This post is based on a presentation given at AIHce EXP 2021 by Laurence Svirchev, Vanessa De Greef, Steven Verpaele, and David Michaels. It is the third in the “Essentials of Pandemic Response” series based on AIHA's recently published ebook.

The global COVID-19 response started as early as the final weeks of 2019, when cases of undiagnosed respiratory disease were detected in Wuhan, China. At the urging of scientists and medical experts, countries scrambled to respond. A few nations took early, decisive, non-pharmaceutical actions that significantly delayed the virus’s appearance within their borders. Even without the availability of vaccines, life in these countries carried on as normal for some time, although circumstances would change in later months because of the appearance of more contagious SARS-CoV-2 variants, including the Delta and Omicron variants.

Meanwhile, AIHce EXP was held virtually in May 2021 due to the continued prevalence of COVID-19 in the U.S. The U.S. and many other countries still struggled with overburdened healthcare systems. AIHA members Laurence Svirchev, CIH, and Jonathan Rosen, CIH, FAIHA, organized a three-part series of educational sessions covering various aspects of pandemic response, titled “Key Topics in Addressing the COVID-19 Pandemic.” The first session in this series, “The Varied International Experience,” was presented by Svirchev, Vanessa De Greef, PhD, Steven Verpaele, and David Michaels, PhD, MPH.

The Strategies of New Zealand, Vietnam, China

Svirchev is an occupational health and safety professional based in Vancouver, Canada, and a visiting researcher on earthquakes and disaster management at the Chengdu University of Technology in Chengdu, China. His experiences lend him a unique perspective on the global response to the pandemic, enhanced by those of his co-presenters De Greef, Verpaele, and Michaels.

Comparing the relative COVID-19 risk for different countries at the beginning of 2021, Svirchev noted that North America and Europe had been the principal drivers of COVID-19 cases for much of the pandemic up to that point in time, despite the highly developed healthcare systems of many countries in those regions. Of the countries that significantly delayed COVID-19 transmission during the pandemic’s early months, such as New Zealand, Vietnam, and China, each has a different governance system, history, culture, and geographic location (ruling out effects due to seasonal differences). Svirchev believed that these countries more successfully responded to the initial appearance of SARS-CoV-2 due to “strategy, leadership at national levels, and social discipline during a prolonged emergency.” Specifically, these countries shared what Svirchev referred to as “elimination” strategies.

New Zealand: Svirchev spoke to Derek Miller, COH, the president of the Health and Safety Association of New Zealand. Miller explained that New Zealand has a single governing body for health, which works with the New Zealand government on a unified national strategy, and that occupational hygienists worked with businesses on all levels to develop and implement strategies for safely reopening. These strategies included the Commit2Fit respiratory protection training program.

Vietnam: Tuan Nguyen, CIH, FAIHA, a member of AIHA’s International Affairs Committee, told Svirchev that Vietnam activated its national network of Emergency Operations Centers, which previously operated during the Ebola and Zika outbreaks of the 2010s, to coordinate national COVID-19 response across the country’s varied geographic landscape and decentralized health system. The country quickly and decisively sealed its borders to prevent cases from being imported. Doctors, nurses, and public health officials collaborated with the police force and military to contain COVID-19 outbreaks.

China: By March 9, China had effectively controlled the outbreak of the virus, which was by then officially named SARS-CoV-2, with a cumulative total of 81,000 cases and 3,100 deaths—a relatively light impact compared to the burgeoning pandemic’s later effects on other nations.

China’s disaster response efforts are coordinated by the country’s chief administrative body, the State Council. Wuhan, a city of more than 11 million people, was completely locked down from Jan. 23 to April 8, 2020. Two new hospitals specifically for COVID-19 patients, each with a capacity of 2,600 beds, were constructed over a 10-day period. Still, by mid-January, the Wuhan healthcare system had become strained, so thousands of healthcare volunteers deployed from across China to relieve the city’s exhausted healthcare workers.

Local authorities were ordered to provide adequate rest, food, and personal protective equipment to healthcare workers, and healthcare workers could qualify for compensation related to COVID-19. Salaries for frontline healthcare workers were tripled. Healthcare workers were rigorously trained in PPE use, supervised to ensure strict adherence to infection control measures, and constantly tested, under the objective that no patient would be able to infect a healthcare worker.

After lockdown measures were lifted, a city-wide SARS-CoV-2 screening program ran from May 14 to June 1, 2020. Until December 2021, a negative COVID-19 test result and two-week quarantine period was still required for all inbound travelers to China. As of January 2022, the quarantine period was dropped for travelers not showing symptoms, but a strict testing and symptom screening procedure was required for entry to the country.

While some of the countries that adopted elimination strategies, including New Zealand and Vietnam, would eventually experience increases in COVID-19 case rates, their ability to significantly delay the virus’s appearance is still a noteworthy achievement. Doing so gives public health systems increased time to prepare and offers lessons for handling the next pandemic.

Selecting COVID-19 Response Strategies

Svirchev characterized most high-income nations as relying on “mitigation” strategies against COVID-19, employing non-pharmaceutical social and public health interventions until vaccines were available. But this type of strategy has disadvantages. First, cycles of opening and closing businesses in response to rising and falling rates of COVID-19 actually increase negative economic impacts, create public confusion, and allow time for variants to develop.

An alternative to mitigation strategies are elimination strategies, which take immediate action to eliminate transmission. According to Svirchev, elimination strategies require informed input from scientists, political commitment, sufficient public health infrastructure, public engagement and trust, and a social safety net to support vulnerable populations. He characterized the strategies employed by New Zealand, Vietnam, and China as elimination strategies.

Svirchev added that, in his opinion, government guidance and regulations comprise the minimum of COVID-19 response measures, as they are often delivered too slowly and may convey conflicting messages that confuse the public. “In other words,” said Svirchev, “as OEHS professionals, we have to actively engage our training and discipline to get to the maximum [necessary measures for COVID-19 prevention].”

Occupational Health in the European Union

De Greef is a postdoctoral researcher for Belgium’s National Fund for Scientific Research and a professor of labor law at the Université libre de Bruxelles. Speaking after Svirchev, De Greef offered perspective on COVID-19 response within the European Union, specifically regarding the EU’s OSH Framework Directive of 1989 (also known as Directive 89/391/EEC), which regulates worker and employer obligations concerning occupational safety and health. She discussed problems posed by the directive’s language requiring occupational safety and health initiatives to work with representatives of organized labor.

According to De Greef, a major difference between the EU and U.S. occupational health and safety systems is that the EU does not have a direct equivalent to OSHA. The European Agency for Safety and Health at Work (EU-OSHA) cannot enforce EU directives in the way that OSHA enforces federal safety and health regulations in the U.S. Every EU member state has a different approach to enforcing the specifications of Directive 89/391/EEC, so occupational health and safety regulations are not harmonized across the EU.

De Greef elaborated that, along with the occupational health directive’s vague wording, this had implications for EU members’ responses to COVID-19. Directive 89/391/EEC is transposed on Belgium’s legal system through the Act of 4 August on the Well-Being of Workers in the Performance of Their Work and the Code on Well Being at Work. When the COVID-19 pandemic began, Belgium implemented measures against COVID-19, but these guidelines are on uncertain legal ground because it is not clear if they follow the prescriptions of Directive 89/391/EEC or the Belgian law. The first version of Belgium’s COVID-19 guidelines did not incorporate the EU directive’s requirement to include workers and union representatives in all occupational health and safety discussions, and the guidance had to be revised. The new guidance is still legally insecure. The penalties put in place duplicate those preexisting for other offenses and may be weaker than those for circumstances outside of the pandemic.

De Greef ended with a general question—what criteria could guide the OEHS community to analyze the effectiveness of occupational health laws in the EU and elsewhere? She proposed five areas of focus:

1. developing an efficient work organization, efficient health and safety organization system, and efficient social security system
2. improving the role of inspections
3. developing databases on occupational health and safety
4. increasing or maintaining the importance of public debate
5. improving workers’ capabilities “to develop health preservation strategies which socialize the problems encountered and the solutions to them” (quoting Laurent Vogel, PhD, of the European Trade Union Institute)

Belgium’s Response to COVID-19

Steven Verpaele, an industrial hygienist with the Nickel Institute in Brussels, Belgium, continued where De Greef left off by discussing COVID-19 prevention and protection in Belgium and across the EU. During the pandemic, each EU member state developed its own COVID-19 strategies, with only a few recommendations issued by the EU itself. Belgium began its national COVID-19 lockdown on March 19, 2020.

The High Council for Prevention and Protection at Work, consisting of social partners, experts, and administrative representatives, advises the Belgian government on matters related to occupational health and safety. The council published a guide to COVID-19 protection at work on April 23, 2020 (PDF), which received a second edition published in May 2020, and produced and distributed a series of COVID-19 awareness videos. As many international workers are employed in Belgium, COVID-19 documents were made available in 17 languages by August 2020.

The third version of the guidance, released in October 2020, included measures that went beyond hand hygiene and social distancing, including mask wearing and ventilation. This was when mask wearing first became obligatory in Belgium. Through the last months of 2020 and into 2021, the COVID-19 guidance was further aligned with Belgian labor laws and updated repeatedly to include a testing strategy, remote work guidelines, and contact tracing. Occupational physicians weren’t involved in Belgium’s COVID-19 plan until January 2021, one year after COVID-19 had first appeared. Complete guidance on ventilation and indoor air quality were not published until April 2021.

“In the systems that we were working [in], we were always a little bit behind,” said Verpaele. “Many of those rules had to wait a bit before they were actually implemented at the workplace because the legal framework [for them] was not there.”

Improving the U.S. Response to COVID-19

Michaels is a professor at the George Washington University School of Public Health and a former assistant secretary of labor for OSHA. He stated that COVID-19 transmission in the U.S. is driven by social determinants of health, including income, class, and race, and that people belonging to communities of color are at higher risk for COVID-19 infection, hospitalization, and death compared to non-Hispanic white Americans. According to a 2019 report by the U.S. Bureau of Labor Statistics (PDF), Black and Hispanic workers were significantly less likely than white workers to work from home in 2017–2018, predicting these groups’ ability to socially distance during the pandemic.

Workplaces are important to disease transmission. Michaels explained that, although it is often difficult to determine where people are exposed to SARS-CoV-2, the significance of work is evident in the concentration of outbreaks around work sites, notably meat and poultry processing plants. Many meat processing workers are also people of color. A more in-depth discussion about the racial inequities exacerbated by the COVID-19 pandemic in the U.S. can be found in the previous blog post in this series, “Addressing COVID-19 in Minority Communities.”

Even prior to the pandemic, OSHA has been challenged by a lack of funding and resources. The standard-making process is cumbersome: in 2016, during Michaels’ tenure as head of OSHA, the agency finally released a silica standard that had been in development since 1997. The modern workplace is also different than when OSHA was founded. In Michaels’ evaluation, these challenges compound each other to make OSHA much less effective than it could be.

As a result, when OSHA investigated a COVID-19 outbreak at a Smithfield Foods pork processing plant in Sioux City, South Dakota, the agency lacked an emergency temporary standard (ETS) for COVID-19 and issued a penalty of only $13,494 to a company that is the largest pork processor in the world. A COVID-19 ETS covering only healthcare workers would later be issued by OSHA in June 2021. OSHA’s COVID-19 Vaccination and Testing ETS, which required private employers with 100 or more employees to develop, implement, and enforce a COVID-19 vaccination and testing policy, was not issued until November 2021. However, in January 2022, the U.S. Supreme Court blocked implementation of the vaccination and testing ETS.

To better address COVID-19 transmission in workplaces in the absence of an ETS, Michaels recommended for OSHA to engage in high-profile enforcement actions to convey to employers that exposing workers to SARS-CoV-2 will result in significant consequences. He also stressed the need for better whistleblower protection and especially for OSHA to use its influence to encourage employers and workers to collaborate in implementing COVID-19 protections. Criticizing the CDC’s lifting of face covering requirements for vaccinated individuals in May 2021, Michaels asserted that many people interpreted this to mean that COVID-19 controls were no longer needed. Cautioning that the lifting of mask requirements would slow the elimination of COVID-19, he called on OEHS professionals to continue to work together to save lives.

COVID-19 protection remains uneven across the U.S. In 2020, some states with state OSHA plans, including Virginia, California, Oregon, and Washington, quickly issued emergency standards, but many states did not. By April 2021, the uneven effects of vaccination had become clear, with a survey by The New York Times finding that college graduates were significantly more likely than non-college graduates to get vaccinated and have favorable attitudes to vaccines. The result is that vulnerable blue-collar worker populations, including meat processing workers, are still less likely to be vaccinated.

“The great work that AIHA and the Back to Work Safely Task Force have done makes it very clear that we know how to protect workers at workplaces,” said Michaels, adding that it wasn’t enough just to make every worker wear a mask. “Every employer needs to develop a plan on assessing their risk at the workplace and then applying the hierarchy of controls.”

Resource:

AIHA: “Key Topics in Addressing the COVID-19 Pandemic, Part 1: The Varied International Experience,” AIHce EXP 2021 (virtual presentation by Laurence Svirchev, Vanessa De Greef, Steven Verpaele, and David Michaels, May 26, 2021).