by everyone, every day, in each encounter, without regard to race, ethnicity, nationality, gender, religious belief, sexual orientation, title, pay grade, or number of degrees?”
2. “Do I have the resources I need—education, training, tools, financial support, and encouragement—so I can make a contribution to this organization that gives meaning to my life?”
3. “Am I recognized and thanked for what I do?”

According to Mitchell, occupational risk scores for occupations that have been required to interface with the public during the pandemic show that, in general, workplaces have failed to uphold O’Neill’s “Three R’s” of respect, resources, and recognition. In particular, non-healthcare essential workers are often not provided the resources they need to protect themselves from COVID-19 at their work sites. Many of these occupations, including meat and poultry processing, grocery and retail, and food industry workers, are also classified as non-healthcare targeted industries in OSHA’s revised COVID-19 National Emphasis Program.

Mitchell then outlined how occupation, setting, and geography affect workers’ exposure to COVID-19. Low-income counties often have higher rates of COVID-19 hospitalizations and deaths; some of these counties are also composed of majority Black or Hispanic populations. In April 2021, CDC reported that, across all four U.S. census regions (Northeast, Midwest, South, and West), Hispanic people made up the highest percentages of patients hospitalized with COVID-19 between March and December 2020. The Jan. 13 SynergistNOW post discusses racial health inequities during the COVID-19 pandemic in more detail.

Moreover, Mitchell briefly discussed the most frequently listed comorbidities for people who die from COVID-19, according to CDC: influenza and pneumonia, hypertension, diabetes, Alzheimer’s disease and dementia, and sepsis.

To tie empathetic OEHS practice with COVID-19 prevention, Mitchell proposed a new way of thinking about workplace controls for infectious diseases, comparable to prevention measures for biohazards and chemical hazards. The source-pathway-receptor model breaks down COVID-19 transmission along three points: the infectious source that generates SARS-CoV-2 viruses; the pathway of virus transmission, which is dependent on both distance and time; and the receiver, an uninfected person. The hierarchy of controls can be applied at each point to eliminate the source, interrupt the pathway, and protect the uninfected worker.

Along with increased collaboration across disciplines and greater appreciation for the total worker, Mitchell suggested that considering the topics listed above could promote OEHS professionals to a healing role and an approach based more in public health.

Vaccination, Screening, and Testing

Dr. Harrison, a medical doctor and clinical professor of medicine at the University of California, San Francisco, followed up on Mitchell’s assertion that employers must keep workers safe from COVID-19 exposure. He also called back to ideas brought up in Steve Lipson’s presentation, covered in the Jan. 11 blog post. At the start of the pandemic, it seemed as if the controls at the top of the traditional OEHS hierarchy were less practicable, so OEHS consultants advised their clients to protect their workers and customers through surface disinfection, social distancing, and the use of face coverings. As the pandemic continued, OEHS professionals came to better understand that COVID-19 was transmissible by aerosols and increasingly recommended ventilation controls. Testing was also improved and became widely used as a biological monitoring tool. By the spring of 2021, vaccines had become available to much of the adult U.S. population.

In Dr. Harrison’s view, which considered vaccination and testing to be elimination controls and ventilation to be an engineering control, the development of COVID-19 prevention strategies nearly followed an inverted hierarchy of controls. Despite the disease’s recent appearance, Dr. Harrison advocated that it could be controlled following the traditional hierarchy—that is, prioritizing the more effective controls at the top of the hierarchy, such as vaccination, over individual behavioral modifications such as social distancing and the use of face coverings.

Dr. Harrison also agreed with Mitchell that the COVID-19 pandemic underscored the overlap between public health and the workplace. In April 2021, a Kaiser Family Fund (KFF) poll of unvaccinated workers found that significant percentages of respondents would be more likely to get the vaccine if their employers provided paid time off to get vaccinated and recover from any side effects, paid them an extra $200 as an incentive to get vaccinated, or arranged for a medical provider to come to their place of work to administer the vaccine. Unvaccinated Hispanic workers especially said they were more willing to get vaccinated if their employer offered these services.

KFF also found that half of the poll respondents believed one of five common myths about the COVID-19 vaccine. Dr. Harrison suggested messaging that he had used when treating patients and that OEHS professionals could use in their occupational health programs to dispel myths and inform workers about the vaccine:

• “The vaccine keeps my family safe and keeps me safe at work.”
• “The vaccine instructs your cells’ machinery but doesn’t cause infection.”
• “You might experience minor side effects. It is much worse to develop persistent, long-term symptoms from COVID-19 infection.”
• “So far, the vaccine has seemed to work for new strains, but some protections must stay in place for workplaces.”
• “If an OEHS professional asks a worker for their vaccination status, that information will be kept private.”

According to Dr. Harrison, it’s acceptable for OEHS professionals to ask workers if they have been vaccinated. This is protected private information and should be kept in one place, such as in human resources or employee health and safety records.

Even with widespread vaccination, Dr. Harrison still predicted that it would be necessary to continue SARS-CoV-2 testing in some workplaces to detect and control transmission and monitor for variant strains of the virus. “Vaccine-adjusted” surveillance testing will be most useful in high-risk workplaces where employees are primarily unvaccinated, such as correctional facilities.

The Critical Role of Worker Training

Rosen presented on a worker training program developed by the National Clearinghouse for Worker Safety and Health Training, a project funded by the National Institute of Environmental Health Sciences Worker Training Program (NIEHS WTP). Rosen cited several studies that found participatory worker training methods that used behavioral modeling and substantial amounts of practice and dialogue to be more effective than other methods. “We have learned that during a disaster,” Rosen said, “people will perform to the level of training they received during the preparedness phase.”

After the onset of the COVID-19 pandemic, the NIEHS WTP faced many challenges in mobilizing its grant recipients to develop and deliver effective worker training materials. Training had to be conducted safely, which required the use of virtual platforms and other methods to prevent participants from being exposed to the virus. Curricula had to be rapidly developed that would prepare peer trainers to communicate honest, evidence-based information to frontline workers in multiple languages. Two free, publicly available programs were designed: an awareness program to help workers protect themselves from COVID-19 in the workplace and a more comprehensive training tool for essential and returning workers.

“The intention of these programs,” said Rosen, “is that [employers and OEHS professionals] will tailor them to the industries, needs, or amount of time that [they] can commit to delivering this type of training.” Many of NIEHS’ grant recipients have adapted the training program for the needs of immigrant workers, retail workers, workers at long-term care facilities, and other essential workers.

The goal of one of National Clearinghouse’s training tools, titled “Building Programs to Protect Workers from COVID-19 in the Workplace,” is to increase workers’ health and safety awareness to prevent COVID-19 exposures. After attending the program, participants are better prepared to assess risk factors for COVID-19 exposures at work, know what protective measures employers should implement in their industry, understand their rights to a safe and healthy workplace, and protect their mental health during the pandemic. The training tool highlights the necessity for employers to inform workers of changes at the workplace and train them in new procedures when they return to work. It also aims to reduce misinformation by alerting participants to the need to keep up with rapidly changing information on COVID-19 and directing them to reliable sources that can answer their questions.

However, “it’s not operational training,” said Rosen. “This awareness program does not train people in the specific policies and procedures at a particular work site.” The training tool warns participants that the information it provides is not adequate for workers who are at risk for occupational SARS-CoV-2 exposure. Site-specific training must either be done separately or integrated into the slides provided by NIEHS.

Workers are encouraged to participate in training: for example, by identifying whether the people shown in photos or illustrations embedded in the presentation slides are taking adequate safety measures. “We find that when you involve the participants in the discussion […] that people leave with a more empowered feeling—that they can take this back to the workplace and their coworkers and hopefully have a voice within the organization or at least know their rights,” said Rosen.

Rosen highlighted the importance of addressing workers’ mental health during the pandemic, and the National Clearinghouse also provides a training program on stress, trauma, and resilience.

During the early stages of the pandemic, developing COVID-19 training programs was hindered by the lack of OSHA requirements for worker training in infection control, the difficulty of establishing training while responding to the pandemic, the staff shortages experienced by the hardest-hit industries, and the lack of workplace cultures invested in safety and health in low-wage industries. Ideally, safety training programs should be developed while preparing for a crisis—not during the process of responding to it.

Resources:

American Journal of Public Health: “Relative Effectiveness of Worker Safety and Health Training Methods” (Feb. 2006).

American Journal of Industrial Medicine: “Assessing the Impact of Health and Safety Training: Increased Behavioral Change and Organizational Performance” (Aug. 5, 2019).

The COVID Tracking Project: “The COVID Racial Data Tracker.”

Mitchell, Amber; Harrison, Robert; and Rosen, Jonathan: “Key Topics in Addressing the COVID-19 Pandemic, Part 3: Preventing SARS-CoV-2 Among Essential Workers,” AIHce EXP Virtual Conference Presentation (May 26, 2021).

Visual Capitalist: “The Front Line: Visualizing the Occupations with the Highest COVID-19 Risk” (April 15, 2020).