What keeps workers safe from COVID-19?

 

Workplaces address  COVID-19 infection risks by highlighting the hazards and implementing a hierarchy of controls.   Observing the strategies and tactics workplaces are actually using  can provide valuable insights and examples.

Science informs workplace safety and health.  Proven measures in the fight against COVID-19 include: physical distancing,

• frequent hand washing,
• not touching your face,
• wearing a mask,
• avoiding crowds, and
• sticking to your immediate “bubble”.

The point of these measures is to keep concentrations of virus out of your airways where the disease takes hold.  

Everyone wants this COVID-19 infection threat to go away.   Until this hazard is eliminated, employers are required (by occupational safety and health authorities, public health orders, and the moral imperative) to protect workers and other persons in the workplace.  In the context of the COVID-19 pandemic, that means active measures to eliminate the workplace hazard or mitigate exposure and infection risk.

The Common Objective

Workplaces share a common objective in this pandemic: 

Prevent workers from contracting COVID-19 virus. 

Workers and other persons in the workplace are at increased risk when they occupy the same workspace, are in close proximity to others, or have contact with contaminated surfaces. 

“Close proximity” is a general term and not the same as the “close contact” term used by public health officials.  Just because you have been in close proximity to others does not make you a “close contact”.

Health Canada, for example, defines close contact for COVID-19 this way:

Close contact: Breathing in someone's respiratory droplets after they cough, sneeze, laugh or sing. [see Health Canada, Coronavirus disease (COVID-19): Prevention and risk] 

For contact-tracing purposes, the CDC uses the following definition of close contacts:

Someone who was within 6 feet of an infected person for a cumulative total of 15 minutes or more over a 24-hour period starting from 2 days before illness onset (or, for asymptomatic patients, 2 days prior to test specimen collection) until the time the patient is isolated. [See CDC, Contact Tracing Plan, Appendix A]

Close-proximity encounters may not meet the formal definition of “Close-contact” but being near enough to someone to potentially breath in their respiratory droplets does create a pathway for transmission.  Interrupting those transmission pathways is the priority. 

From research, experience, and incident investigations, we know this virus is most often transferred person-to-person by respiratory droplets (generated when we speak, sneeze, cough, sing, shout, laugh or talk); surface-to-person transfer of the virus occurs to a lesser degree and effectively controlled with sanitation and hygiene. Reported contact-tracing results have focused on person-to-person chains of transmission as the most common pathway.  Most workplace COVID-19 safety plan strategies and tactics are focused on this priority.   

 

Common Strategies

Workplaces are following eight main observed strategies:

•       Keep workers FAR from hazard

•       Distance workers and others from each other

•       Reduce potential viral presence in workspace

•       Eliminate close spatial contact

•       Stop droplet exposure risk (non-medical settings)

•       Stop droplet and viral particle transmission (medical and similar settings)

•       Control close-proximity encounters

•       Actively limit chains of transmission

This is not an exhaustive list and few organizations rely on just one strategy.  That said, each strategy has its own rationale, and each workplace develops or selects tactics that work best for that workplace. 

Observing the tactics—and how well they are implemented—illustrates what can be done to minimize workplace risks amid this pandemic. 

Strategy 1:  Keep workers FAR from hazard

If you live alone on an island, you have no direct risk of exposure to the virus.  Life is generally not like that; however, creating islands or “bubbles” that keep occupants far from the virus is a valid strategy that has been implemented with some success.

Work-from-home policies are now commonplace.  Working and living in your own bubble far away from potential sources of infection works well.  The recent National Hockey League (NHL) and National Basketball Association (NBA) playoffs demonstrated that large bubbles can also work.  On a smaller scale, the Villanova Nursing home is a great illustration of how bubbles in the healthcare sector.

The Vilanova nursing home - How workers and staff avoided the first wave

As the first wave of the virus swept across Europe, a nursing home in France locked down.  Over the next 47 days, 29 of the staff of 50 stayed with the residents day and night, sleeping on mattresses on the floor.  Other staff who came from the outside to assist were kept separate from the sequestered staff and residents; they also wore PPE.  In the beginning, residents were confined to their rooms while staff did a deep clean of the facility.  After that, the staff and residents mixed freely, maintaining morale and the mental health of all concerned.  [See The Associated Press, “How a nursing home in France stopped coronavirus from killing elderly in its care”, May 04, 2020 available at https://www.cbc.ca/news/world/france-vilanova-nursing-home-1.5554296 ]

Broken Bubbles:  The Melbourne Outbreak

Bubbles can work both ways:  to keep uninfected people in and to keep infected people from contacting others. Victoria, Australia is currently experiencing a second wave centred in and around Melbourne, the state’s largest city.  Beginning in May 2020, foreign visitors were required to quarantine in specific hotels for two weeks.  The mandatory quarantine was enforced by contracted private security guards.  The bubble in this case was for quarantined individuals. Within weeks, COVID-19 had spread in these locations among guests and the staff and guards charged with maintaining the quarantine.  Gene sequencing of the virus that has now spread widely in the state traces the origin back to the quarantine hotels.  The exact exposures that resulted in infection have not been formally reported but lack of training, lack of PPE, inadequate hygiene, breaches in protocols have been mentioned as probable contributing factors.  The premier of the state cited the sharing of a lighter among security guards and certain “carpooling” arrangements as examples that contributed to the outbreak, although more fundamental issues such as work insecurity and lack of clear lines of responsibility likely contributed.  [See   Ben Schneiders, “How hotel quarantine let COVID-19 out of the bag in Victoria,” The Age, July 3, 2020 at https://www.theage.com.au/national/victoria/how-hotel-quarantine-let-covid-19-out-of-the-bag-in-victoria-20200703-p558og.html]. 

[Note:  Australia clamped down hard on this outbreak.  As of this writing, no or very few positive COVID-19 tests are being recorded]

Like all the strategies for keeping workers safe, success is dependent on how well the supporting tactics are implemented and maintained. Maintaining bubbles is hard.  Staying home or working from home is hard.  Necessities such as groceries and medical attention may be sought remotely; realistically, most of us need to physically leave our homes for many purposes. Each time the bubble is breached, the risk of infection goes up.  That applies to everyone in the bubble.  Keeping bubbles small makes them more manageable but each time anyone in the bubble interacts outside the bubble, everyone in the bubble has increased risk.

Working-from-home policies do not fully insulate employers from workers’ compensation liability.  Work-related risks may still exist for every worker carrying out work, including COVID-19 infection risks and other risks associated with working from home, (e.g., workers’ compensation claim  by a worker who was injured while carrying personally acquired office furniture upstairs at home for employer approved work-from-home setup was allowed [State of New York Supreme Court, Appellate Division, Third Judicial Department,  530530, October 22, 2020].  Each time I open the door to sign for a courier delivery or leave my home to get work supplies, I am also opening the door to an interaction that carries risk.

Strategy 2:  Distance workers and others from each other

Keeping workers far from the virus is not a practical strategy for many workplaces.  Despite voluntary and ordered closures in many communities, enterprises deemed “essential” have remained open. Fire fighters, healthcare workers and police officers are universally accepted as essential. In my community, the list of essential businesses includes local hardware, drug, and grocery stores.  Many non-essential businesses including construction and retail have continued to operate during the pandemic (albeit with some restrictions). 

The main strategy implemented to keep workers safe in these environments are designed to distance staff and patrons.  In the local hardware store, the counters were widened overnight with improvised plywood sheets to ensure patrons and service staff had a six-foot or two-meter distance between them.  Monitors were in place at the grocery store to ensure capacity never exceeded the allowed set number.  Tape on sidewalks and markers on floors guided customers to maintain distances.  Directional arrows ensured aisles would not become congested (at least not with people facing each other and forced to pass within the required distance). 

Capacity limits may be mandated by public health.  Many restaurants and retail spaces are small and capacity limits are needed to allow for spacing between staff and patrons. 

Again, this strategy and associated tactics require active monitoring to be effective.  Coupled with other strategies and tactics, the risk of infection can be reduced.  The more space between workplace participants, the greater the protective effect.

Strategy 3:  Reduce potential virus presence in the workspace

Even with distancing methods in place, staff and other persons in the workplace may still be infected with Covid-19 and shedding the virus (often unknowingly while asymptomatic or pre-symptomatic). One observed tactic now in many workplaces is the presence (or increased presence) of sanitation stations.  At one roadside construction site, I saw a sink had been installed to a fire hydrant so workers could wash with soap and water more readily.  Several retailers have put hand-sanitizing stations throughout their stores.  The number of staff performing spot cleaning and sanitation duties is observably higher than ever.  In several large retailers, frequent public address system announcements to staff direct them to specific tasks like sanitizing their workstations or breaking to wash their hands.

The added costs of these measures are minor compared to the costs of lockdowns.  When outbreaks do occur, “deep cleaning” and sanitation of the workplace are implemented to further reduce the potential for any further infection even if surfaces were not the obvious or immediately identified source of infection.  In our community, the few incidents observed have resulted in short closures and a resumption of activities within a day. 

Visible signs of increased sanitation efforts and well stocked sanitation stations for customers certainly increases my willingness to visit certain businesses during the pandemic. That said, this strategy focuses on things, not people; it only works with other preventative efforts including distancing. 

Strategy 4:  Eliminate close spatial contact

Wider counters and capacity control tactics can distance workers from others in the workplace but much of service, sales and administration involves in-person contact.  A key strategy is to reduce the close spatial “pinch points” and hand-offs that are often required.  Home delivery and curbside pickup are common tactics that has been implemented to eliminate spatial contact.  Orders are placed online or over the phone and payment pre-arranged; patrons arrive and pick up orders already at or orders are delivered to the curb or doorstep. Restaurants, office supply houses, and petfood stores are among the stores in my neighborhood who have implemented these tactics. 

Our local library has implemented another similar tactic: choreography.  each patron approaches an outside window and holds their library card to the glass; a staff member scans the barcode from inside the library, retrieves the books and DVDs requested online.  Next, the patron steps back and the staff member places the order outside the door on a table then returns inside, allowing the patron to then come forward to retrieve the items being loaned.  This dance may be inefficient in terms of time but completely effective in eliminating close spatial contact. By the way, the staff member (wearing mask and face shield and sitting behind plexiglass) manning the door also asks each patron wanting to enter the library a set of COVID-19 questions, ensures mask use, and directs hand sanitization upon entry to the library.     

Eliminating close spatial contact works well for transactional operations.  When UPS recently delivered our new tablet, they skipped the signature requirement in order to eliminate the close spatial contact needed to sign the electronic delivery tracker.   Process design changes like these are likely to continue.  There may be some loss of service opportunities, queuing issues and time efficiencies of in-person close spatial contacts as a result of these tactics.

Strategy 5: Stop droplet exposure risk (non-medical settings)

The Covid-19 virus is primarily spread in respiratory droplets.  Well-fitting, non-surgical masks covering mouth and nose have been proven to reduce droplet transmission from the wearer and there is some evidence that they limit droplets from being inhaled by the wearer.  [see, “Scientific Brief: Community Use of Cloth Masks to Control the Spread of SARS-CoV-2”, CDC, Updated Nov. 10, 2020].

Facial shields prevent droplet splashes or projections from a cough or sneeze from reaching the wearer’s face (eyes, nose and mouth in particular).  Plexiglass and suspended plastic shields have a similar effect, and their height and width add distance between the point of droplet generation and possible exposure.  This does not remove the risk entirely. 

We know indoor spaces and spaces with poor ventilation allow droplets to travel further and remain afloat in the air longer than in outdoor spaces.  Increasing the ventilation by opening a window or changing external air mix in HVAC systems may be options (although more costly particularly in the winter season).  The US Environmental Protection Agency notes:

By themselves, portable air cleaners and HVAC filters are not enough to protect people from the virus that causes COVID-19. When used along with other best practices recommended by CDC and others, filtration can be part of a plan to protect people indoors. [see Air Cleaners, HVAC Filters, and Coronavirus (COVID-19), EPA webpage]

 

Tactics that rely on physical barriers degrade communications often required between workers or workers and others in the workplace.  In my community, I have seen both customers and employees bypass the barrier and work around the edge to speak with each other, thus defeating the purpose of the barrier.   

Again, this strategy does not work on its own.  Sanitation of barriers, capacity limits, and other measures are important. 

Strategy 6: Stop droplet and particle exposure risk (medical and similar settings)

Testing for Covid-19, transporting patients with the virus, and caring for them in hospitals and intensive care units are obvious examples of situations with elevated risk of infection.  In an environment with high potential for viral infection, more protections are needed.  Nurses, respiratory technicians, physicians, cleaners, and care aides put themselves in these high hazard environments every day. 

In a sea of known COVID-19 virus, stopping droplets and particles is hard.  The PPE, safe work procedures, supervision and training are among the most effective safeguards, barriers and defenses for keeping healthcare workers safe.  It is not just an N95 mask or a facial shield that achieves the objective; protection is achieved by multiple layers.  Each layer of protection has value but is not perfect. James Reason’s classic “Swiss Cheese” model provides an accessible, memorable metaphor for understanding how multiple layers work.  Active and latent defects occur in every barrier, but the multiple layers reduce the probability of these gaps aligning in such a way as to allow the virus to infect the worker. 

Just because there is a pandemic doesn’t mean that the rest of life stops.  People need blood tests, dental work, physiotherapy, and a range of medical and similar services that can only be given in close-contact care.  The risk in each situation must be assessed.  In many cases, several items of PPE may be required.  Achieving a safe work situation requires more than the provision of PPE.  The right PPE, supervision, training and safe work procedures are essential in these medical and similar workplaces.

The CDC includes consideration of increased ventilation and filtration in its guidelines for healthcare:

Optimize air-handling systems (ensuring appropriate directionality, filtration, exchange rate, proper installation, and up to date maintenance)....Consider the addition of portable solutions (e.g., portable HEPA filtration units) to augment air quality in areas when permanent air-handling systems are not a feasible option.

[Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, CDC Updated July 15, 2020].

This strategy, like the others, has its limits.  It cannot stop workers from being exposed outside the work environment.  Reported cases of workers infecting each other in breakrooms and social events among their peers illustrate some of these risks. 

 

Strategy 7: Control close-proximity encounters

Close-proximity encounters with customers and co-workers are often unavoidable.  Passing people in a corridor, cooperating in a lift of a heavy object, or handing a receipt to customer involves close- proximity interactions.   Most such interactions are fleeting; risk increases with increased duration and closer positioning. 

Despite rules, procedures, and efforts to prevent them, close-proximity situations arise.  This is particularly true in manufacturing, construction, fabrication, personal services, and processing tasks where multiple workers must work closely for periods of time. 

After considering and implementing PPE and procedures, some companies are implementing technologies to help lessen the number and duration of close-proximity contacts.  Proximity sensors and apps on cellphones can alert workers when they are in close proximity to others.  Several sensors are in the form of wearable disks or tokens that provide light and/or sound cues when workers are within defined distances.  Enhanced versions can also track the identities of the participants and even their locations during encounters—factors that could be useful should the need for contact tracing arise. 

Several token-based products are directed more at industrial applications such as food processing and equipment manufacturing.  Safeteams technology implementation requires each employee to be issued a wearable fob.  The fob emits a light cue if a worker is near another worker.  “Beacons” installed in the workplace periodically communicate via Bluetooth allowing for mapping and contact tracing.   [See Mary George, Contact Tracing, Social Distancing Monitoring, and Other Technologies for Keeping Workers Safe, Food Industry Executive, 22 July 2020 at https://foodindustryexecutive.com/2020/07/contact-tracing-social-distancing-monitoring-and-other-technologies-for-keeping-workers-safe/ ]

 

Again, tokens or other monitors (including human observers) are not a complete solution.  A sensor chip is into a shield.  Like any protection, it has its limitations including how well users actually attend to the warnings emitted.  Other strategies and tactics including active supervision to ensure safe work procedures are followed are needed.   

Strategy 8: Actively limit chains of transmission

This strategy relies on frequent, wide or universal testing within the workplace, rapid results and rapid, thorough contact tracing with effective support for quarantine and isolation. Quickly identifying a workplace exposure to Covid-19 and stopping the transmission of the virus in a workplace is essential to safe work.  Procedures for rapid reporting and contact tracing within workplaces are essential to limiting chains of transmission.

This strategy is particularly applicable in natural resource and construction camps where accommodations are often closely spaced and food services are provided en masse.  Camps often operate in a sort of bubble but with rotating members.  The possibility of an infected worker entering the camp and unknowing spreading the virus puts all personnel at risk. 

To better manage this risk, New Gold Mining in Northern Ontario is now testing every employee for COVID-19.  New Gold has 150 workers in 14 day rotations entering the camp.  The company uses Precision Biomonitoring test kits at its River operations.  The battery-operated analysis device is about the size of a toaster and contains the necessary reagents and technology to analyze nine samples at a time and deliver results to a smartphone app in about an hour. Rapid identification of anyone carrying the virus allows containment of virus and protect other workers.  [see Sarah Bridge, Ioanna Roumeliotis, “Ontario mining company 1st to try new mobile test that diagnoses COVID-19 in as little as an hour,” CBC News, 11 August 2020 available at https://www.cbc.ca/news/canada/rapid-onsite-covid-test-1.5680526 ]

Rapid testing with rapid results is essential to limiting chains of transmission in the community.  That is why many jurisdictions place such an emphasis on contact tracing.  While smartphone-based contact-tracing apps are being implemented in many countries and some firms, not everyone has a cellphone and many who do have older ones that may not be compatible with the contact tracing app. 

Singapore was among the first to roll out a contact tracing app but privacy concerns and low uptake from the general population limited its use. Although migrant workers were required to download the app, large gaps in coverage made the app less effective.  Now Singapore is handing out small TraceTogether “tokens” to those without phones or reluctant to use GPS based technologies.  The battery-operated token is worn or carried in a purse or pocket.  It interacts with other tokens and smartphones with the enabled TraceTogether app.  In the event of a positive COVID-19 test result, the token can be turned over to public health contact tracers.  Close-proximity Bluetooth contacts over the previous 25 days stored on the device facilitate contact tracing.  [See Saira Asher, “Coronavirus: Why Singapore turned to wearable contact-tracing tech”, BBC Singapore, 5 July 2020 at https://www.bbc.com/news/technology-53146360 ]

Testing poses lots of questions: who to test, how often, how quickly can results be obtained, how reliable are the results, how are results communicated and to whom… Equally important is what happens next.  Without rapid isolation of positive cases and quarantine of close contacts, testing does not effectively break the chains of transmission. 

Many other strategies and tactics

This set of observed strategies and tactics illustrate what steps are being taken to protect workers, but these observations are illustrations not a comprehensive examination.  Organizations are innovating and implementing many other ideas to achieve the objective of keeping workers and others in the workplace safe from Covid-19 infection.  As our understanding of the virus, the sources of transmission and the means of prevention improve, strategies and tactics must evolve.

Most techniques rely on more than awareness of the hazard.  Managing this risk relies on training, supervision, and support.  Implementing broad use of PPE, for example, requires more than putting a box of masks and gloves on the breakroom table or a bottle of hand sanitizer in the lobby.

Strategies and tactics may be fine in the abstract but meaningless if not fully implemented. If the COVID-19 safety plan posted in most businesses is not being followed, everyone who engages in that workplace is at increased risk—a risk that they may unknowingly carry with them to their families and community. 

Almost all effective safety plans rely on more than one strategy and associated tactics.  Even in isolated bubbles, handwashing, testing, monitoring, and PPE are needed.  Multiple strategies may overlap but never think of that overlap as wasteful.  Safeguards, controls, and defenses are always subject to defects—latent or active deficiencies that can permeate allow the hazard a pathway.  Each additional layer of protection decreases the risk of harm. 

As you traverse your communities, engage in your workplaces, and patronize businesses observe the actual COVID-19 prevention actions being taken.  Think about the underlying strategies and how well the implemented tactics contribute to achieving the prevention objective.      

Final comment

All the signage, plexiglass, and PPE in the world will make a difference in the trajectory of this pandemic if there is no buy-in from workplace participants.  As a consumer, I now where a three-layer non-surgical mask inside all inside workplaces I visit.  I have walked out of businesses that are obviously exceeding their allowed capacity.  I have gone out of my way to engage in businesses visibly following and enforcing their own workplace COVID-19 safety plans.

The best strategies and most effective tactics will not work if they are not followed.  Complacency and failures to prioritize safety are the biggest threats to the success of any safety plan.  As a worker, supervisor, consumer or other person in the workplace, this is not just a matter of following the plan but helping others to maintain vigilance and compliance every day.  COVID-19 will be a risk in the workplace for months and months to come.  Despite the natural tendency toward fatigue, making the strategies and tactics in every COVID-19 safety plan part of the culture is the only effective way forward.