[Federal Register Volume 86, Number 116 (Monday, June 21, 2021)]
[Rules and Regulations]
[Pages 32376-32628]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2021-12428]


Vol. 86

Monday,

No. 116

June 21, 2021

Part II





Department of Labor





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Occupational Safety and Health Administration





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29 CFR Part 1910





Occupational Exposure to COVID-19; Emergency Temporary Standard; 
Interim Final Rule

Federal Register / Vol. 86 , No. 116 / Monday, June 21, 2021 / Rules 
and Regulations


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DEPARTMENT OF LABOR

Occupational Safety and Health Administration

29 CFR Part 1910

[Docket No. OSHA-2020-0004]
RIN 1218-AD36


Occupational Exposure to COVID-19; Emergency Temporary Standard

AGENCY: Occupational Safety and Health Administration (OSHA), 
Department of Labor.

ACTION: Interim final rule; request for comments.

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SUMMARY: The Occupational Safety and Health Administration (OSHA) is 
issuing an emergency temporary standard (ETS) to protect healthcare and 
healthcare support service workers from occupational exposure to COVID-
19 in settings where people with COVID-19 are reasonably expected to be 
present. During the period of the emergency standard, covered 
healthcare employers must develop and implement a COVID-19 plan to 
identify and control COVID-19 hazards in the workplace. Covered 
employers must also implement other requirements to reduce transmission 
of COVID-19 in their workplaces, related to the following: Patient 
screening and management; Standard and Transmission-Based Precautions; 
personal protective equipment (PPE), including facemasks or 
respirators; controls for aerosol-generating procedures; physical 
distancing of at least six feet, when feasible; physical barriers; 
cleaning and disinfection; ventilation; health screening and medical 
management; training; anti-retaliation; recordkeeping; and reporting. 
The standard encourages vaccination by requiring employers to provide 
reasonable time and paid leave for employee vaccinations and any side 
effects. It also encourages use of respirators, where respirators are 
used in lieu of required facemasks, by including a mini respiratory 
protection program that applies to such use. Finally, the standard 
exempts from coverage certain workplaces where all employees are fully 
vaccinated and individuals with possible COVID-19 are prohibited from 
entry; and it exempts from some of the requirements of the standard 
fully vaccinated employees in well-defined areas where there is no 
reasonable expectation that individuals with COVID-19 will be present.

DATES: 
    Effective dates: The rule is effective June 21, 2021. The 
incorporation by reference of certain publications listed in the rule 
is approved by the Director of the Federal Register as of June 21, 
2021.
    Compliance dates: Compliance dates for specific provisions are in 
29 CFR 1910.502(s). Employers must comply with all requirements of this 
section, except for requirements in paragraphs (i), (k), and (n) by 
July 6, 2021. Employers must comply with the requirements in paragraphs 
(i), (k), and (n) by July 21, 2021.
    Comments due: Written comments, including comments on any aspect of 
this ETS and whether this ETS should become a final rule, must be 
submitted by July 21, 2021 in Docket No. OSHA-2020-0004. Comments on 
the information collection determination described in Section VII.K of 
the preamble (OMB Review under the Paperwork Reduction Act of 1995) may 
be submitted by August 20, 2021 in Docket Number OSHA-2021-0003.

ADDRESSES: In accordance with 28 U.S.C. 2112(a), the agency designates 
Edmund C. Baird, Associate Solicitor of Labor for Occupational Safety 
and Health, Office of the Solicitor, U.S. Department of Labor, to 
receive petitions for review of the ETS. Service can be accomplished by 
email to zzSOL-Covid19-ETS@dol.gov.
    Written comments: You may submit comments and attachments, 
identified by Docket No. OSHA-2020-0004, electronically at 
www.regulations.gov, which is the Federal e-Rulemaking Portal. Follow 
the online instructions for making electronic submissions.
    Instructions: All submissions must include the agency's name and 
the docket number for this rulemaking (Docket No. OSHA-2020-0004). All 
comments, including any personal information you provide, are placed in 
the public docket without change and may be made available online at 
www.regulations.gov. Therefore, OSHA cautions commenters about 
submitting information they do not want made available to the public or 
submitting materials that contain personal information (either about 
themselves or others), such as Social Security Numbers and birthdates.
    Docket: To read or download comments or other material in the 
docket, go to Docket No. OSHA-2020-0004 at www.regulations.gov. All 
comments and submissions are listed in the www.regulations.gov index; 
however, some information (e.g., copyrighted material) is not publicly 
available to read or download through that website. All comments and 
submissions, including copyrighted material, are available for 
inspection through the OSHA Docket Office. Documents submitted to the 
docket by OSHA or stakeholders are assigned document identification 
numbers (Document ID) for easy identification and retrieval. The full 
Document ID is the docket number plus a unique four-digit code. OSHA is 
identifying supporting information in this ETS by author name and 
publication year, when appropriate. This information can be used to 
search for a supporting document in the docket at http://www.regulations.gov. Contact the OSHA Docket Office at 202-693-2350 
(TTY number: 877-889-5627) for assistance in locating docket 
submissions.

FOR FURTHER INFORMATION CONTACT: 
    General information and press inquiries: Contact Frank Meilinger, 
Director, Office of Communications, U.S. Department of Labor; telephone 
(202) 693-1999; email meilinger.francis2@dol.gov.
    For technical inquiries: Contact Andrew Levinson, Directorate of 
Standards and Guidance, U.S. Department of Labor; telephone (202) 693-
1950.

SUPPLEMENTARY INFORMATION: The preamble to the ETS on occupational 
exposure to COVID-19 follows this outline:

Table of Contents

I. Executive Summary
II. History of COVID-19
III. Pertinent Legal Authority
IV. Rationale for the ETS
    A. Grave Danger
    B. Need for the ETS
V. Need for Specific Provisions of the ETS
VI. Feasibility
    A. Technological Feasibility
    B. Economic Feasibility
VII. Additional Requirements
VIII. Summary and Explanation of the ETS
Authority and Signature

I. Executive Summary

    This ETS is based on the requirements of the Occupational Safety 
and Health Act (OSH Act or Act) and legal precedent arising under the 
Act. Under section 6(c)(1) of the OSH Act, 29 U.S.C. 655(c)(1), OSHA 
shall issue an ETS if the agency determines that employees are exposed 
to grave danger from exposure to substances or agents determined to be 
toxic or physically harmful or from new hazards, and an ETS is 
necessary to protect employees from such danger. These legal 
requirements are more fully discussed in Pertinent Legal Authority 
(Section III of this preamble).
    For the first time in its 50-year history, OSHA faces a new hazard 
so grave that it has killed nearly 600,000


people in the United States in barely over a year, and infected 
millions more (CDC, May 24, 2021a). And the impact of this new illness 
has been borne disproportionately by the healthcare and healthcare 
support workers tasked with caring for those infected by this disease. 
As of May 24, 2021, over 491,816 healthcare workers have contracted 
COVID-19, and more than 1,600 of those workers have died (CDC, May 24, 
2021b). OSHA has determined that employee exposure to this new hazard, 
SARS-CoV-2 (the virus that causes COVID-19), presents a grave danger to 
workers in all healthcare settings in the United States and its 
territories where people with COVID-19 are reasonably expected to be 
present. This finding of grave danger is based on the science of how 
the virus spreads and the elevated risk in workplaces where COVID-19 
patients are cared for, as well as the adverse health effects suffered 
by those diagnosed with COVID-19, as discussed in Grave Danger (Section 
IV.A. of this preamble).
    OSHA has also determined that an ETS is necessary to protect 
healthcare and healthcare support employees in covered healthcare 
settings from exposures to SARS-CoV-2, as discussed in Need for the ETS 
(Section IV.B. of this preamble). Workers face a particularly elevated 
risk of exposure to SARS-CoV-2 in settings where patients with 
suspected or confirmed COVID-19 receive treatment or where patients 
with undiagnosed illnesses come for treatment (e.g., emergency rooms, 
urgent care centers), especially when providing care or services 
directly to those patients. Through its enforcement efforts to date, 
OSHA has encountered significant obstacles, revealing that existing 
standards, regulations, and the OSH Act's General Duty Clause are 
inadequate to address the COVID-19 hazard for employees covered by this 
ETS. The agency has determined that a COVID-19 ETS is necessary to 
address these inadequacies. Additionally, as states and localities have 
taken increasingly more divergent approaches to COVID-19 workplace 
regulation--ranging from states with their own COVID-19 ETSs to states 
with no workplace protections at all--it has become clear that a 
Federal standard is needed to ensure sufficient protection for 
healthcare employees in all states.
    The development of safe and highly effective vaccines and the on-
going nationwide distribution of these vaccines are encouraging 
milestones in the nation's response to COVID-19. OSHA recognizes the 
promise of vaccines to protect workers, but as of the time of the 
promulgation of the ETS, vaccination has not eliminated the grave 
danger presented by the SARS-CoV-2 virus to the entire healthcare 
workforce. Indeed, approximately a quarter of healthcare workers have 
not yet completed COVID-19 vaccination (King et al., April 24, 2021). 
Nonetheless, vaccination is critical in combatting COVID-19, and the 
standard requires employers to provide paid leave to employees so that 
they can be vaccinated and recover from any side effects. Additionally, 
certain workplaces and well-defined areas where all employees are fully 
vaccinated are exempted from all of the standard's requirements, and 
certain fully vaccinated workers are exempted from several of the 
standard's requirements. OSHA will continue to monitor trends in COVID-
19 infections and deaths as more of the workforce and the general 
population become vaccinated and the pandemic continues to evolve. 
Where OSHA finds a grave danger from the virus no longer exists for the 
covered workforce (or some portion thereof), or new information 
indicates a change in measures necessary to address the grave danger, 
OSHA will update the ETS, as appropriate.
    To protect workers in the meantime, however, a multi-layered 
approach to controlling occupational exposures to SARS-CoV-2 in 
healthcare workplaces is required. As discussed in the Need for 
Specific Provisions (Section V of this preamble), OSHA relied on the 
best available science for its decisions concerning appropriate 
provisions for the ETS and its determinations regarding the kind and 
degree of protective actions needed to protect against exposure to 
SARS-CoV-2 at work and the feasibility of instituting these provisions. 
More specifically, the agency's analysis demonstrates that an effective 
COVID-19 control program must utilize a suite of overlapping controls 
in a layered approach to protect workers from workplace exposure to 
SARS-CoV-2. OSHA emphasizes that the infection control practices 
required by the ETS are most effective when used together; however, 
they are also each individually protective.
    The agency has also evaluated the feasibility of this ETS and has 
determined that the requirements of the ETS are both economically and 
technologically feasible, as outlined in Feasibility (Section VI of 
this preamble). Table I.-1, which is derived from material presented in 
Section VI of this preamble, provides a summary of OSHA's best estimate 
of the costs and benefits of the rule using a discount rate of 3 
percent. The specific requirements of the ETS are outlined and 
described in the Summary and Explanation (Section VIII of this 
preamble). OSHA requests comments on the provisions of the ETS and 
whether it should be adopted as a permanent standard.

[GRAPHIC] [TIFF OMITTED] TR21JN21.000

II. History of COVID-19

    The global pandemic of respiratory disease (coronavirus disease 
2019 or ``COVID-19'') caused by a novel coronavirus (SARS-CoV-2) has 
been taking an enormous toll on individuals, workplaces, and 
governments around the world since early 2020. According to the World 
Health Organization (WHO), as of May 24, 2021, there had been 
166,860,081 confirmed cases of COVID-19 globally, resulting in more 
than 3,459,996 deaths (WHO, May 24, 2021). In the United States as of 
the same date, the CDC reported over 32,947,548 cases in the United 
States and over 587,342 deaths due to the disease (CDC, May 24, 2021a; 
CDC, May 24, 2021c). Among healthcare workers specifically, as of May 
24, 2021, 491,816 healthcare workers in the United States had 
contracted COVID-19, and at least 1,611 of those workers had died; both 
of those figures are likely an undercount (CDC, May 24, 2021b).
    The first confirmed case of COVID-19 was identified in the Hubei 
Province of China in December of 2019 (Chen et al., August 6, 2020). On 
December 31, 2019, China reported to the WHO that it had identified 
several influenza-like cases of unknown cause in Wuhan, China (WHO, 
January 5, 2020). Soon, COVID-19 infections had spread throughout Asia, 
Europe, and North and South America. By February 2020, 58 other 
countries had reported COVID-19 cases (WHO, March 1, 2020). By March 
2020, widespread local transmission of the virus was established in 88 
countries. Because of the widespread transmission and severity of the 
disease, along with what the WHO described as alarming levels of 
inaction, the WHO officially declared COVID-19 a pandemic on March 11, 
2020 (WHO, March 11, 2020).
    The first reported case of COVID-19 in the United States was in the 
state of Washington, on January 21, 2020, in a person who had returned 
from Wuhan, China on January 15, 2020 (CDC, January 21, 2020). On 
January 31, 2020, the COVID-19 outbreak was declared to be a U.S. 
public health emergency (US DHHS, January 31, 2020). After the initial 
report of the virus in January 2020, a steep increase in COVID-19 cases 
in the U.S. was observed though March and early April. In the six weeks 
between March 1, 2020 and April 12, 2020, the 7-day moving average of 
new cases rose from only 57 to 31,779 (CDC, May 24, 2021d). The 
President declared the COVID-19 outbreak a national emergency on March 
13, 2020 (The White House, March 13, 2020). As of March 19, 2020, all 
50 states and the District of Columbia had declared emergencies related 
to the pandemic

(NGA, March 19, 2020; NGA, December 4, 2020; Ayanian, June 3, 2020).
    The U.S. Food and Drug Administration (FDA) issued or expanded 
emergency use authorizations (EUAs) for three COVID-19 vaccines between 
December 2020 and May 2021. Currently, everyone in the United States 
age 12 and older is eligible to receive a COVID-19 vaccine. As of May 
24, 2021, the CDC reported that 163,907,827 people had received at 
least one dose of vaccine and 130,615,797 people were fully vaccinated, 
representing 45 percent and 32.8 percent of the total U.S. population, 
respectively (CDC, May 24, 2021e). Vaccination rates are higher among 
people ages 65 and older than among the rest of the population.
    Despite the relatively rapid distribution of vaccines in many areas 
of the U.S., a substantial proportion of the working age population 
remains unvaccinated and susceptible to COVID-19 infection, including 
approximately a quarter of all healthcare and healthcare support 
workers (King et al., April 24, 2021). And, as discussed in more detail 
in Grave Danger (Section IV.A. of this preamble), because workers in 
healthcare settings where COVID-19 patients are treated continue to 
have regular exposure to SARS-CoV-2 and any variants that develop, they 
remain at an elevated risk of contracting COVID-19 regardless of 
vaccination status. Therefore, OSHA has determined that a grave danger 
to healthcare and healthcare support workers remains, despite the 
fully-vaccinated status of some workers, and that an ETS is necessary 
to address this danger (see Grave Danger and Need for the ETS (Sections 
IV.A. and IV.B. of this preamble)).
References
Ayanian, JZ. (2020, June 3). Taking shelter from the COVID storm. 
JAMA Health Forum. https://jamanetwork.com/channels/health-forum/fullarticle/2766931. (Ayanian, June 3, 2020).
Centers for Disease Control and Prevention (CDC). (2020, January 
21). First travel-related case of 2019 novel coronavirus detected in 
United States. https://www.cdc.gov/media/releases/2020/p0121-novel-coronavirus-travel-case.html. (CDC, January 21, 2020).
Centers for Disease Control and Prevention (CDC). (2021a, May 24). 
COVID data tracker. Trends in number of COVID-19 cases and deaths in 
the US reported to CDC, by state/territory: Trends in Total COVID-19 
Deaths in the United States Reported to CDC. https://covid.cdc.gov/covid-data-tracker/#trends_dailytrendscases. (CDC, May 24, 2021a)
Centers for Disease Control and Prevention (CDC). (2021b, May 24). 
Cases & Deaths among Healthcare Personnel. https://covid.cdc.gov/covid-data-tracker/#health-care-personnel. (CDC, May 24, 2021b)
Centers for Disease Control and Prevention (CDC). (2021c, May 24). 
COVID data tracker. Trends in number of COVID-19 cases and deaths in 
the US reported to CDC, by state/territory: Trends in Total COVID-19 
Cases in the United States Reported to CDC. https://covid.cdc.gov/covid-data-tracker/#trends_dailytrendscases. (CDC, May 24, 2021c).
Centers for Disease Control and Prevention (CDC). (2021d, May 24). 
COVID data tracker. Trends in number of COVID-19 cases and deaths in 
the US reported to CDC, by state/territory: Daily Trends in Number 
of COVID-19 Cases in the United States Reported to CDC. https://covid.cdc.gov/covid-data-tracker/#trends_dailytrendscases. (CDC, May 
24, 2021d).
Centers for Disease Control and Prevention (CDC). (2021e, May 24). 
COVID-19 Vaccinations in the United States. https://covid.cdc.gov/covid-data-tracker/#vaccinations. (CDC, May 24, 2021e).
Chen, Y.-T, et al., (2020, August 6). An examination on the 
transmission of COVID-19 and the effect of response strategies: A 
comparative analysis. International Journal of Environmental 
Research and Public Health 17(16):5687. https://www.mdpi.com/1660-4601/17/16/5687. (Chen et al., August 6, 2020).
King, WC, et al., (2021, April 24). COVID-19 vaccine hesitancy 
January-March 2021 among 18-64 year old US adults by employment and 
occupation. medRxiv; https://www.medrxiv.org/content/10.1101/2021.04.20.21255821v3. (King et al., April 24, 2021).
National Governor's Association (NGA). (2020, March 19). 
Coronavirus:what you need to know. https://www.nga.org/coronavirus/. 
(NGA, March 19, 2020).
National Governor's Association (NGA). (2020, December 4). Summary 
of state pandemic mitigation actions. https://www.nga.org/coronavirus-mitigation-actions/. (NGA, December 4, 2020).
The White House. (2020, March 13). Proclamation on declaring a 
national emergency concerning the novel coronavirus disease (COVID-
19) outbreak. https://web.archive.org/web/20200313234554/https://www.whitehouse.gov/presidential-actions/proclamation-declaring-national-emergency-concerning-novel-coronavirus-disease-covid-19-outbreak/. (The White House, March 13, 2020).
United States Department of Health and Human Services (US DHHS). 
(2020, January 31). Determination that a public health emergency 
exists. https://www.phe.gov/emergency/news/healthactions/phe/Pages/2019-nCoV.aspx. (US DHHS, January 31, 2020).
World Health Organization (WHO). (2020, January 5). Emergencies 
preparedness, response--Pneumonia of unknown cause--China. Disease 
outbreak news. https://www.who.int/csr/don/05-january-2020-pneumonia-of-unkown-cause-china/en/. (WHO, January 5, 2020).
World Health Organization (WHO). (2020, March 1). Coronavirus 
disease 2019 (COVID-19) situation report--41. https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200301-sitrep-41-covid-19.pdf?sfvrsn=6768306d_2. (WHO, March 1, 2020).
World Health Organization (WHO). (2020, March 11). Coronavirus 
disease 2019 (COVID-19) situation report--51. https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200311-sitrep-51-covid-19.pdf?sfvrsn=1ba62e57_10. (WHO, March 11, 2020).
World Health Organization (WHO). (2021, May 24). WHO Coronavirus 
Disease (COVID-19) Dashboard. https://covid19.who.int/table. (WHO, 
May 24, 2021).

III. Pertinent Legal Authority

    The purpose of the Occupational Safety and Health Act of 1970 (OSH 
Act), 29 U.S.C. 651 et seq., is ``to assure so far as possible every 
working man and woman in the Nation safe and healthful working 
conditions and to preserve our human resources.'' 29 U.S.C. 651(b). To 
this end, Congress authorized the Secretary of Labor (Secretary) to 
promulgate and enforce occupational safety and health standards under 
sections 6(b) and (c) of the OSH Act.\1\ 29 U.S.C. 655(b). These 
provisions provide bases for issuing occupational safety and health 
standards under the Act. Once OSHA has established as a threshold 
matter that a health standard is necessary under section 6(b) or (c)--
i.e., to reduce a significant risk of material health impairment, or a 
grave danger to employee health--the Act gives the Secretary ``almost 
unlimited discretion to devise means to achieve the congressionally 
mandated goal'' of protecting employee health, subject to the 
constraints of feasibility. See United Steelworkers of Am. v. Marshall, 
647 F.2d 1189, 1230 (D.C. Cir. 1981). A standard's individual 
requirements need only be ``reasonably related'' to the purpose of 
ensuring a safe and healthful working environment. Id. at 1237, 1241; 
see also Forging Industry Ass'n v. Sec'y of Labor, 773 F.2d 1436, 1447 
(4th Cir. 1985). OSHA's authority to regulate employers is hedged by 
constitutional considerations and, pursuant to section 4(b)(1) of the 
OSH Act, the regulations and enforcement policies of other

federal agencies. Chao v. Mallard Bay Drilling, Inc., 534 U.S. 235, 241 
(2002).
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    \1\ The Secretary has delegated most of his duties under the OSH 
Act to the Assistant Secretary of Labor for Occupational Safety and 
Health. Secretary's Order 08-2020, 85 FR 58393 (Sept. 18, 2020). 
This section uses the terms Secretary and OSHA interchangeably.
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    The OSH Act reflects Congress's determination that the costs of 
compliance with the Act and OSHA standards are part of the cost of 
doing business and OSHA may foreclose employers from shifting those 
costs to employees. See Am. Textile Mfrs. Inst., Inc. v. Donovan, 452 
U.S. 490, 514 (1981); Phelps Dodge Corp. v. OSHRC, 725 F.2d 1237, 1239-
40 (9th Cir. 1984); see also Sec'y of Labor v. Beverly Healthcare-
Hillview, 541 F.3d 193 (3d Cir. 2008). Furthermore, the Act and its 
legislative history ``both demonstrate unmistakably'' OSHA's authority 
to require employers to temporarily remove workers from the workplace 
to prevent exposure to a health hazard. United Steelworkers of Am., 647 
F.2d at 1230.
    The OSH Act states that the Secretary ``shall'' issue an emergency 
temporary standard (ETS) if he finds that the ETS is necessary to 
address a grave danger to workers. See 29 U.S.C. 655(c). In particular, 
the Secretary shall provide, without regard to the requirements of 
chapter 5, title 5, United States Code, for an emergency temporary 
standard to take immediate effect upon publication in the Federal 
Register if he determines that employees are exposed to grave danger 
from exposure to substances or agents determined to be toxic or 
physically harmful or from new hazards, and that such emergency 
standard is necessary to protect employees from such danger. 29 U.S.C. 
655(c)(1).
    A separate section of the OSH Act, section 8(c), authorizes the 
Secretary to prescribe regulations requiring employers to make, keep, 
and preserve records that are necessary or appropriate for the 
enforcement of the Act. 29 U.S.C. 657(c)(1). Section 8(c) also provides 
that the Secretary shall require employers to keep records of, and 
report, work-related deaths and illnesses. 29 U.S.C. 657(c)(2).
    The ETS provision, section 6(c)(1), exempts the Secretary from 
procedural requirements contained in the OSH Act and the Administrative 
Procedure Act, including those for public notice, comments, and a 
rulemaking hearing. See, e.g., 29 U.S.C. 655(b)(3); 5 U.S.C. 552, 553. 
For that reason, ETSs have been referred to as the ``most dramatic 
weapon in [OSHA's] arsenal.'' Asbestos Info. Ass'n/N. Am. v. OSHA, 727 
F.2d 415, 426 (5th Cir. 1984).
    The Secretary must issue an ETS in situations where employees are 
exposed to a ``grave danger'' and immediate action is necessary to 
protect those employees from such danger. 29 U.S.C. 655(c)(1); Pub. 
Citizen Health Research Grp. v. Auchter, 702 F.2d 1150, 1156 (D.C. Cir. 
1983). The determination of what exact level of risk constitutes a 
``grave danger'' is a ``policy consideration that belongs, in the first 
instance, to the Agency.'' Asbestos Info. Ass'n, 727 F.2d at 425 
(accepting OSHA's determination that eighty lives at risk over six 
months was a grave danger); Indus. Union Dep't, AFL-CIO v. Am. 
Petroleum Inst., 448 U.S. 607, 655 n.62 (1980). However, a ``grave 
danger'' represents a risk greater than the ``significant risk'' that 
OSHA must show in order to promulgate a permanent standard under 
section 6(b) of the OSH Act, 29 U.S.C. 655(b). Int'l Union, United 
Auto., Aerospace, & Agr. Implement Workers of Am., UAW v. Donovan, 590 
F. Supp. 747, 755-56 (D.D.C. 1984), adopted, 756 F.2d 162 (D.C. Cir. 
1985); see also Indus. Union Dep't, AFL-CIO, 448 U.S. at 640 n.45 
(noting the distinction between the standard for risk findings in 
permanent standards and ETSs).
    In determining the type of health effects that may constitute a 
``grave danger'' under the OSH Act, the Fifth Circuit emphasized ``the 
danger of incurable, permanent, or fatal consequences to workers, as 
opposed to easily curable and fleeting effects on their health.'' Fla. 
Peach Growers Ass'n, Inc. v. U.S. Dep't of Labor, 489 F.2d 120, 132 
(5th Cir. 1974). Although the findings of grave danger and necessity 
must be based on evidence of ``actual, prevailing industrial 
conditions,'' see Int'l Union, 590 F. Supp. at 751, OSHA need not wait 
for deaths to occur before promulgating an ETS, see Fla. Peach Growers 
Ass'n., 489 F.2d at 130. When OSHA determines that exposure to a 
particular hazard would pose a grave danger to workers, OSHA can assume 
an exposure to a grave danger wherever that hazard is present in a 
workplace. Dry Color Mfrs. Ass'n, Inc. v. Department of Labor, 486 F.2d 
98, 102 n.3 (3d Cir. 1973). In demonstrating that an ETS is necessary, 
the Fifth Circuit considered whether OSHA had shown that there were no 
other means of addressing the risk than an ETS. Asbestos Info. Ass'n, 
727 F.2d at 426 (holding that necessity had not been proven where OSHA 
could have increased enforcement of already-existing standards to 
address the grave risk to workers from asbestos exposure).
    On judicial review of an ETS, OSHA is entitled to great deference 
on the determinations of grave danger and necessity required under 
section 6(c)(1). See, e.g., Pub. Citizen Health Research Grp., 702 F.2d 
at 1156; Asbestos Info. Ass'n, 727 F.2d at 422 (judicial review of 
these legislative determinations requires deference to the agency); cf. 
American Dental Ass'n v. Martin, 984 F.2d 823, 831 (7th Cir. 1993) 
(``the duty of a reviewing court of generalist judges is merely to 
patrol the boundary of reasonableness''). These determinations are 
``essentially legislative and rooted in inferences from complex 
scientific and factual data.'' Pub. Citizen Health Research Grp., 702 
F.2d at 1156. The agency is not required to support its conclusions 
``with anything approaching scientific certainty'' and has the 
``prerogative to choose between conflicting evidence.'' Indus. Union 
Dep't, AFL-CIO, 448 U.S. at 656; Asbestos Info. Ass'n, 727 F.2d at 425.
    The determinations of the Secretary in issuing standards under 
section 6 of the OSH Act, including ETSs, must be affirmed if supported 
by ``substantial evidence in the record considered as a whole.'' 29 
U.S.C. 655(f). The Supreme Court described substantial evidence as `` 
`such relevant evidence as a reasonable mind might accept as adequate 
to support a conclusion.' '' Am. Textile Mfrs. Inst., 452 U.S. at 522-
23 (quoting Universal Camera Corp. v. NLRB, 340 U.S. 474, 477 (1951)). 
The Court also noted that `` `the possibility of drawing two 
inconsistent conclusions from the evidence does not prevent an 
administrative agency's finding from being supported by substantial 
evidence.' '' Am. Textile Mfrs. Inst., 452 U.S. at 523 (quoting Consolo 
v. FMC, 383 U.S. 607, 620 (1966)). The Fifth Circuit, recognizing the 
size and complexity of the rulemaking record before it in the case of 
OSHA's ETS for organophosphorus pesticides, stated that a court's 
function in reviewing an ETS to determine whether it meets the 
substantial evidence standard is ``basically [to] determine whether the 
Secretary carried out his essentially legislative task in a manner 
reasonable under the state of the record before him.'' Fla Peach 
Growers Ass'n., 489 F.2d at 129.
    Although Congress waived the ordinary rulemaking procedures in the 
interest of ``permitting rapid action to meet emergencies,'' section 
6(e) of the OSH Act, 29 U.S.C. 655(e), requires OSHA to include a 
statement of reasons for its action when it issues any standard. Dry 
Color Mfrs., 486 F.2d at 105-06 (finding OSHA's statement of reasons 
inadequate). By requiring the agency to articulate its reasons for 
issuing an ETS, the requirement acts as ``an essential safeguard to 
emergency temporary standard-setting.'' Id. at 106. However, the Third 
Circuit noted that it did not require justification of ``every 
substance, type of use or production

technique,'' but rather a ``general explanation'' of why the standard 
is necessary. Id. at 107.
    ETSs are, by design, temporary in nature. Under section 6(c)(3), an 
ETS serves as a proposal for a permanent standard in accordance with 
section 6(b) of the OSH Act (permanent standards), and the Act calls 
for the permanent standard to be finalized within six months after 
publication of the ETS. 29 U.S.C. 655(c)(3); see Fla. Peach Growers 
Ass'n., 489 F.2d at 124. The ETS is effective ``until superseded by a 
standard promulgated in accordance with'' section 6(c)(3). 29 U.S.C. 
655(c)(2).
    It is crucial to note that the language of section 6(c)(1) is not 
discretionary: The Secretary ``shall'' provide for an ETS when OSHA 
makes the prerequisite findings of grave danger and necessity. Pub. 
Citizen Health Research Grp., 702 F.2d at 1156 (noting the mandatory 
language of section 6(c)). OSHA is entitled to great deference in its 
determinations, and it must also account for ``the fact that `the 
interests at stake are not merely economic interests in a license or a 
rate structure, but personal interests in life and health.' '' Id. 
(quoting Wellford v. Ruckelshaus, 439 F.2d 598, 601 (D.C. Cir. 1971)).

IV. Rationale for the ETS

A. Grave Danger

I. Introduction
    On January 31, 2020, the Secretary of Health and Human Services 
(HHS) declared COVID-19 to be a public health emergency in the U.S. 
under section 319 of the Public Health Service Act. The World Health 
Organization declared COVID-19 to be a global health emergency on the 
same day. President Donald Trump declared the COVID-19 outbreak to be a 
national emergency on March 13, 2020 (The White House, March 13, 2020). 
HHS renewed its declaration of COVID-19 as a public health emergency 
effective April 21, 2021 (HHS, April 15, 2021).\2\
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    \2\ HHS declarations of public health emergencies last for 90 
days and then can be considered for renewal (https://www.phe.gov/emergency/news/healthactions/phe/Pages/default.aspx).
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    Consistent with these declarations, and in carrying out its legal 
duties under the OSH Act, OSHA has determined that healthcare employees 
face a grave danger from the new hazard of workplace exposures to SARS-
CoV-2 except under a limited number of situations (e.g., a fully 
vaccinated workforce in a breakroom).\3\ The virus is both a physically 
harmful agent and a new hazard, and it can cause severe illness, 
persistent health effects, and death (morbidity and mortality, 
respectively) from the subsequent development of the disease, COVID-
19.\4\ OSHA bases its grave danger determination on evidence 
demonstrating the lethality of the disease, the serious physical and 
psychiatric health effects of COVID-19 morbidity (in mild-to-moderate 
as well as in severe cases), and the transmissibility of the disease in 
healthcare settings where people with COVID-19 are reasonably expected 
to be present. The protections of this ETS--which will apply, with some 
exceptions, to healthcare settings where people may share space with 
COVID-19 patients or interact with others who do--are designed to 
protect employees from infection with SARS-CoV-2 and from the dire, 
sometimes fatal, consequences of such infection.
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    \3\ References in this preamble to healthcare employees and 
healthcare workers indicate those employees covered by the 
protections in the ETS, including employees providing healthcare 
support services.
    \4\ OSHA is defining the grave danger as workplace exposure to 
SARS-CoV-2, the virus that causes the development of COVID-19. 
COVID-19 is the disease that can occur in people exposed to SARS-
CoV-2, and that leads to the health effects described in this 
section. This distinction applies despite OSHA's use of these two 
terms interchangeably in some parts of this preamble.
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    The fact that COVID-19 is not a uniquely work-related hazard does 
not change the determination that it is a grave danger to which 
employees are exposed, nor does it excuse employers from their duty to 
protect employees from the occupational transmission of SARS-CoV-2. The 
OSH Act is intended to ``assure so far as possible every working man 
and woman in the Nation safe and healthful working conditions,'' 29 
U.S.C. 651(b), and there is nothing in the Act to suggest that its 
protections do not extend to hazards which might occur outside of the 
workplace as well as within. Indeed, COVID-19 is not the first hazard 
that OSHA has regulated that occurs both inside and outside the 
workplace. For example, the hazard of noise is not unique to the 
workplace, but the Fourth Circuit has upheld OSHA's Occupational Noise 
Exposure standard, 29 CFR 1910.95 (Forging Industry Ass'n v. Secretary, 
773 F.2d 1437, 1444 (4th Cir. 1985)). Diseases caused by bloodborne 
pathogens, including HIV/AIDS and hepatitis B, are also not unique to 
the workplace, but the Seventh Circuit upheld the majority of OSHA's 
Bloodborne Pathogens standard, 29 CFR 1910.1030 (Am. Dental Ass'n v. 
Martin, 984 F.2d 823 (7th Cir. 1993)). Moreover, employees have more 
freedom to control their environment outside of work, and to make 
decisions about their behavior and their contact with others to better 
minimize their risk of exposure. However, during the workday, while 
under the control of their employer, healthcare employees providing 
care directly to known or suspected COVID-19 patients are required to 
have close contact with infected individuals, and other employees in 
those settings also work in an environment in which they have little 
control over their ability to limit contact with individuals who may be 
infected with COVID-19 even when not engaged in direct patient care. 
Accordingly, even though SARS-CoV-2 is a hazard to which employees are 
exposed both inside and outside the workplace, healthcare employees in 
workplaces where individuals with suspected or confirmed COVID-19 
receive care have limited ability to avoid exposure resulting from a 
work setting where those individuals are present. OSHA has a mandate to 
protect employees from hazards they are exposed to at work, even if 
they may be exposed to similar hazards before and after work.
    As described above in Section III, Legal Authority, ``grave 
danger'' indicates a risk that is more than ``significant'' (Int'l 
Union, United Auto., Aerospace, & Agr. Implement Workers of Am., UAW v. 
Donovan, 590 F. Supp. 747, 755-56 (D.D.C. 1984); Indus. Union Dep't, 
AFL-CIO v. Am. Petroleum Inst., 448 U.S. 607, 640 n.45, 655 (1980) 
(stating that a rate of 1 worker in 1,000 workers suffering a given 
health effect constitutes a ``significant'' risk)). ``Grave danger,'' 
according to one court, refers to ``the danger of incurable, permanent, 
or fatal consequences to workers, as opposed to easily curable and 
fleeting effects on their health'' (Fla. Peach Growers Ass'n, Inc. v. 
U. S. Dep't of Labor, 489 F.2d 120, 132 (5th Cir. 1974)). Fleeting 
effects were described as nausea, excessive salivation, perspiration, 
or blurred vision and were considered so minor that they often went 
unreported, which is in contrast to the adverse health effects of cases 
of COVID-19, which are formally referenced as ranging from ``mild'' to 
``critical.'' \5\ Beyond this, however, ``the determination of what 
constitutes a risk worthy of Agency action is a policy consideration 
that belongs, in the first instance, to the Agency'' (Asbestos Info.

Ass'n/N. Am. v. OSHA, 727 F.2d 415, 425 (5th Cir. 1984)).
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    \5\ Definitions of severity of COVID-19 illness used in this 
document are found in the National Institutes of Health's COVID-19 
treatment guidelines (https://www.covid19treatmentguidelines.nih.gov/overview/clinical-spectrum/) 
(NIH, December 17, 2020).
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    In the context of ordinary 6(b) rulemaking, the Supreme Court has 
said that the OSH Act is not a ``mathematical straitjacket,'' nor does 
it require the agency to support its findings ``with anything 
approaching scientific certainty,'' particularly when operating on the 
``frontiers of scientific knowledge'' (Indus. Union Dep't, AFL-CIO v. 
Am. Petroleum Inst., 448 U.S. 607, 656, 100 S. Ct. 2844, 2871, 65 L. 
Ed. 2d 1010 (1980)). Courts reviewing OSHA's determination of grave 
danger do so with ``great deference'' (Pub. Citizen Health Research 
Grp. v. Auchter, 702 F.2d 1150, 1156 (D.C. Cir. 1983)). In one case, 
the Fifth Circuit, in reviewing an OSHA ETS for asbestos, declined to 
question the agency's finding that 80 worker lives at risk over six 
months constituted a grave danger (Asbestos Info. Ass'n/N. Am., 727 
F.2d at 424). In stark contrast, as of May 24, 2021, 1,611 healthcare 
personnel have died (out of 491,816 healthcare COVID-19 cases where 
healthcare personnel status and death status is known by the CDC) (May 
24, 2021a). This is likely an undercount of cases and deaths as the 
healthcare personnel status is not known for 81.63% of cases and death 
status is unknown in 20.42% of cases where healthcare personnel status 
is known. OSHA estimates that this rule would save almost 800 worker 
lives over the course of the next six months as noted in Table I.-1 in 
the Executive Summary. Here, the mortality and morbidity risk to 
employees from COVID-19 is so dire that the grave danger from exposures 
to SARS-CoV-2 is clear.
    OSHA's previous ETSs addressed physically harmful agents that had 
been familiar to the agency for many years prior to the ETS. In most 
cases, the ETSs were issued in response to new information about 
substances that had been used in workplaces for decades (e.g., Vinyl 
Chloride (39 FR 12342 (April 5, 1974)); Benzene (42 FR 22516 (May 3, 
1977)); 1,2-Dibromo-3-chloropropane (42 FR 45536 (Sept. 9, 1977))). In 
some cases, the hazards of the toxic substance were already so well 
established that OSHA promulgated an ETS simply to update an existing 
standard (e.g., Vinyl cyanide (43 FR 2586 (Jan. 17, 1978)). In no case 
did OSHA claim that an ETS was required to address a grave danger from 
a substance that had only recently come into existence. Thus, no court 
has had occasion to separately examine OSHA's authority under section 
(6)(c) of the OSH Act (29 U.S.C. 655(c)) to address a grave danger from 
a ``new hazard.'' Yet by any measure, SARS-CoV-2 is a new hazard. 
Unlike any of the hazards addressed in previous ETSs, SARS-CoV-2 was 
not known to exist until January 2020. Since then, more than 3 million 
people have died worldwide and nearly 600,000 people have died in the 
U.S. alone (WHO, May 24, 2021; CDC, May 24, 2021b). This monumental 
tragedy is largely handled by healthcare employees who provide care for 
those who are ill and dying, leading to introduction of the virus not 
only in their daily lives in the community but also in their workplace, 
and more than a thousand healthcare workers have died from COVID-19. 
Clearly, exposure to SARS-CoV-2 is a new hazard that presents a grave 
danger to workers in the U.S.
    In the following sections within Grave Danger, OSHA summarizes the 
best available scientific evidence on employee exposure to SARS-CoV-2 
and shows how that evidence establishes COVID-19 to be a grave danger 
to healthcare employees. OSHA's determination that there is a grave 
danger to healthcare employees rests on the severe health consequences 
of COVID-19, the high risk to employees of developing the disease as a 
result of transmission of SARS-CoV-2 in the workplace, and that these 
workplace settings provide direct care to known or suspected COVID-19 
cases. With respect to the health consequences of COVID-19, OSHA finds 
a grave danger to employees based on mortality data showing 
unvaccinated people of working age (18-64 years old) have a 1 in 217 
chance of dying when they contract the disease (May 24, 2021c; May 24, 
2021d). When broken down by age range, that includes a 1 in 788 chance 
of dying for those aged 30-39, a 1 in 292 chance of dying for those 
aged 40-49, and as much as a 1 in 78 chance of dying for those aged 50-
64 (May 24, 2021c; May 24, 2021d). Furthermore, workers in racial and 
ethnic minority groups are often over-represented in many healthcare 
occupations and face higher risks for SARS-CoV-2 exposure and 
infection, as noted in a study on workers in Massachusetts (Hawkins, 
June 15, 2020) and discussed in more detail in the section ``Observed 
Disparities in Risk Based on Race and Ethnicity,'' below. While 
vaccination greatly reduces adverse health outcomes to healthcare 
workers, it does not eliminate the grave danger faced by vaccinated 
healthcare workers in settings where patients with suspected or 
confirmed COVID-19 receive treatment (CDC, April 27, 2021; Howard, May 
22, 2021).
    OSHA also finds a grave danger based on the severity and prevalence 
of other health effects caused by COVID-19, short of death. While some 
SARS-CoV-2 infections are asymptomatic, even the cases labeled ``mild'' 
by the CDC involve symptoms that far exceed in severity the group of 
symptoms dismissed in the Florida Peach Growers Ass'n decision as not 
rising to the level of grave danger required by the OSH Act (i.e., 
minor cases of nausea, excessive salivation, perspiration, or blurred 
vision) (489 F.2d at 132). Even ``mild'' cases of COVID-19--where 
hypoxia (low oxygen in the tissues) is not present--require isolation 
and may require medical intervention and multiple weeks of 
recuperation, while severe cases of COVID-19 typically require 
hospitalization and a long recovery period (see the section on ``Health 
Effects,'' below). For example, in a study of 1,733 patients, three 
quarters of remaining hospitalized cases and approximately half of all 
symptomatic cases resulted in the individual continuing to experience 
at least one symptom (e.g., fatigue, breathing difficulties) at least 
six months after initial infection (Huang et al., January 8, 2021; 
Klein et al., February 15, 2021). These cases might be referred to as 
``long COVID'' because symptoms persist long after recovery from the 
initial illness, and could potentially be significant enough to 
negatively affect an individual's ability to work or perform other 
everyday activities.
    Finally, OSHA concludes that the serious and potentially fatal 
consequences of COVID-19 pose a particular threat to employees, as the 
nature of SARS-CoV-2 transmission readily enables the virus to spread 
when employees are working in spaces shared with others (e.g., co-
workers, patients, visitors), a common characteristic of healthcare 
settings where direct care is provided. While not every setting is 
represented in the evidence that OSHA has assembled, the best available 
evidence illustrates that clusters and outbreaks \6\ of COVID-19 have 
occurred in a wide variety of occupations in healthcare settings. The 
scientific

evidence of SARS-CoV-2 transmission, presented below, makes clear that 
the virus can be spread wherever an infectious person is present and 
shares space with other people, and OSHA therefore expects transmission 
across healthcare workplaces where known or suspected COVID-19 patients 
are treated (see Dry Color Mfrs. Ass'n, Inc. v. Dep't of Labor, 486 
F.2d 98, 102 n.3 (3d Cir. 1973) (holding that when OSHA determines a 
substance poses a grave danger to workers, OSHA can assume an exposure 
to a grave danger wherever that substance is present in a workplace)). 
OSHA's conclusion that there is a grave danger to which employees are 
specifically exposed is further supported by evidence demonstrating the 
widespread prevalence of the disease across the country generally. As 
of May 2021, over 32 million cases of COVID-19 have been reported in 
the United States (CDC, May 24, 2021e). Over 1 in 11 people of working 
age have been reported infected (cases for individuals age 18-64, CDC, 
May 24, 2021d; estimated number of people ages 15-64, Census Bureau, 
June 25, 2020). And data shows that employees across a myriad of 
workplace settings have suffered death and serious illness from COVID-
19 through the duration of the pandemic (WSDH and WLNI, December 17, 
2020; Allan-Blitz et al., December 11, 2020; Marshall et al., June 30, 
2020).\7\ From May 18, 2021 to May 24, 2021, COVID-19 resulted in 4,216 
cases and nine deaths for healthcare personnel each day (CDC, May 18, 
2021; CDC, May 24, 2021a). Thus, COVID-19 continues to present a grave 
danger to the nation's healthcare employees.
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    \6\ ``Outbreaks'' are generally defined as an increase, often 
sudden, in the number of cases of a disease above what is normally 
expected in a limited geographic area. ``Clusters'' are generally 
defined as an unusual number of cases grouped in one place that is 
more than expected to occur (CDC, May 18, 2012). Researchers 
investigating outbreaks and have to decide how to define the 
geographic area, while researchers investigating clusters may use a 
variety of strategies to determine what is ``unusual.'' While the 
terms are slightly different, their overall significance to the 
grave danger discussion is the same. For the studies and reports 
relied upon in this section, OSHA will generally use whichever term 
is used in the study or report itself.
    \7\ Of note, on February 25, 2021, the Superior Court of 
California issued a decision denying a motion for a preliminary 
injunction seeking to restrain the California Occupational Safety 
and Health Standards Board from enforcing a COVID-19 ETS promulgated 
on November 30, 2020 (Nat'l Retail Fed'n v. Cal. Dep't of Indus. 
Relations, Div. of Occupational Safety & Health, Case Nos. CGC-20-
588367, CPF-21-517344 (Cal. Super. Ct., Feb. 25, 2021)). In its 
decision, the court found that COVID-19 presents an emergency to 
employees, noting that any argument to the contrary was ``fatuous'' 
(id. at 17). The court found that ``the virus spreads any place 
where persons gather and come into contact with one another--whether 
it happens to be an office building, a meatpacking plant, a wedding 
reception, a business conference, or an event in the Rose Garden of 
the White House. Workplaces, where employees often spend eight hours 
a day or more in close proximity to one another, are no exception, 
which of course is why the pandemic has emptied innumerable office 
buildings, stores, shopping centers, restaurants, and bars around 
the world'' (id. at 17-18 (emphasis in original) (footnotes 
omitted)).
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References
Allan-Blitz, LT et al., (2020, December 11). High frequency and 
prevalence of community-based asymptomatic SARS-CoV-2 
infection.medRxivpre-print. https://www.medrxiv.org/content/10.1101/2020.12.09.20246249v1. (Allan-Blitz et al., December 11, 2020).
Centers for Disease Control and Prevention (CDC). (2021, April 27). 
Updated healthcare infection prevention and control recommendation 
in response to COVID-19 vaccination. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-after-vaccination.html. 
(CDC, April 27, 2021).
Centers for Disease Control and Prevention (CDC). (2021, May 18). 
COVID Data Tracker: Cases & deaths among healthcare personnel. 
https://covid.cdc.gov/covid-data-tracker/#health-care-personnel. 
(CDC, May 18, 2021).
Centers for Disease Control and Prevention (CDC). (2021a, May 24). 
Cases & Deaths among Healthcare Personnel. https://covid.cdc.gov/covid-data-tracker/#health-care-personnel. (CDC, May 24, 2021a).
Centers for Disease Control and Prevention (CDC). (2021b, May 24). 
COVID data tracker. Trends in number of COVID-19 cases and deaths in 
the US reported to CDC, by state/territory: Trends in Total COVID-19 
Deaths in the United States Reported to CDC. https://covid.cdc.gov/covid-data-tracker/#trends_dailytrendscases. (CDC, May 24, 2021b).
Centers for Disease Control and Prevention (CDC). (2021c, May 24). 
Demographic Trends of COVID-19 cases and deaths in the US reported 
to CDC: Deaths by age group. https://covid.cdc.gov/covid-data-tracker/#demographics (CDC, May 24, 2021c).
Centers for Disease Control and Prevention (CDC). (2021d, May 24). 
Demographic Trends of COVID-19 cases and deaths in the US reported 
to CDC: Cases by age group. https://covid.cdc.gov/covid-data-tracker/#demographics (CDC, May 24, 2021d).
Centers for Disease Control and Prevention (CDC). (2021e, May 24). 
COVID data tracker. Trends in number of COVID-19 cases and deaths in 
the US reported to CDC, by state/territory: Trends in Total COVID-19 
Cases in the United States Reported to CDC. https://covid.cdc.gov/covid-data-tracker/#trends_dailytrendscases. (CDC, May 24, 2021e).
Census Bureau. (2020, June 25). Annual estimates of the resident 
population for selected age groups by sex for the United States: 
April 2010 to July 1, 2019. https://www2.census.gov/programs-surveys/popest/tables/2010-2019/national/asrh/nc-est2019-agesex.xlsx. (Census Bureau, June 25, 2020).
Hawkins, D. (2020, June 15). Differential occupational risk for 
COVID-19 and other infection exposure according to race and 
ethnicity. American Journal of Industrial Medicine 63:817-820. 
https://doi.org/10.1002/ajim.23145. (Hawkins, June 15, 2020).
Howard, J. (2021). ``Response to request for an assessment by the 
National Institute for Occupational Safety and Health, Centers for 
Disease Control and Prevention, U.S. Department of Health and Human 
Services, of the current hazards facing healthcare workers from 
Coronavirus Disease-2019 (COVID-19).'' (Howard, May 22, 2021).
Huang, C et al., (2021, January 8). 6-month consequences of COVID-19 
in patients discharged from hospital: A cohort study. The Lancet 
397:220-232. https://doi.org/10.1016/S0140-6736(20)32656-8. (Huang 
et al., January 8, 2021).
Klein, H et al., (2021, February 15). Onset, duration and unresolved 
symptoms, including smell and taste changes, in mild COVID-19 
infections: A cohort study in Israeli patients. Clinical 
Microbiology and Infection 27(5):769-774. https://doi.org/10.1016/j.cmi.2021.02.008. (Klein et al., February 15, 2021).
Marshall, K et al., (2020, June 30). Exposure before issuance of 
stay-at-home orders among persons with laboratory-confirmed COVID-
19--Colorado, March 2020. Morbidity and Mortality Weekly Report: 
69(26):847-9. (Marshall et al., June 30, 2020).
United States Department of Health and Human Services (US DHHS). 
(2021, April 15). Renewal of Determination That A Public Health 
Emergency Exists. https://www.phe.gov/emergency/news/healthactions/phe/Pages/COVID-15April2021.aspx. (HHS, April 15, 2021).
Washington State Department of Health and Washington State 
Department of Labor and Industries (WSDH and WDLI). (2020, December 
17). COVID-19 confirmed cases by industry sector. Publication Number 
421-002. https://www.doh.wa.gov/Portals/1/Documents/1600/coronavirus/data-tables/IndustrySectorReport.pdf. (WSDH and WDLI, 
December 17, 2020).
The White House. (2020, March 13). Proclamation on declaring a 
national emergency concerning the novel coronavirus disease (COVID-
19) outbreak.  https://web.archive.org/web/20200313234554/https://www.whitehouse.gov/presidential-actions/proclamation-declaring-national-emergency-concerning-novel-coronavirus-disease-covid-19-outbreak/. (The White House, March 13, 2020).
World Health Organization (WHO). (2021, May 24). WHO Coronavirus 
Disease (COVID-19) Dashboard. https://covid19.who.int/table. (WHO, 
May 24, 2021).
II. Nature of the Disease
a. Health and Other Adverse Effects of COVID-19
Death From COVID-19
    COVID-19 is a potentially fatal disease. As of May 24, 2021, there 
had been 587,432 deaths from the disease out of 32,947,548 million 
infections in the United States alone (CDC, May 24, 2021a; CDC, May 24, 
2021b). For the U.S. population as a whole (i.e., unlinked to known 
SARS-CoV-2

infections) as of May 24, 2021, 1.8 out of every 1,000 people have died 
from COVID-19 (CDC, May 24, 2021a). COVID-19 was the third leading 
cause of death in the United States in 2020 among those aged 45 to 84, 
trailing only heart disease and cancer (Woolf, January 12, 2021). 
During the surges in the spring and fall/winter of 2020, COVID-19 was 
the leading cause of death. Despite a decrease in recent weeks, the 
death rate remains high (7-day moving average death rate of 500 on May 
23, 2021) (CDC, May 24, 2021c). Not only are healthcare employees 
included in these staggering figures, they are exposed to COVID-19 at a 
much higher frequency than the general population while providing 
direct care for both sick and dying COVID-19 patients during their most 
infectious moments.
    The impact of morbidity and mortality on healthcare employees might 
also be underreported. The information associated with cases and deaths 
are incomplete. Only 18.37% of cases were reported with information on 
whether or not the infected individual was a healthcare employee (CDC, 
May 24, 2021d). For those who were identified as healthcare personnel, 
only 79.58% of these cases noted whether the individual survived the 
illness (CDC, May 24, 2021d). Despite the incomplete data, the toll on 
healthcare personal is clear. As of May 24, 2021, CDC reported 491,816 
healthcare personnel cases (10% of cases that included information on 
healthcare personnel status) and 1,611 fatalities (0.4% of healthcare 
employee cases with known death status). This number is staggering when 
compared with, for example, the 2018-2019 influenza season, during 
which only 0.1% of known influenza infections were estimated to be 
fatal for the entire population (CDC, October 5, 2020).
    The risk of mortality and morbidity from COVID-19 has changed, and 
may continue to change over time. Viruses mutate and those mutations 
can result in variants of concern that may be more transmissible, cause 
more severe illness, or impact diagnostics, treatments, or vaccines 
(CDC, May 5, 2021). For example, the UK's New and Emerging Respiratory 
Virus Threats Advisory Group (NERVTAG) issued a report on how risk 
might have changed with the development of a new variant there called 
``B.1.1.7'' (February 11, 2021). The group determined that analysis 
from multiple different datasets indicated that B.1.1.7 infections 
resulted in an increased risk of hospitalization and death compared 
with the ancestral virus and other variants in circulation. Challen et 
al., (March 10, 2021) found that B.1.1.7 increased mortality risk by 
64%. As virus mutations result in variants of concern, the 
effectiveness of medical countermeasures such as therapeutics and 
vaccines might be affected. Lastly, depending on the variant, potential 
immune escape properties of the virus may increase a person's 
susceptibility to reinfection.
Severe and Critical Cases of COVID-19
    Apart from mortality, COVID-19 causes significant morbidity that 
can result in incurable, permanent, and non-fleeting consequences. As 
discussed below, people who become ill with COVID-19 might require 
hospitalization and specialized treatment, and can suffer respiratory 
failure, blood clots, long-term cardiovascular effects, organ damage, 
and significant neurological and psychiatric effects. Approximately 
6.7% of COVID-19 cases are severe and require hospitalization and more 
specialized care (total hospitalizations and total cases, CDC, May 24, 
2021e; CDC, May 24, 2021f). Given that this is a novel virus, long-term 
effects are still unknown. A severe case of COVID-19 is described as 
when the patient presents with hypoxia and is in need of oxygen therapy 
(NIH, April 21, 2021a). Cases become critical when respiratory failure, 
septic shock, and/or multiple organ dysfunction occurs.
    The majority of the data currently available on the health outcomes 
for hospitalized patients is derived from the first surge of the 
pandemic between March and May of 2020. However, newer data indicates 
that health outcomes for hospitalized patients have changed over the 
course of the pandemic. A study from Emory University reviewed COVID-19 
patient data from a large multi-hospital healthcare network and 
compared the data from the first surge early in the pandemic (March 1 
to May 30, 2020) with the second surge that occurred in the summer of 
2020 (June 1 to September 13, 2020) (Meena et al., March 1, 2021). The 
study found that during the second surge, ICU admission decreased from 
38% to 30%, ventilator use decreased from 26% to 15%, and mortality 
decreased from 15% to 9%. The study authors postulated that improved 
patient outcomes during the second stage may have resulted in part from 
aggressive anticoagulation therapies to prevent venous thromboembolism.
    Similar findings were reported in a retrospective study of 20,736 
COVID-19 patients admitted to 107 hospitals in 31 states from March 
through November 2020 (Roth et al., May 3, 2021). The proportions of 
patients placed on mechanical ventilation dropped from 23.3% in March 
and April 2020 to 13.9% in September through November 2020. During 
those same respective time periods, mortality rates dropped from 19.1% 
to 10.8%. The reasons for the reductions in mechanical ventilation and 
mortality are not known, but study authors postulated that reductions 
in mechanical ventilation may have resulted from increased use of 
noninvasive ventilation, high flow nasal oxygen, and prone positioning. 
They hypothesized that the high patient count and staff unfamiliarity 
with infection control procedures that were being rapidly implemented 
in March and April could have accounted for the high mortality rate 
during that period. In addition, the authors noted that changes in 
pharmacology treatments occurred during that time period, but their 
impact on improved outcomes is not known.
    This data on improvements in health outcomes between earlier and 
later stages of the pandemic is significant, but also demonstrates that 
overall health outcomes for hospitalized COVID-19 patients still remain 
poor. Even with these improvements in health outcomes, COVID-19 still 
results in considerable loss of life and significant adverse health 
outcomes for patients hospitalized with COVID-19. The COVID-19-
Associated Hospitalization Surveillance Network (COVID-NET), which 
conducts population-based surveillance in select U.S. counties, 
reported a cumulative hospitalization rate of 1 in 255 people between 
the ages of 18 and 49 as well as 1 in 123 people between the ages of 50 
and 64 between March 1, 2020, and May 15, 2021 (CDC, May 24, 2021g).
    Patients hospitalized with COVID-19 frequently need supplemental 
oxygen and supportive management of the disease's most common 
complications, which are discussed in further detail below and include 
pneumonia, respiratory failure, acute respiratory distress syndrome 
(ARDS), acute kidney injury, sepsis, myocardial injury, arrhythmias, 
and blood clots. Among 35,302 inpatients in a nationwide U.S. study, 
median length of stay was 6 days overall (Rosenthal, et al., December 
10, 2020). When cases required treatment in the ICU, ICU stays were on 
median 5 days in addition to time spent hospitalized outside of the 
ICU. The Roth et al., (May 3, 2021) study described above reported that 
mean length of hospital stays decreased from 10.7 days in April and May 
2020 to 7.5 days from September to November 2020, and the respective 
values for ICU stays over the same time period decreased from 13.9 days 
to 6.6 days. As discussed

in more detail above, improvements in infection control and treatment 
interventions might be responsible for the improved outcome, but the 
specific reason is not known, and the numbers of individuals 
hospitalized with COVID-19 remains high.
    The pneumonia associated with the SARS-CoV-2 virus can become 
severe, resulting in respiratory failure and ARDS, a life-threatening 
lung injury. In a U.S. study of 35,302 COVID-19 inpatients, 55.8% 
suffered respiratory failure with 8.1% experiencing ARDS (Rosenthal, et 
al., December 10, 2020). Thus, the need for oxygen therapy is a key 
reason for hospitalization. The specific therapy received during 
hospitalization often depends on the severity of lung distress and can 
include supplemental oxygen, noninvasive ventilation, intubation for 
invasive mechanical ventilation, and extracorporeal membrane 
oxygenation when mechanical ventilation is insufficient (NIH, April 21, 
2021a).
    Although COVID-19 was initially considered to be primarily a 
respiratory disease, adverse effects in numerous organs have now been 
reported. For example, in a New York City area study of 9,657 COVID-19 
patients, 39.9% of patients developed acute kidney injury (AKI), a 
sudden episode of kidney failure or kidney damage; of the approximately 
40% of patients who developed AKI, 17% required dialysis (Ng et al., 
September 19, 2020). AKI similarly occurred in 33.9% of 35,302 
inpatients in a nationwide U.S. study (Rosenthal et al., December 10, 
2020). For patients who experience AKI associated with COVID-19, a 
study of patients in the New York area reported a median length of stay 
in the hospital of 11.6 days for patients who did not require dialysis, 
but for those who did, the median length of stay almost tripled to 29.2 
days (Ng et al., September 19, 2020). Many critically ill COVID-19 
patients require renal replacement therapy (NIH, April 21, 2021a). For 
example, one study including 67 U.S. hospitals found that 20.6% of 
critically ill COVID-19 patients developed AKI that requires renal 
replacement therapy (Gupta et al., 2021).
    COVID-19 is also capable of causing viral sepsis, a condition where 
the immune response dysregulates and causes life-threatening harm to 
organs (e.g., lungs, brain, kidneys, heart, and liver). In Rosenthal et 
al.'s, (December 10, 2020) U.S. study through May 31, 2020, 33.7% of 
COVID-19 inpatients developed sepsis. A study of 18-49 year olds in the 
COVID-NET surveillance system found that 16.6% of patients in that age 
range developed sepsis (Owusu et al., December 3, 2020). In a study of 
VA hospitals, sepsis was found to be the most common complication that 
resulted in readmission within 60 days of being discharged (Donnelly et 
al., January 19, 2020).
    COVID-19 patients have also been reported to experience a number of 
adverse cardiac complications, including arrhythmias, myocardial injury 
with elevated troponin levels, and myocarditis (Caforio, December 2, 
2020). Acute ischemic heart disease occurred in 8% of 35,302 inpatients 
in a nationwide U.S. study (Rosenthal et al., December 10, 2020). 
Patients hospitalized with COVID-19 may also experience shock, a 
critical condition caused by a sudden drop in blood pressure that can 
lead to fatal cardiac complications. Shock occurred in 4,028 of 35,302 
(11.4%) inpatients in a nationwide U.S. study (Rosenthal et al., 
December 10, 2020). And a study of 70 COVID-19 patients in a Freiburg 
ICU found that shock was a complicating factor in 24% of fatal cases 
(Rieg et al., November 12, 2020). A New York City area study reported 
that 21.5% of the study's 9,657 patients experience serious drops in 
blood pressure that required medical intervention during their hospital 
stay (Ng et al., September 19, 2020).
    In addition to its adverse effects on specific organs, COVID-19 may 
cause patients to develop a hypercoagulable state, a condition in which 
blood clots can develop in someone's legs and embolize to their lungs, 
further worsening oxygenation. Blood clots in COVID-19 patients have 
also been reported in arteries, resulting in strokes--even in young 
people--as well as heart attacks and acute ischemia from lack of oxygen 
in limbs in which arterial clots have occurred (Cuker and Peyvandi, 
November 19, 2020; Oxley et al., May 14, 2020). Blood clots have been 
reported even in COVID-19 patients on prophylactic-dose 
anticoagulation. A systematic review of more than 28,000 COVID-19 
patients found that venous thromboembolism (deep vein thrombosis, 
pulmonary embolism or catheter-related thrombosis) occurred in 14% of 
hospitalized patients overall and 22.7% of ICU patients (Nopp et al., 
September 25, 2020). Pulmonary embolism was reported in 3.5% of non-ICU 
and 13.7% of ICU patients. Embolism and thrombosis can cause death. 
COVID-19 poses such a threat of blood clots that NIH guidelines now 
recommend that hospitalized non-pregnant adults with COVID-19 should 
receive prophylactic dose anticoagulation (NIH, April 21, 2021a).
    These health effects are particularly relevant to healthcare 
workers because there is evidence that healthcare workers are more 
likely to develop more severe COVID-19 symptoms than workers in non-
healthcare settings. While the reason for this is not certain, one 
cause could be that healthcare workers are exposed to higher viral 
loads (more viral particles entering the body) because of the nature of 
their work often involving frequent and sustained close contact with 
COVID-19 patients. For example, a British study compared healthcare 
workers to other ``essential'' and ``non-essential'' workers and found 
that healthcare workers were more than 7 times as likely to experience 
severe COVID-19 disease following infection (i.e., disease requiring 
hospitalization) than infected non-essential workers (Mutambudzi et 
al., 2020).
Mild to Moderate Cases of COVID-19
    Even the less severe health effects of COVID-19 cover a wide range 
of symptoms and severity, from serious illness to milder symptomatic 
illness to asymptomatic cases. The most common symptoms include fever 
or chills, cough, shortness of breath or difficulty breathing, fatigue, 
muscle or body aches, headache, developing a loss of taste or smell, 
sore throat, congestion or runny nose, nausea, vomiting, and/or 
diarrhea (CDC, February 22, 2021).
    Approximately 80% of symptomatic COVID-19 cases are mild to 
moderate (Wu and McGoogan, April 7, 2020), which is defined as having 
any symptom of COVID-19 but without substantially decreased oxygen 
levels, shortness of breath, or difficulty breathing (NIH, April 21, 
2021b). Moderate cases, however, also show evidence of lower 
respiratory disease, although these cases largely do not require 
admission into hospitals (CDC, February 16, 2021). While deaths and 
severe health consequences of COVID-19 are sufficiently robust in 
support of OSHA's finding that COVID-19 presents a grave danger, even 
many of the typical mild or moderate cases surpass the Florida Peach 
Growers threshold of ``fleeting effects . . . so minor that they often 
went unreported'' (supra). Mild and moderate cases can be treated at 
home but may still require medical intervention (typically through 
telehealth visits) (Wu and McGoogan, April 7, 2020). Individuals with 
mild cases often need at least one to two weeks to recover enough to 
resume work, but effects can potentially last for months. Fatigue, 
headache, and muscle aches are among the most commonly-reported 
symptoms in people who are

not hospitalized (CDC, February 16, 2021), and their effects are not 
fleeting and often linger. In a multistate telephone survey of 292 
adults with COVID-19, the majority of whom did not eventually require 
hospitalization, 274 (94%) of the survey respondents were symptomatic 
at the time of their SARS-CoV-2 test, reporting illness for a median of 
three days prior to the positive test (Tenforde et al., July 24, 2020). 
Around one third of symptomatic respondents (95 of 274) reported that 
they still had not returned to their usual state of health 2-3 weeks 
after testing positive. Even among the young adults (aged 18-34 years) 
with no chronic medical conditions, nearly one in five had not returned 
to their usual state of health 2-3 weeks after testing.
    Even though these cases rarely result in hospitalization, 
individuals with mild to moderate cases of COVID-19 are also 
significantly impacted by their illness as a result of CDC isolation 
recommendations. According to the current CDC criteria, a person with 
symptomatic COVID-19 should generally discontinue isolation only when 
all three of the following conditions have been met: (1) At least 10 
days have passed since symptom onset; (2) at least 24 hours have passed 
since experiencing a fever without the use of fever-reducing 
medications; and (3) other symptoms have improved (other than loss of 
taste or smell) (CDC, February 18, 2021). And the CDC notes with 
respect to the first criteria that individuals with severe illness or 
with compromised immunity might require up to 20 days of isolation. 
Even those with mild or moderate cases of COVID-19 may be prevented by 
their illness from working from home during the period of isolation.
Longer-Term Health Effects
    Recovery from acute infection with the SARS-CoV-2 virus can be 
prolonged. Three categories of patients in particular are known to 
require ongoing care after resolution of their acute viral infection: 
Those with a severe illness requiring hospitalization (especially ICU 
care); those with a specific medical complication from the infection, 
such as a stroke; and those with milder acute illnesses who experience 
persistent symptoms such as fatigue and breathlessness. The lingering 
of, or development of, related health effects after a SARS-CoV-2 
infection is known as post-acute sequelae. Dr. Francis Collins, 
Director of the National Institutes of Health, testified that recovery 
can be prolonged even in previously healthy young adults with milder 
infections. Some people experience persistent symptoms for weeks or 
even months after the acute infection (Collins, April 28, 2021). Post-
Acute COVID-19 syndrome has been proposed as a diagnostic term for 
these patients, although the term ``long COVID'' is more common outside 
the medical community. According to the CDC, the most common symptoms 
of Post-Acute COVID-19 syndrome are fatigue, shortness of breath, 
cough, and joint and chest pain (CDC, April 8, 2020). Other symptoms 
reported by these patients include decreased memory and concentration, 
depression, muscle pain, headache, intermittent fever, and racing heart 
(CDC, April 8, 2021). Additional common symptoms, as reported by Dr. 
Collins, are abnormal sleep patterns and persistent loss of taste or 
smell (Collins, April 28, 2021). The cause of these long-term effects 
and effective treatments have yet to be established. The report from 
the Pulmonary Breakout Session of the National Institute of Allergy and 
Infectious Diseases (NIAID) Workshop on Post-Acute Sequelae of COVID-19 
stated that the ``burden of post-acute sequelae overall could be 
enormous'' (NIAID, December 4, 2020). Dr. John Brooks, the chief 
medical officer for the CDC's COVID-19 response, said he expected long-
term symptoms would affect ``on the order of tens of thousands in the 
United States and possibly hundreds of thousands'' (Belluck, December 
5, 2020). Dr. Collins testified that longer-term health impairments may 
occur in up to 30% of recovered COVID-19 patients (Collins, April 28, 
2021).
    Prolonged illness is common in patients who required 
hospitalization because of COVID-19, and particularly in those who 
required ICU admission. In a large nationwide U.S. study, 18.5% of 
hospitalized patients were discharged to a long-term care or 
rehabilitation facility (Rosenthal et al., December 10, 2020). Of 1,250 
patients in a Michigan study, 12.6% were discharged to a skilled 
nursing or rehabilitation facility and 15.1% of hospital survivors were 
re-hospitalized within 60 days of discharge (Chopra et al., November 
11, 2020). Of the 195 who were employed prior to hospitalization, 23% 
were unable to return to work due to health reasons and 26% of those 
who returned to work required reduced hours or modified duties (Chopra 
et al., November 11, 2020). Those who returned to work did so a median 
of 27 days after hospital discharge (Chopra et al., November 11, 2020). 
Existing evidence indicates that COVID-19 patients requiring ICU care 
and mechanical ventilation may experience Post Intensive Care Syndrome 
(PICS), which is a constellation of cognitive dysfunction, psychiatric 
conditions, and/or physical disability that persists after patients 
leave the ICU (Society of Critical Care Medicine, 2013). In a study at 
3 months post-discharge of 19 COVID-19 patients who required mechanical 
ventilation while hospitalized, 89% reported pain or discomfort, 47% 
experienced decreased mobility, and 42% experienced anxiety/depression 
(Valent, October 10, 2020). The authors noted that these results are 
similar to those reported in follow-up studies of patients who survived 
ARDS due to other viral infections. Many employees hospitalized with 
COVID-19 may require a long period of recovery should this trajectory 
continue to hold. In a 5-year follow-up of 67 previously-employed ARDS 
survivors, 34 had not returned to work within one year of discharge and 
21 had not returned at five years (Kamdar, February 1, 2018). ARDS is a 
serious complication that may have an impact on employees' ability to 
return to work after a COVID-19 diagnosis.
    Several studies conducted outside the U.S. have also noted the 
persistence of COVID-19 symptoms after hospital discharge. In a study 
of 1,733 discharged patients in China, 76% reported at least one 
symptom of COVID-19 six months after hospital discharge with 63% 
experiencing persistent fatigue or muscle weakness (Huang et al., 
January 8, 2021). Similarly, an Irish study found 52% of 128 patients 
reported persistent fatigue a median of 10 weeks after initial symptoms 
first appeared (Townsend et al., November 9, 2020). A study of 991 
pregnant women (5% hospitalized) in the U.S. found that the median time 
for symptoms to resolve was 37 days and that 25% had persistent 
symptoms (mainly cough, fatigue, headache, and shortness of breath) 
eight weeks after onset (Afshar et al., December, 2020). A study of 86 
previously-hospitalized Austrian patients observed that 88% had CT 
scans still indicating lung damage at 6 weeks after their hospital 
discharge; at 12 weeks, 56% of CT scans still revealed damage (European 
Respiratory Society, September 7, 2020). A study of 152 previously-
hospitalized patients with laboratory-confirmed COVID-19 disease who 
required at least 6 liters of oxygen during admission found that 30 to 
40 days after discharge, 74% reported shortness of breath and 13.5% 
still required oxygen at home (Weerahandi et al., August 14, 2020). A 
UK study found that among 100

hospitalized patients (32% required ICU care), 72% of the ICU patients 
and 60% of the non-ICU patients reported fatigue a mean of 48 days 
after discharge (Halpin et al., July 27, 2020). Breathlessness was also 
common, affecting 65.6% of ICU patients and 42.6% of non-ICU patients.
    In a New York City study, of the 638 COVID-19 patients who required 
dialysis for AKI while hospitalized, only 108 survived. Of those 108, 
33 still needed dialysis at discharge (Ng et al., September 19, 2020). 
A study of Chinese patients reported that 11% of 333 hospitalized 
patients with COVID-19 pneumonia developed AKI (Pei et al., June, 
2020). Only half (45.7%) experienced complete recovery of kidney 
function with a median follow up of 12 days. A similar study in Spain 
also found only half (45.72%) experienced complete recovery with a 
median follow up of 11 days (Procaccini et al., February 14, 2021). A 
Hong Kong study provided a longer follow-up period including 30 and 90 
days after the initial AKI event. At 7, 30, and 90 days after the 
initial AKI event, recovery was observed in 84.6, 87.3% and 92.1%, 
respectively (Teoh et al., 2021). A study in New York City found that 
77.1% of patients with AKI experienced complete recovery during the 
follow up period, excluding those who died or were sent to hospice 
(Charytan et al., January 25, 2021). While 88% of these AKI cases were 
in March and April with a final follow-up date of August 25, it is 
uncertain how long it took for recovery to occur.
    Long-term cardiovascular effects also appear to be common after 
SARS-CoV-2 infections, even among those who did not require hospital 
care. A German study evaluated the presence of myocardial injury in 100 
patients a median of 71 days after COVID-19 diagnosis (Puntmann et al., 
July 27, 2020). While only a third (33%) of study participants required 
hospitalization, cardiovascular magnetic resonance (CMR) imaging was 
abnormal in 78%. In the U.S., a study of COVID-19 cases in college 
athletes, of whom 16 of 54 (30%) were asymptomatic, identified abnormal 
findings in 27 (56.3%) of the 48 athletes who completed both imaging 
studies, with 39.5% consistent with resolving pericardial inflammation 
(Brito et al., November 4, 2020). A small number remained symptomatic 
with fatigue and shortness of breath at 5 weeks and were referred to 
cardiac rehabilitation (Lowry, November 12, 2020).
    A database for clinicians in the UK to report COVID-19 patients 
with neurological complications revealed that 62% of the initial 125 
patients enrolled presented with a cerebrovascular event including 
ischemic strokes and intracerebral hemorrhages (Varatharaj et al., June 
25, 2020). A UK study comparing COVID-19 ischemic stroke and 
intracerebral cases with similar non-COVID-19 cases found a fatality 
rate of 19.8% for COVID-19 patients in comparison to a fatality rate of 
6.9% for non-COVID-19 patients (Perry et al., 2021). As discussed 
above, PICS, involving prolonged impairments in cognition, physical 
health, and/or mental health, may also occur. Other neurologic 
diagnoses, including encephalopathy, Guillain-Barre syndrome, and a 
range of other less-common diagnoses, may cause morbidity that persists 
during recovery (Elkind et al., April 9, 2021; Sharifian-Dorche et al., 
August 7, 2020). A recent autopsy study of brain tissue from 18 COVID-
19 patients reported the presence of small blood vessel inflammation 
and damage in multiple different brain areas (Lee et al., February 4, 
2021). Persistent abnormalities in brain imaging have also been 
reported in patients after discharge (Lu et al., August 3, 2020). A 
study of 509 hospitalized patients in the Chicago area early in the 
pandemic reported that a third had encephalopathy, resulting in 
symptoms such as confusion or decreased levels of consciousness (Liotta 
et al., October 5, 2020). Encephalopathy was associated with worse 
functional outcomes at discharge (only 32% were able to handle their 
own affairs without assistance) and higher deaths in the 30 days post-
discharge.
    COVID-19 also impacts mental health, both as a result of the toll 
of living and working through such a disruptive pandemic, but also 
because of actual medical impacts the virus might have on the brain 
itself. As de Erausquin et al., (January 5, 2021) notes, SARS-CoV-2 is 
a suspected neurotropic virus and ``neurotropic respiratory viruses 
have long been known to result in chronic brain pathology including 
emerging cognitive decline and dementia, movement disorders, and 
psychotic illness. Because brain inflammation accompanies the most 
common neurodegenerative disorders and may contribute to major 
psychiatric disorders, the neurological and psychiatric sequelae of 
COVID[hyphen]19 need to be carefully tracked.'' An international 
consortium guided by WHO is attempting to determine these long-term 
neurodegenerative consequences more definitively, with follow up 
studies ending in 2022 (de Erausquin et al., January 5, 2021).
    In the short term, a number of studies have already demonstrated 
the potential mental health effects caused by COVID-19. In the UK 
database mentioned above, 21 of 125 COVID-19 patients had new 
psychiatric diagnoses, including 10 who became psychotic and others 
with dementia-like symptoms or depression (Varatharaj et al., June 25, 
2020). An Italian study screened 402 adults with COVID-19 for 
psychiatric symptoms with clinical interviews and self-report 
questionnaires at one month follow-up after hospital treatment for 
COVID-19. Patients rated in the psychopathological range as follows: 
28% for post-traumatic stress disorder (PTSD), 31% for depression, 42% 
for anxiety, 20% for obsessive-compulsive symptoms, and 40% for 
insomnia. Overall, 56% scored in the pathological range in at least one 
clinical dimension (Mazza et al., July 30, 2020). The TriNetX analytics 
network was used to capture de-identified data from electronic health 
records of a total of 69.8 million patients from 54 healthcare 
organizations in the United States (Taquet et al., November 9, 2020). 
Of those patients, 62,354 adults were diagnosed with COVID-19 between 
January 20 and August 1, 2020. Within 14 to 90 days after being 
diagnosed with COVID-19, 5.8% of those patients received a first 
recorded diagnosis of psychiatric illness, which was measured as 
significantly greater than psychiatric onset incidence during the same 
time period after diagnoses of other medical issues including influenza 
(2.8%), other respiratory diseases (3.4%), skin infections (3.3%), 
cholelithiasis (3.2%), urolithiasis (2.5%), and fractures (2.5%). At 
the NIAID Workshop on Post-Acute Sequelae of COVID-19, medical 
personnel discussed their experiences treating COVID-19 patients in the 
Johns Hopkins Post-Acute COVID-19 Team (PACT) Clinic. Among 49 patients 
in the Clinic, more than 50% had some form of cognitive impairment 3 
months after acute illness (Parker, December 3, 2020). Both ICU and 
non-ICU patients were affected, but impairment was more pronounced in 
ICU survivors (Parker, December 3, 2020). The medical personnel also 
reported mental health impairments among patients treated at the PACT 
Clinic.
    The studies and evidence discussed above give some indication of 
the many serious long-term health effects COVID-19 patients might 
experience, including respiratory, cardiovascular, neurological, and 
psychiatric complications. However, the full extent of the long-term 
health consequences of COVID-19 is unknown because the

virus has only been transmitted between humans since the end of 2019. 
Therefore, to fully appreciate the likely long-term risks to 
individuals with COVID-19, it is important to consider the long-term 
impacts of similar coronaviruses found among human populations where 
there has been more time to gather data.
    The previous SARS outbreak in 2002 to 2003, caused by the SARS-CoV-
1 virus, is one such example, and it indicates long-term impacts to 
infection survivors, which might result from the viral infection, 
medications used, or a combination of those factors. Patients who 
survived a SARS-CoV-1 infection report that they have a reduced quality 
of life at least 6 months after illness (Hui et al., October 1, 2005). 
These patients were found to have reduced exercise capacity; some had 
abnormal chest radiographs and lung function, and weak respiratory 
muscles at least 6 months after illness (Hui et al., October 1, 2005). 
Survivors reported experiencing depression, insomnia, anxiety, PTSD, 
chronic fatigue, and decreased lung capacity with patient follow up as 
long as four years after infection (Lam et al., December 14, 2009; Lee 
et al., April 1, 2007; Hui et al., October 1, 2005). Long term studies 
have revealed that some survivors of SARS-CoV-1 infections have chronic 
pulmonary and skeletal damage after a 15 year follow up (Zhang et al., 
February 14, 2020). Zhang et al., found that approximately half of the 
area of ground glass opacities present after infection in a 2003 CT 
scan (9.4%) remained after 15 years (4.6%). The study also found 
significant femoral head loss (25.52%) remained in 2018. Bone loss was 
likely an indirect effect caused by the high pulse steroid therapies 
used to treat the infection in many patients with severe disease. 
Survivors also suffer long-term neurologic complications, deficits in 
cognitive function, musculoskeletal pain, fatigue, depression, and 
disordered sleep up to at least three years after infection (Moldofsky 
and Patcai, March 24, 2011).
Individuals at Increased Risk From COVID-19
    Many members of the workforce are at increased risk of death and 
severe disease from COVID-19 because of their age or pre-existing 
health conditions. Comorbidities are fairly common among adults of 
working age in the U.S. For instance, 46.1% of individuals with cancer 
are in the 20-64 year old age range (NCI, April 29, 2015), and over 40% 
of working age adults are obese (Hales et al., February 2020). 
Furthermore, over a quarter of those between 65 and 74 years old remain 
in the workforce, as well as almost 10% of those 75 and older (BLS, May 
29, 2019). In hospitals and other health services (e.g., physician 
offices, residential care facilities), 1,078,000 workers are employed 
who are 65 years old and older (BLS, January 22, 2021). Individuals who 
are at increased risk of severe infection (hospitalization, admission 
to the ICU, or death) include: Individuals who have cancer, chronic 
kidney disease, chronic lung disease (e.g., chronic obstructive 
pulmonary disease (COPD), asthma (moderate-to-severe), interstitial 
lung disease, cystic fibrosis, and pulmonary hypertension), serious 
heart conditions, obesity, pregnancy, sickle cell disease, type 2 
diabetes, and individuals who are over 65 years of age, 
immunocompromised and/or smokers (CDC, May 13, 2021). Of 5,700 COVID-19 
patients hospitalized from March 1 to April 4, 2020 in the New York 
City area, the most common comorbidities were hypertension (56.6%), 
obesity (41.7%), and diabetes (33.8%), excluding age (Richardson et 
al., April 22, 2020).
Observed Disparities in Risk Based on Race and Ethnicity
    During the COVID-19 pandemic, research has found that employees in 
racial and ethnic minority groups, and especially Black and Latinx 
employees, have often faced substantially higher risks of SARS-CoV-2 
exposure and infection through the workplace than have non-Hispanic 
White employees (Hawkins, June 15, 2020; Hertel-Fernandez et al., June 
2020; Roberts et al., November 26, 2020). Among the general U.S. 
population, American Indian, Alaskan Native, Latinx, and Black 
populations are more likely than White populations to be infected with 
SARS-CoV-2 (CDC, April 23, 2021). Once infected, people in these 
demographics are also more likely than their White counterparts to be 
hospitalized for and/or die from COVID-19 (CDC, April 23, 2021). These 
observed disparities in risk of infection, risk of adverse health 
consequences, and risk of death may be attributable to a number of 
factors, including that people from racial and ethnic minority groups 
are often disproportionately represented in essential frontline 
occupations that require close contact with the public and that offer 
limited ability to work from home or take paid sick days. Disease 
severity is also likely exacerbated by long-standing healthcare 
inequities (CDC, April 19, 2021).
    Hawkins (June 15, 2020) compared data on worker demographics from 
the Bureau of Labor Statistics' 2019 Current Population Survey and 
O*NET (a Department of Labor database that contains detailed 
occupational information on the nature of work for more than 900 
occupations across the U.S.) to determine occupation-specific COVID-19 
risks. The model found that among O*NET's 57 physical and social 
factors related to work, the two predictive variables of COVID-19 risk 
were frequency of exposure to diseases and physical proximity to other 
people. The author found that Black individuals were overwhelmingly 
employed in essential industries and that people of color--which in 
this study included Black, Asian, and Hispanic populations--were more 
likely than White individuals to work in essential occupations (e.g., 
healthcare and social assistance, personal care aids) that were 
identified as having greater disease exposure risk characteristics. A 
similar evaluation of workers employed in frontline industries (e.g., 
healthcare) found that people of color--defined in this study to 
include individuals who are Black, Hispanic, Asian-American/Pacific 
Islander, or some category other than White--are well represented in 
these types of work (Rho et al., April 7, 2020). These studies suggest 
that people in racial and ethnic minority groups are greatly 
represented among the American workforce in jobs associated with 
greater risk of exposure to SARS-CoV-2, including those in healthcare 
and related industries.
    Through April 2021, infection rates compared to White, Non-Hispanic 
persons in the United States are 60% greater for American Indian or 
Alaskan Native persons, 100% greater for Latinx persons, and 10% 
greater for Black persons (CDC, April 23, 2021). This disparity is also 
reflected in studies addressing infections by occupation, race, and 
ethnicity. In a large study of healthcare employees in Los Angeles, 
researchers found that increased risk of infection was significantly 
related to whether an employee was Latinx or Black (Ebinger et al., 
February 12, 2021). Another study of frontline healthcare workers in 
the U.S. and UK found that Black, Asian, and minority ethnic workers 
were more likely to report a positive COVID-19 test than non-Hispanic, 
White workers (Nguyen et al., September 1, 2020). The study also found 
that Black, Asian, and minority ethnic healthcare workers were more 
likely to report reuse of or inadequate PPE, were more likely to work 
in higher-risk clinical settings (e.g., in-patient hospitals or nursing 
homes), and were more likely to care for patients with

suspected or documented COVID-19. These studies illustrate that racial 
and ethnic minorities are likely to be at increased risk of 
occupational SARS-CoV-2 exposures and related infections.
    In addition to an increased likelihood of exposures and potential 
infection, Native American, Alaskan Native, Latinx, and Black 
populations all have increased risk of hospitalization and/or death 
from COVID-19 in comparison to White populations (CDC, April 23, 2021). 
Chen et al., (January 22, 2021) studied increased mortality risk 
between different racial and ethnic minority groups and occupations for 
working age Californians in pre-pandemic and pandemic time frames. 
Measured mortality risks increased during the pandemic for all races 
and ethnicities, but White populations had lower increased risk (6% 
increase) compared to Asian populations (18%), Black populations (28%) 
and Latinx populations (36%). A similar disparity in excess mortality 
was also observed between races and ethnicities within the same 
occupational sector (Chen et al., January 22, 2021). In the ``health or 
emergency'' sector, risk ratios were far greater for Asian (1.40), 
Black (1.27), and Latinx (1.32) workers in comparison to White workers 
(1.02).
    Health equity is a major concern in assessing the pandemic's 
effects (CDC, April 19, 2021). Some of the factors that contribute to 
increased risk of morbidity and mortality from COVID-19 include: 
Discrimination, healthcare access/utilization, economic issues, and 
housing (CDC, April 23, 2021). And although racial and ethnic minority 
groups are more likely to be exposed to and infected with SARS-CoV-2, 
research indicates that testing for the virus is not markedly higher 
for these demographic groups (Rubin-Miller et al., September 16, 2020). 
Rubin-Miller et al., note that there may be barriers to testing that 
decrease access or delay testing to a greater degree than in White 
populations. These barriers to testing can delay needed medical care 
and lead to worse outcomes. And even when able to seek care, other 
barriers may exist. In discussing widespread health inequities, studies 
have noted that American Indian communities lacked sufficient 
facilities to respond to COVID-19 (Hatcher et al., August 28, 2020; van 
Dorn et al., April 18, 2020).
References
Afshar, Y et al., (2020, December). Clinical presentation of 
coronavirus disease 2019 (COVID-19) in pregnant and recently 
pregnant people. Obstetrics and Gynecology 136(6): 1117-1125. 
https://doi.org/10.1097/AOG.0000000000004178. PMID: 33027186; PMCID: 
PMC7673633. (Afshar et al., December, 2020).
Belluck, P. (2020, December 5). Covid Survivors With Long-Term 
Symptoms Need Urgent Attention, Experts Say. The New York Times. 
https://www.nytimes.com/2020/12/04/health/covid-long-term-symptoms.html. (Belluck, December 5, 2020).
Brito, D et al., (2020, November 4). High Prevalence of Pericardial 
Involvement in College Student Athletes Recovering From COVID-19. 
JACC Cardiovascular Imaging S1936-878X(20)30946-3. doi: 10.1016/
j.jcmg.2020.10.023. Epub ahead of print. PMID: 33223496; PMCID: 
PMC7641597. (Brito et al., November 4, 2020).
Bureau of Labor and Statistics (BLS). (2019, May 29). TED: Labor 
force participation rate for workers age 75 and older projected to 
be over 10 percent by 2026. The Economics Daily. https://www.bls.gov/opub/ted/2019/labor-force-participation-rate-for-workers-age-75-and-older-projected-to-be-over-10-percent-by-2026.htm. (BLS, May 29, 2019).
Bureau of Labor and Statistics (BLS). (2021, January 22). Household 
Data Annual Averages: 18b Employed persons by detailed industry and 
age. https://www.bls.gov/cps/cpsaat18b.pdf. (BLS, January 22, 2021).
Caforio, ALP. (2020, December 2). Coronavirus disease 2019 (COVID-
19): Cardiac manifestations in adults. In: UpToDate, Post, TW (Ed), 
UpToDate, Waltham, MA, 2020. https://www.uptodate.com/contents/coronavirus-disease-2019-covid-19-cardiac-manifestations-in-adults/print?search=Coronavirus. (Caforio, December 2, 2020).
Centers for Disease Control and Prevention (CDC). (2020, October 5). 
Disease Burden of Influenza. https://www.cdc.gov/flu/about/burden/index.html. (CDC, October 5, 2020).
Centers for Disease Control and Prevention (CDC). (2021, February 
16). Interim Clinical Guidance for Management of Patients with 
Confirmed Coronavirus Disease (COVID-19). https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html. (CDC, February 16, 2021).
Centers for Disease Control and Prevention (CDC). (2021, February 
18). Discontinuation of Isolation for Persons with COVID-19 Not in 
Healthcare Settings. https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-in-home-patients.html. (CDC, February 18, 2021).
Centers for Disease Control and Prevention (CDC). (2021, February 
22). Symptoms of Coronavirus. https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html. (CDC, February 22, 2021).
Centers for Disease Control and Prevention (CDC). (2021, April 8). 
Post-COVID Conditions. https://www.cdc.gov/coronavirus/2019-ncov/long-term-effects.html. (CDC, April 8, 2021).
Centers for Disease Control and Prevention (CDC). (2021, April 19). 
Health equity considerations and racial and ethnic minority groups. 
https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/race-ethnicity.html. (CDC, April 19, 2021).
Centers for Disease Control and Prevention (CDC). (2021, April 23). 
Risk for COVID-19 Infection, Hospitalization, and Death by Race/
Ethnicity. C5319360-A. (CDC, April 23, 2021).
Centers for Disease Control and Prevention (CDC). (2021, May 13). 
COVID-19 (Coronavirus Disease). People with Certain Medical 
Conditions. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/groups-at-higher-risk.html. (CDC, May 13, 2021).
Centers for Disease Control and Prevention (CDC). (2021a, May 24). 
COVID data tracker. Trends in number of COVID-19 cases and deaths in 
the US reported to CDC, by state/territory: Trends in Total COVID-19 
Deaths in the United States Reported to CDC. https://covid.cdc.gov/covid-data-tracker/#trends_dailytrendscases. (CDC, May 24, 2021a).
Centers for Disease Control and Prevention (CDC). (2021b, May 24). 
COVID data tracker.Trends in number of COVID-19 cases and deaths in 
the US reported to CDC, by state/territory: Trends in Total COVID-19 
Cases in the United States Reported to CDC. https://covid.cdc.gov/covid-data-tracker/#trends_dailytrendscases. (CDC, May 24, 2021b).
Centers for Disease Control and Prevention (CDC). (2021c, May 
24).COVID data tracker. Trends in number of COVID-19 cases and 
deaths in the US reported to CDC, by state/territory Daily Trends in 
Number of COVID-19 Deaths in the United States Reported to CDC. 
https://covid.cdc.gov/covid-data-tracker/#trends_dailytrendscases. 
(CDC, May 24, 2021c).
Centers for Disease Control and Prevention (CDC). (2021d, May 24). 
Cases & Deaths among Healthcare Personnel. https://covid.cdc.gov/covid-data-tracker/#health-care-personnel. (CDC, May 24, 2021d).
Centers for Disease Control and Prevention (CDC). (2021e, May 24). 
COVID data tracker. New Admissions of Patients with Confirmed COVID-
19, United States. https://covid.cdc.gov/covid-data-tracker/#new-hospital-admissions. (CDC, May 24, 2021e).
Centers for Disease Control and Prevention (CDC). (2021f, May 24). 
COVID data tracker. Trends in number of COVID-19 cases and deaths in 
the US reported to CDC, by state/territory: Daily Trends in Number 
of COVID-19 Cases in the United States Reported to CDC. https://covid.cdc.gov/covid-data-tracker/#trends_dailytrendscases. (CDC, May 
24, 2021f).
Centers for Disease Control and Prevention (CDC). (2021g, May 24). 
Laboratory-confirmed COVID-19-Associated Hospitalizations. https://gis.cdc.gov/grasp/covidnet/covid19_3.html. (CDC, May 24, 2021g).

Challen, R et al., (2021, March 10). Risk of mortality in patients 
infected with SARS-CoV-2 variant of concern 202012/1: matched cohort 
study. BMJ. doi: https://doi.org/10.1136/bmj.n579. (Challen et al., 
March 10, 2021).
Charytan, DM et al., (2021, January 25). Decreasing incidence of AKI 
in patients with COVID-19 critical illness in New York City. Kidney 
International Reports. DOI: https://doi.org/10.1016/j.ekir.2021.01.036. (Charytan et al., January 25, 2021).
Chen, Y et al., (2021, January 22). Excess mortality associated with 
the COVID-19 pandemic among Californians 18-65 years of age, by 
occupational sector and occupation: March through October 2020. 
MedRxiv. doi: 10.1101/2021.01.21.21250266. (Chen et al., January 22, 
2021).
Chopra, V et al., (2020, November 11). Sixty-Day Outcomes Among 
Patients Hospitalized With COVID-19. Ann Intern Med. 2021; 174: 576-
578. doi: 10.7326/M20-5661. (Chopra et al., November 11, 2020).
Clark, E et al., (2020, July 13). Disproportionate impact of the 
COVID-19 pandemic on immigrant communities in the United States. 
PLOS Neglected Tropical Diseases 14(7). https://doi.org/10.1371/journal.pntd.0008484. (Clark et al., July 13, 2020).
Collins, FS. (2021, April 28). Testimony before the House Energy and 
Commerce Health Subcommittee. Hearing on The Long Haul: Forging a 
Path Through The Lingering Effects of COVID-19. https://energycommerce.house.gov/sites/democrats.energycommerce.house.gov/files/documents/Witness%20Testimony_Collins_HE_2021.04.28.pdf. 
(Collins, April 28, 2021).
Cuker, A. and Peyvandi, F. (2020, November 19). Coronavirus disease 
2019 (COVID-19): Hypercoagulability. In: UpToDate, Post, TW (Ed), 
UpToDate, Waltham, MA, 2020. https://www.uptodate.com/contents/coronavirus-disease-2019-covid-19-hypercoagulability. (Cuker and 
Peyvandi, November 19, 2020).
de Erausquin, GA et al., (2021, January 5). The chronic 
neuropsychiatric sequelae of COVID-19: The need for a prospective 
study of viral impact on brain functioning. Alzheimer's Dement. 
2021; 1-9. (de Erausquin et al., January 5, 2021).
Donnelly, JP et al., (2021, January 19). Readmission and death after 
initial hospital discharge among patients with COVID-19 in a large 
multihospital system. JAMA 325(3): 304-305. (Donnelly et al., 
January 19, 2021).
Ebinger, JE et al., (2021, February 12). Seroprevalence of 
antibodies to SARS-CoV-2 in healthcare workers: a cross-sectional 
study. BMJ Open. doi: 10.1136/bmjopen-2020-043584. (Ebinger et al., 
February 12, 2021).
Elkind, MSV et al., (2021, January 9). Coronavirus disease 2019 
(COVID-19): Neurologic complications and management of neurologic 
conditions, In: UpToDate, Post, TW (Ed), UpToDate, Waltham, MA, 
2020. (Elkind et al., January 9, 2021).
European Respiratory Society. (2020, September 7). COVID-19 patients 
suffer long-term lung and heart damage but it can improve with time. 
https://www.ersnet.org/the-society/news/covid-19-patients-suffer-long-term-lung-and-heart-damage-but-it-can-improve-with-time. 
(European Respiratory Society, September 7, 2020).
Gupta, et al., (2021). AKI Treated with Renal Replacement Therapy in 
Critically Ill Patients with COVID-19. JASN Jan 2021, 32 (1) 161-
176; DOI: 10.1681/ASN.2020060897. (Gupta et al., 2021).
Hales, CM et al., (2020, February). Prevalence of Obesity and Severe 
Obesity Among Adults: United States, 2017-2018. National Center for 
Health Statistics No. 30. https://www.cdc.gov/nchs/products/databriefs/db360.htm. (Hales et al., February, 2020).
Halpin, SJ et al., (2020, July 27). Postdischarge symptoms and 
rehabilitation needs in survivors of COVID-19 infection: A 
cross[hyphen]sectional evaluation. J Med Virol. 2020; 1-10. DOI: 
10.1002/jmv.26368. (Halpin et al., July 27, 2020).
Hatcher, SM et al., (2020, August 28). COVID-19 Among American 
Indian and Alaska Native Persons--23 States, January 31-July 3, 
2020. MMWR Morb Mortal Wkly Rep 2020; 69: 1166-1169. http://dx.doi.org/10.15585/mmwr.mm6934e1. (Hatcher et al., August 28, 
2020).
Hawkins, D. (2020, June 15). Differential occupational risk for 
COVID-19 and other infection exposure according to race and 
ethnicity. American Journal of Industrial Medicine 63:817-820. 
https://doi.org/10.1002/ajim.23145. (Hawkins, June 15, 2020).
Hertel-Fernandez, A et al., (2020, June). Understanding the COVID-19 
Workplace: Evidence from a survey of essential workers. Roosevelt 
Institute Brief. https://rooseveltinstitute.org/wp-content/uploads/2020/07/RI_SurveryofEssentialWorkers_IssueBrief_202006-1.pdf. 
(Hertel-Fernandez et al., June, 2020).
Huang, C et al., (2021, January 8). 6-month consequences of COVID-19 
in patients discharged from hospital: a cohort study. The Lancet. 
https://doi.org/10.1016/S0140-6736(20)32656-8. (Huang et al., 
January 8, 2021).
Hui, DS et al., (2005). The 1-year impact of severe acute 
respiratory syndrome on pulmonary function, exercise capacity, and 
quality of life in a cohort of survivors. Chest 128: 2247-2261. (Hui 
et al., 2005).
Kamdar, BB et al., (2018, February 1). Return to work and lost 
earnings after acute respiratory distress syndrome: a 5-year 
prospective, longitudinal study of long-term survivors. Thorax. 
2018; 73(2): 125-133. https://www.ncbi.nlm.nih.gov/pubmed/28918401. 
(Kamdar et al., February 1, 2018).
Lam, MH et al., (2009, December 14). Mental Morbidities and Chronic 
Fatigue in Severe Acute Respiratory Syndrome Survivors: Long-term 
Follow-up. Arch Intern Med. 2009; 169(22): 2142-2147. doi: 10.1001/
archinternmed.2009.384. (Lam et al., December 14, 2009).
Lee, AM et al., (2007, April 1). Stress and psychological distress 
among SARS survivors 1 year after the outbreak. Can J Psychiatry. 
2007 Apr; 52(4): 233-40. doi: 10.1177/070674370705200405. PMID: 
17500304. (Lee et al., April 1, 2007).
Lee, MH et al., (2021, February 4). Microvascular injury in the 
brains of patients with COVID-19. NEJM 384:5. (Lee et al., February 
4, 2021).
Liotta, EM et al., (2020, October 5). Frequent neurologic 
manifestations and encephalopathy-associated morbidity in Covid-19 
patients. Annals of Clinical and Translational Neurology 2020; 
7(11): 2221-2230. doi: 10.1002/acn3.51210. (Liotta et al., October 
5, 2020).
Lowry, F. (2020, November 12). New reports guide return to play in 
athletes with COVID-19. Medscape. https://www.medscape.com/viewarticle/940882. (Lowry, November 12, 2020).
Lu, Y et al., (2020, August 3). Cerebral micro-structural changes in 
COVID-19 patients--an MRI-based 3-month follow-up study. 
EClinicalMedicine. 2020; 25: 100484 doi: 10.1016/
j.eclinm.2020.100484. (Lu et al., August 3, 2020).
Mazza, MG et al., (2020, July 30). Anxiety and depression in COVID-
19 survivors: Role of inflammatory and clinical predictors. Brain 
Behav Immun. 2020; 89: 594-600. https://www.ncbi.nlm.nih.gov/pubmed/32738287. (Mazza et al., July 30, 2020).
Meena, RA et al., (2021, March 1). A tale of two surges: improved 
mortality during the second wave of COVID-19 infections. Journal of 
Vascular Surgery 73(3): 47. (Meena et al., March 1, 2021).
Moldofsky, H and Patcai, J. (2011, March 24). Chronic widespread 
musculoskeletal pain, fatigue, depression and disordered sleep in 
chronic post-SARS syndrome; a case-controlled study. BMC Neurol. 
2011 Mar 24; 11: 37. doi: 10.1186/1471-2377-11-37. PMID: 21435231; 
PMCID: PMC3071317. (Moldofsky and Patcai, March 24, 2011).
Mutambudzi, M et al., (2020). Occupation and risk of severe COIVD-
19: prospective cohort study of 120075 UK Biobank participants. 
Occup Environ Med 0: .1-8 [Early view]. https://doi.org/10.1136/oemed-2020-106731. (Mutambudzi et al., 2020).
National Cancer Institute (NCI). (2015, April 29). Age and Cancer 
Risk. https://www.cancer.gov/about-cancer/causes-prevention/risk/age. (NCI, April 29, 2015).
National Institute of Allergy and Infectious Diseases (NIAID). 
(2020, December 4). Workshop on Post-Acute Sequelae of COVID-19. 
https://www.niaid.nih.gov/news-events/workshop-post-acute-sequelae-covid-19; Slides and breakout session notes at: https://
web.cvent.com/event/cf41e3b5-04e7-4e09-b25d-

f33dfcd16fed/summary. (NIAID, December 4, 2020).
National Institutes of Health (NIH), Coronavirus Disease (COVID-19) 
Treatment Guidelines Panel. (2021a, April 21). Coronavirus Disease 
(COVID-19) Treatment Guidelines. https://www.covid19treatmentguidelines.nih.gov/. (NIH, April 21, 2021a).
National Institutes of Health (NIH). (2021b, April 21). Clinical 
Spectrum of SARS-CoV-2 Infection. https://www.covid19treatmentguidelines.nih.gov/overview/clinical-spectrum//. 
(NIH, April 21, 2021b).
New and Emerging Respiratory Virus Threats Advisory Group (NERVTAG). 
(2021, February 11). Update Note on B.1.1.7 Severity. https://www.gov.uk/government/publications/nervtag-update-note-on-b117-severity-11-february-2021. (NERVTAG, February 11, 2021).
Ng, JH et al., (2020, September 19). Outcomes Among Patients 
Hospitalized With COVID-19 and Acute Kidney Injury. Am J Kidney Dis. 
2021 Feb; 77(2): 204-215.e1. doi: 10.1053/j.ajkd.2020.09.002. Epub 
2020 Sep 19. PMID: 32961245; PMCID: PMC7833189. (Ng et al., 
September 19, 2020).
Nguyen, LH et al., (2020, September 1). Risk of COVID-19 among 
front-line health-care workers and the general community: a 
prospective cohort study. The Lancet Public Health. 5 (9): e475-
e483. https://doi.org/10.1016/S2468-2667(20)30164-X. (Nguyen et al., 
September 1, 2020).
Nopp, S et al., (2020, September 25). Risk of venous thromboembolism 
in patients with COVID-19: a systematic review and meta-analysis. 
Res Pract Thromb Haemost. 2020; 4: 1178-1191. (Nopp et al., 
September 25, 2020).
Owusu, et al., (2020, December 3). Characteristics of adults aged 
18-49 years without underlying conditions hospitalized with 
laboratory-confirmed coronavirus disease 2019 in the United States: 
COVID-NET--March-August 2020. Clinical Infectious Diseases. DOI: 
10.1093/cid/ciaa1806. (Owusu et al., December 3, 2020).
Oxley, TJ et al., (2020, May 14). Large-Vessel Stroke as a 
Presenting Feature of Covid-19 in the Young. New Eng J Med. 382; 20 
e60 1-3. DOI: 10.1056/NEJMc2009787. (Oxley et al., May 14, 2020).
Parker, AM. (2020, December 3). Johns Hopkins Post-Acute COVID-19 
Team (PACT) Clinic Experience. Presentation. (Parker, December 3, 
2020).
Pasco, RF et al., (2020, October 29). Estimated association of 
construction work with risks of COVID-19 infection and 
hospitalization in Texas. JAMA Network Open 2020; 3(10): e2026373. 
doi: 10.1001/jamanetworkopen.2020.26373. (Pasco et al., October 29, 
2020).
Pei, G et al., (2020, June). Renal Involvement and Early Prognosis 
in Patients with COVID-19 Pneumonia. J Am Soc Nephrol. 2020 Jun; 
31(6): 1157-1165. doi: 10.1681/ASN.2020030276. Epub 2020 Apr 28. 
(Pei et al., June, 2020).
Perry, RJ et al., (2021). Characteristics and outcomes of COVID-19 
associated stroke: a UK multicenter case-control study. J Neurol 
Neurosurg Psychiatry. 92: 242-248. doi: 10.1136/jnnp-2020-324927. 
(Perry et al., 2021).
Procaccini, et al., (2021, February 14). Acute kidney injury in 3182 
patients admitted with COVID-19: a single center retrospective case-
control study. Oxford Univeristy Press. https://academic.oup.com/ckj/advance-article/doi/10.1093/ckj/sfab021/6122698. (Procaccini et 
al., February 14, 2021).
Puntmann, VO et al., (2020, July 27). Outcomes of Cardiovascular 
Magnetic Resonance Imaging in Patients Recently Recovered From 
Coronavirus Disease 2019 (COVID-19). JAMA Cardiol, 5(11), 1265-1273. 
doi: 10.1001/jamacardio.2020.3557. (Puntmann et al., July 27, 2020).
Rho, HJ et al., (2020, April 7). A Basic Demographic Profile of 
Workers in Frontline Industries. Center for Economic and Policy 
Research. https://cepr.net/a-basic-demographic-profile-of-workers-in-frontline-industries/. (Rho et al., April 7, 2020).
Richardson, S et al., (2020, April 22). Presenting Characteristics, 
Comorbidities, and Outcomes Among 5700 Patients Hospitalized With 
COVID-19 in the New York City Area. JAMA. 2020 May 26; 323(20): 
2052-2059. doi: 10.1001/jama.2020.6775. Erratum in: JAMA. 2020 May 
26; 323(20): 2098. PMID: 32320003; PMCID: PMC7177629. (Richardson et 
al., April 22, 2020).
Rieg, et al., (2020, November 12). COVID-19 in-hospital mortality 
and mode of death in a dynamic and non-restricted tertiary care 
model in Germany. PLOS ONE. 15(11): e0242127. https://doi.org/10.1371/journal.pone.0242127. (Rieg et al., November 12, 2020).
Rosenthal, N et al., (2020, December 10). Risk Factors Associated 
With In-Hospital Mortality in a US National Sample of Patients With 
COVID-19. JAMA Netw Open. 2020 Dec 1; 3(12): e2029058. doi: 10.1001/
jamanetworkopen.2020.29058. (Rosenthal, et al., December 10, 2020).
Roberts, JD et al., (2020, November 26). Clinicians, cooks, and 
cashiers: examining health equity and the COVID-19 risks to 
essential workers. 2020 Sep; 36(9):689-702. doi: 10.1177/
0748233720970439. PMID: 33241763; PMCID: PMC7691477. (Roberts et 
al., November 26, 2020).
Roth, GA et al., (2021, May 3). Trends in Patient Characteristics 
and COVID-19 In-Hospital Mortality in the United States During the 
COVID-19 Pandemic. JAMA Netw Open. 2021 May 3; 4(5): e218828. doi: 
10.1001/jamanetworkopen.2021.8828. PMID: 33938933. (Roth et al., May 
3, 2021).
Rubin-Miller, L et al., (2020, September 16). COVID-19 Racial 
disparities in testing, infection, hospitalization, and death: 
analysis of epic patient data. Kaiser Family Foundation. Issue Brief 
9530. (Rubin-Miller et al., September 16, 2020).
Sharifian-Dorche, M et al., (2020, August 7). Neurological 
complications of coronavirus infection; a comparative review and 
lessons learned during the COVID-19 pandemic. J Neurol Sci. 2020 Oct 
15; 417: 117085. Published online 2020 Aug 7. doi: 10.1016/
j.jns.2020.117085. (Sharifian-Dorche et al., August 7, 2020).
Society of Critical Care Medicine. (2013). Post-intensive care 
syndrome. https://www.sccm.org/MyICUCare/THRIVE/Post-intensive-Care-Syndrome. (Society of Critical Care Medicine, 2013).
Taquet, M et al., (2020, November 9). Bidirectional associations 
between COVID-19 and psychiatric disorder: retrospective cohort 
studies of 62[puncsp]354 COVID-19 cases in the USA. The Lancet 
Psychiatry. doi: 10.1016/s2215-0366(20)30462-4. (Taquet et al., 
November 9, 2020).
Tenforde, MW et al., (2020, July 24). Symptom Duration and Risk 
Factors for Delayed Return to Usual Health Among Outpatients with 
COVID-19 in a Multistate Health Care Systems Network--United States, 
March-June 2020. MMWR Morb Mortal Wkly Rep 2020; 69: 993-998. 
(Tenforde et al., July 24, 2020).
Teoh, et al., (2021). Risks of AKI and major adverse clinical 
outcomes in patients with severe acute respiratory syndrome or 
coronavirus disease 2019. JASN 32. doi: https://doi.org/10.1681/ASN.2020071097. (Teoh et al., 2021).
Townsend, L et al., (2020, November 9). Persistent fatigue following 
SARS-CoV-2 infection is common and independent of severity of 
initial infection. PLoS One. 2020; 15(11): e0240784. (Townsend et 
al., November 9, 2020).
Valent, A et al., (2020, October 10). Three-month quality of life in 
survivors of ARDS due to COVID-19: A preliminary report from a 
French academic centre. Anaesth Crit Care Pain Med 39 (2020) 740-
741. (Valent et al., October 10, 2020).
van Dorn, A et al., (2020, April 18). COVID-19 exacerbating 
inequalities in the US. Lancet 395: 1243-1244. (van Dorn et al., 
April 18, 2020).
Varatharaj, A et al., (2020, June 25). Neurological and 
neuropsychiatric complications of COVID-19 in 153 patients: a UK-
wide surveillance study. Lancet Psychiatry 7: 875-882. (Varatharaj 
et al., June 25, 2020).
Weerahandi, H et al., (2020, August 14). Post-discharge health 
status and symptoms in patients with severe COVID-19. MedRxiv 
preprint. doi: https://doi.org/10.1101/2020.08.11.20172742. 
(Weerahandi et al., August 14, 2020).
Woolf, SH et al., (2021, January 12). COVID-19 as the Leading Cause 
of Death in the United States. JAMA. doi: 10.1001/jama.2020.24865. 
(Woolf, January 12, 2021).
Wu, Z and McGoogan, JM. (2020, April 7). Characteristics of and 
Important Lessons From the Coronavirus Disease 2019 (COVID-19) 
Outbreak in China: Summary of a Report of 72,314 Cases

From the Chinese Center for Disease Control and Prevention. JAMA. 
323(13): 1239-1242. doi: 10.1001/jama.2020.2648. (Wu and McGoogan, 
April 7, 2020).
Zhang, P et al., (2020, February 14). Long-term bone and lung 
consequences associated with hospital-acquired severe acute 
respiratory syndrome: a 15-year follow-up from a prospective cohort 
study. Bone Research. 8(8). https://doi.org/10.1038/s41413-020-0084-5. (Zhang et al., February 14, 2020).
b. Transmission of SARS-CoV-2
    SARS-CoV-2 is a highly transmissible virus. Since the first case 
was detected in the U.S., there have been over 32 million reported 
cases of COVID-19, affecting every state and territory, with thousands 
more infected each day. According to the CDC, the primary way the SARS-
CoV-2 virus spreads from an infected person to others is through the 
respiratory droplets that are produced when an infected person coughs, 
sneezes, sings, talks, or breathes (CDC, May 7, 2021).\8\ Infection 
could then occur when another person breathes in the virus. Most 
commonly this occurs when people are in close contact with one another 
in indoor spaces (within approximately six feet for at least fifteen 
minutes) (CDC, May, 2021).
---------------------------------------------------------------------------

    \8\ On May 7, 2021, the CDC updated its guidance regarding 
airborne transmission (CDC, May 7, 2021; https://www.cdc.gov/coronavirus/2019-ncov/science/science-briefs/sars-cov-2-transmission.html). OSHA notes that this change does not alleviate 
the need for any of the controls in this ETS. Because OSHA has 
determined that the controls in this ETS are necessary to address a 
grave danger as quickly as possible, the agency determined that it 
was appropriate to issue the ETS while it continues to evaluate the 
new evidence to determine whether additional controls may be 
necessary at a later date.
---------------------------------------------------------------------------

    The best available current scientific evidence demonstrates that 
the farther a person is away from the source of the respiratory 
droplets, the fewer infectious viral particles will reach that person's 
eyes, nose, or mouth because gravity pulls the droplets to the ground 
(see the Need for Specific Provisions, Section V of the preamble, on 
Physical Distancing). For example, a systematic review of SARS-CoV-2 
(up to early May 2020) and similar coronaviruses (i.e., SARS-CoV-1 (a 
virus related to SARS-CoV-2) and Middle Eastern Respiratory Syndrome 
(MERS) (a disease caused by a virus that is similar to SARS-CoV-2 and 
spreads through droplet transmission)) found 38 studies, containing 
18,518 individuals, to use in a meta-analysis that found that the risk 
of viral infection decreased significantly as distance increased (Chu 
et al., June 27, 2020). A second COVID-19 study from Thailand reviewed 
physical distancing information collected from 1,006 individuals who 
had an exposure to infected individuals (Doung-ngern et al., September 
14, 2020). The study revealed that the group with direct physical 
contact and the group within one meter but without physical contact 
were equally likely to become infected with SARS-CoV-2. However, the 
group that remained more than one meter away had an 85% lower infection 
risk than the other two groups. The studies' findings on physical 
distancing combined with expert opinion firmly establish the importance 
of droplet transmission as a driver of SARS-CoV-2 infections and COVID-
19 disease.
    COVID-19 may also be spread through airborne particles under 
certain conditions (Schoen, May 2020; CDC, May 7, 2020; Honein et al., 
December 11, 2020). That airborne transmission can occur during 
aerosol-generating procedures (AGPs) in healthcare (such as when 
intubating an infected patient) is a reasonable concern (see CDC, March 
12, 2020). CDC provides recommendations for infection prevention and 
control practices when caring for a patient with suspected or confirmed 
SARS-CoV-2 infection that include the use of a respirator (CDC, 
February 23, 2021). There are several studies examining the risks 
associated with AGPs. For example, a publication detailing one of the 
first known SARS-CoV-2 occupational transmission events in U.S. 
healthcare providers reported a statistically significant increased 
risk from AGPs (Heinzerling et al., April 17, 2020). However, the 
currently available information specifically related to SARS-CoV-2 
exposure during AGPs is limited (Harding et al., June 1, 2020).
    Data from the Respiratory Protection Effectiveness Trial (ResPECT), 
designed to assess effectiveness of PPE to prevent respiratory 
infections, were analyzed to identify risk factors for endemic 
coronavirus infections among healthcare personnel (Cummings et al., 
July 9, 2020). This study found that AGPs may double the risk of 
infection among healthcare providers. Although the infectious agents 
studied were surrogate coronaviruses and not the SARS-CoV-2 virus, the 
study indicates increased risk from such procedures for infections from 
the coronavirus family, and thus the study is relevant. In addition, a 
systematic review of research on transmission of acute respiratory 
infections from patients to healthcare employees focused on 
publications from the first SARS virus outbreak (Tran et al., April 26, 
2012). Risks of SARS-CoV-1 infection in those performing AGPs were 
several times higher than in healthcare workers not exposed to AGPs. 
Workers may also be exposed to the SARS-CoV-2 virus during AGPs 
conducted outside of the hospital setting, including certain dental 
surgical procedures (Leong et al., December 2020), cardiopulmonary 
resuscitation (CPR) provided by homecare workers (Payne and Peache, 
February 4, 2021), and endoscopy (Teng et al., September 16, 2020; 
Sagami et al., January 2021).
    Risk from AGPs during autopsies is evident from reports of staff 
infections during autopsies on decedents infected with tuberculosis, 
which is a well-known airborne infectious agent (Nolte et al., December 
14, 2020). Additionally, research that measured airborne particles 
released during the use of an oscillating saw with variable saw blade 
frequencies and different saw blade contact loads concluded that, even 
in the best-case scenario tested on dry bone, the number of aerosol 
particles produced was still high enough to provide a potential health 
risk to forensic practitioners (Pluim et al., June 6, 2018). Other 
reports from healthcare settings have raised the possibility of spread 
of airborne particles from suspected or confirmed COVID-19 patients, 
absent AGPs. For example, infectious viral particles were collected 
from in the room of a COVID-19 patient from distances as far as 4.8 
meters away in non-AGP hospital settings (Lednicky et al., September 
11, 2020), and transmission via aerosol was suspected in a 
Massachusetts hospital (Klompas et al., February 9, 2021). For more 
discussion of this subject, see the Need for Specific Provisions 
(Section V of the preamble) on Respirators.
    The extent to which COVID-19 may spread through airborne particles 
in other contexts is less clear. CDC has noted that in some 
circumstances airborne particles can remain suspended in the air and be 
breathed in by others, and travel distances beyond 6 feet (for example, 
during choir practice, in restaurants, or in fitness classes) in 
situations that would not be defined as involving close contact:

    With increasing distance from the source, the role of inhalation 
likewise increases. Although infections through inhalation at 
distances greater than six feet from an infectious source are less 
likely than at closer distances, the phenomenon has been repeatedly 
documented under certain preventable circumstances. These 
transmission events have involved the presence of an infectious 
person exhaling virus indoors for an extended time (more than 15 
minutes and in some cases hours) leading to virus concentrations in 
the air space sufficient to transmit infections to people more than 
6 feet away, and in some cases to people who have passed through 
that space soon after the infectious person left.



(CDC, May 7, 2021).
    In general, enclosed environments, particularly those without good 
ventilation, increase the risk of airborne transmission (CDC, May 7, 
2021; Tang et al., August 7, 2020; Fennelly, July 24, 2020). In one 
scientific brief, CDC provides a basic overview of how airborne 
transmission occurs in indoor spaces. Once respiratory droplets are 
exhaled, CDC explains, they move outward from the source and their 
concentration decreases through fallout from the air (largest droplets 
first, smaller later) combined with dilution of the remaining smaller 
droplets and particles into the growing volume of air they encounter 
(CDC, May 7, 2020). Without adequate ventilation, continued exhalation 
can cause the amount of infectious smaller droplets and particles 
produced by people with COVID-19 to become concentrated enough in the 
air to spread the virus to other people (CDC, May 7, 2020). For 
example, an investigation of a cluster of cases among meat processing 
employees in Germany found that inadequate ventilation within the 
facility, including low air exchange rates and constant air 
recirculation, was one key factor that led to transmission of SARS-CoV-
2 within the workplace (Gunther et al., October 27, 2020). An 
epidemiological investigation of a cluster of COVID-19 cases in an 
indoor athletic court in Slovenia demonstrated that the humid and warm 
environment of the setting, combined with the turbulent air flow that 
resulted from the physical activity of the players, allowed COVID-19 
particles to remain suspended in the air for hours (Brlek et al., June 
16, 2020). A cluster of cases in a restaurant in China also suggested 
transmission of SARS-CoV-2 via airborne particles because of little 
mixing of air throughout the restaurant (Li et al., November 3, 2020). 
Infections have been observed with as little as five minutes of 
exposure in an enclosed room (Kwon et al., November 23, 2020). Outdoor 
settings (i.e., open air or structures with one wall) typically have a 
lower risk of transmission (Bulfone et al., November 29, 2020), which 
is likely due to increased ventilation with fresh air and a greater 
ability to maintain physical distancing. For more discussion of this 
subject, see the Need for Specific Provisions (Section V of the 
preamble) on Ventilation.
    Transmission of SARS-CoV-2 is also possible via contact 
transmission (both direct contact as well as surface contact), though 
this risk is generally considered to be low compared to other forms of 
transmission (CDC, April 5, 2021). Infectious droplets produced by an 
infected person can land on and contaminate surfaces. Surface, or 
indirect, transmission can then occur if another person touches the 
contaminated surface and then touches their own mouth, nose, or eyes 
(CDC, April 5, 2021). Contact transmission can also occur through 
direct contact with someone who is infectious. In direct contact 
transmission, the hands of a person who has COVID-19 can become 
contaminated with the virus when the person touches their face, blows 
their nose, coughs, or sneezes. The virus can then spread to another 
person through direct contact such as a handshake or a hug.
    The risk posed by contact transmission depends on a number of 
factors, including airflow and ventilation, as well as environmental 
factors (e.g., heat, humidity), time between surface contamination and 
a person touching those surfaces, the efficiency of transference of 
virus particles, and the dose of virus needed to cause infection. 
Studies show that the virus can remain viable on surfaces in 
experimental conditions for hours to days, but that under typical 
environment conditions 99% of the virus is no longer viable after three 
days (Riddell et al., October 7, 2020; van Doremalen, April 16, 2020; 
CDC, April 5, 2021). At this time, it is not clear what proportion of 
SARS-CoV-2 infection are acquired through contact transmission and 
infections can often be attributed to multiple transmission pathways.
    In recognition of the potential for contact transmission, CDC 
recommends cleaning, hand hygiene, and, under certain circumstances, 
disinfection for helping to prevent transmission of SARS-CoV-2 (CDC, 
May 17, 2020; CDC, April 5, 2021). These are long established 
recommendations to prevent the transmission of viruses that cause 
respiratory illnesses (Siegel et al., 2007). The potential for contact 
transmission was demonstrated in one study that reviewed cleaning and 
disinfection in households (Wang et al., May 11, 2020). The study found 
that the transmission of SARS-CoV-2 to family members was 77% lower 
when chlorine- or ethanol-based disinfectants were used on a daily 
basis compared to use only once in two or more days, irrespective of 
other protective measures taken such as mask wearing and physical 
distancing. For more discussion of this subject, see the Need for 
Specific Provisions (Section V of the preamble) on Cleaning and 
Disinfection.
    These methods of transmission are not mutually exclusive, and each 
can present a risk to employees in healthcare settings. Based on these 
methods of transmission, there are a number of factors--often present 
in healthcare settings--that can increase the risk of transmission: 
Indoor settings, prolonged exposure to respiratory particles, and lack 
of proper ventilation (CDC, May 7, 2020). First, and most 
significantly, healthcare employees in settings where patients with 
suspected or confirmed COVID-19 receive treatment may be required to 
have frequent close contact with infectious individuals, these settings 
are typically not designed for physical distancing, and many areas in 
these facilities are not ventilated for the purpose of minimizing 
infectious diseases capable of droplet or airborne transmission. 
Employees frequently touch shared surfaces and use shared items. Even 
in healthcare settings where employees have their own offices or 
equipment, they often share a number of common spaces with other 
workers, including bathrooms, break rooms, and elevators. Based on 
these characteristics, SARS-CoV-2 appears to be transmissible in 
healthcare environments, a conclusion supported by existing data 
(Howard, May 22, 2021). COVID-19 incidence rates have increased 
significantly for adults of working age as the pandemic has progressed 
in comparison with other age groups, with researchers noting that 
occupational status might be a driver (Boehmer et al., September 23, 
2020). Currently, case rates continue to be predominantly higher in 
working age groups in comparison to children and those over the age of 
65 (CDC, May 24, 2021).
    Given the high transmissibility expected in healthcare 
environments, the exposure risk that employees face is high. This risk 
is related to some extent to viral prevalence, which refers to the 
number of individuals in healthcare settings who may be infectious at 
any moment. As explained below, current data indicates that viral 
prevalence in the population is based on a number of factors, including 
the virus's existing reproductive number, the prevalence of pre-
symptomatic and asymptomatic transmission, and the recent documentation 
of mutations of the virus that appear to be more infectious.
    The transmissibility of viruses is measured in part by their 
reproductive number or ``R0.'' This number represents the average 
number of subsequently-infected people (or secondary cases) that are 
expected to occur from each existing case, which includes low 
transmission events as well as super-spreading phenomenon. Thus, an R0 
of ``1'' indicates that on average every one case of infection will

lead to one additional case. As long as a virus has an R0 of more than 
1, it is expected to continue to spread throughout the population. The 
observed R0 (also known as simply R) must be below 1 to prevent 
sustained spread; such a reduction can be achieved through infection 
control interventions (e.g., vaccination, non-pharmaceutical 
interventions) that either reduce the susceptibility of the population 
to the virus or reduce the likelihood of transmission within the 
population (Delamater et al., 2019). During the early part of the 
COVID-19 outbreak in China, before consistent protective measures were 
put into place, the R0 for SARS-CoV-2 was estimated as 2.2 (Riou and 
Althaus, January 30, 2020). Higher estimates of the R0 early in China 
(5.7) have also been published (Sanche et al., April 7, 2020). R0 
ranges from 2 to 5 have been published for earlier MERS and SARS-CoV-1 
coronavirus outbreaks (WHO, May 2003; Choi et al., September 25, 2017). 
Since the start of the COVID-19 pandemic, the R0 has varied depending 
on the natural ebb and flow of rolling infection surges as well as the 
fluctuating non-pharmaceutical interventions (NPIs) put in place, such 
as face coverings, nonessential business shutdowns, and testing with 
follow-up isolation and quarantining. The R0 value in the U.S. early in 
the pandemic was estimated to be approximately 2 (Li et al., October 
22, 2020), and this value has generally remained above 1 for the 
country as a whole throughout the pandemic, with various states well 
above and below this value at various times (Harvard Chan School of 
Public Health, February 26, 2021; Shi et al., May 18, 2021).
    Pre-symptomatic and asymptomatic transmission are significant 
drivers of the continued spread of COVID-19 (Johansson et al., January 
7, 2021). Individuals are considered most infectious in the 48 hours 
before experiencing symptoms and during the first few symptomatic days 
(Cevik et al., October 23, 2020). The time it takes for a person to be 
infected and then transmit the virus to another individual is called 
the serial interval. Several studies have indicated that the serial 
interval for COVID-19 is shorter than the time for symptoms to develop, 
meaning that many individuals can transmit SARS-CoV-2 before they begin 
to feel ill (Nishiura et al., March 4, 2020; Tindale et al., June 22, 
2020). It is also possible for individuals to be infected and 
subsequently transmit the virus without ever exhibiting symptoms. This 
is called asymptomatic transmission. As noted earlier, a recent meta-
analysis reviewed 13 studies in which the asymptomatic prevalence 
ranged from 4% to up to 41% (Byambasuren et al., December 11, 2020).
    The existence of both pre-symptomatic transmission and asymptomatic 
infection and transmission pose serious challenges to containing the 
spread of the virus. Although the risk of asymptomatic transmission is 
42% lower than from symptomatic COVID-19 patients (Byambasuren et al., 
December 11, 2020), asymptomatic transmission may result in more 
transmissions than symptomatic cases, perhaps because asymptomatic 
persons are less likely to be aware of their infection and can 
unknowingly continue to spread the disease to others. Similarly, pre-
symptomatic individuals can transmit the virus to others before they 
know they are sick and should isolate, assuming they are aware of their 
exposure. Existing evidence demonstrates that asymptomatic transmission 
is a significant contributor to the spread of COVID-19 in the United 
States. Johansson et al., (January 7, 2021) conducted a study to assess 
the proportion of SARS-CoV-2 transmission from pre-symptomatic, never 
symptomatic, and symptomatic individuals in the community. Based on 
their modeling, they found 59% of transmission came from asymptomatic 
transmission, including 35% from pre-symptomatic individuals and 24% 
from individuals who never develop symptoms (Johansson et al., January 
7, 2021).
    The SARS-CoV-2 virus also regularly mutates over time into 
different genetic variants. Many of these variants results in no 
increase in transmission or disease severity. However, the CDC monitors 
for variants of interest, variants of concern, and variants of high 
consequence (CDC, May 5, 2021). A variant of interest is one ``with 
specific genetic markers that have been associated with changes to 
receptor binding, reduced neutralization by antibodies generated 
against previous infection or vaccination, reduced efficacy of 
treatments, potential diagnostic impact, or predicted increase in 
transmissibility or disease severity'' (CDC, May 5, 2021). CDC-listed 
variants of interest include strains first identified in the United 
States (e.g., B.1.526, B.1.526.1), the United Kingdom (e.g., B.1.525), 
and Brazil (e.g., P.2). A variant of concern is one for which there is 
``evidence of an increase in transmissibility, more severe disease 
(e.g., increased hospitalizations or deaths), significant reduction in 
neutralization by antibodies generated during previous infection or 
vaccination, reduced effectiveness of treatments or vaccines, or 
diagnostic detection failures'' (CDC, May 5, 2021). CDC-listed variants 
of concern include strains first identified in the United States (e.g., 
B.1.427, B.1.429), United Kingdom (e.g., B.1.17), Brazil (e.g., P.1), 
and South Africa (e.g., B.1.351). As of April 24, B.1.1.7 made up 60% 
of infections in the United States (CDC, May 11, 2021). CDC notes that 
B.1.1.7 is associated with a 50% increase in transmission, as well as 
potentially increased incidence of hospitalizations and fatalities 
(CDC, May 5, 2021). As new strains with increased transmissibility or 
more severe effects enter the U.S. population, healthcare workers may 
be among the first to be exposed to them when those who are infected 
seek medical care (Howard, May 22, 2021).
    OSHA also recognizes that reported cases of SARS-CoV-2 likely 
undercount actual infections in the U.S. population. This finding is 
based on seroprevalence data, which measure the presence of specific 
antibodies in the blood that are typically developed when an individual 
is infected with SARS-CoV-2. Reported cases, in contrast, are based on 
COVID-19 tests that measure active infections. Recent reported case 
numbers suggest that approximately 10% of the US population has been 
infected. However, only seven states reported seroprevalence below 10% 
(i.e., Alaska, Hawaii, Maine, New Hampshire, Oregon, Vermont, 
Washington) and 23 states plus Washington DC and Puerto Rico exceeded 
20% (CDC, May 14, 2021). The likely reason for this difference is that 
serological tests measure antibodies in the blood that can be detected 
for a longer period of time than can an active COVID-19 infection. As 
such, serological testing may be able to detect past COVID-19 
infections in individuals who never sought out a viral test. A sampling 
of states from the Nationwide Commercial Laboratory Seroprevalence 
Survey illustrates this (CDC, May 14, 2021). On March 30, 2021, 
California had reported 3,564,431 cases, but seroprevalence estimates 
indicate that there have been 7,986,000 cases in the state (95% CI: 
7,023,000-8,965,000). Similarly, Texas has reported 2,780,903 cases, 
but seroprevalence data indicate 6,692,000 cases (95% CI: 5,624,000-
7,819,000). Given the very real possibility of higher numbers of cases 
than are reported in national case counts, the disease burden discussed 
in this document may well be underestimated.

References
Boehmer, TK et al., (2020, September 23). Changing Age Distribution 
of the COVID-19 Pandemic--United States, May-August 2020. MMWR Morb 
Mortal Wkly Rep 2020; 69: 1404-1409. DOI: http://dx.doi.org/10.15585/mmwr.mm6939e1external. (Boehmer et al., September 23, 
2020).
Brlek, A et al., (2020, June 16). Possible indirect transmission of 
COVID-19 at a squash court, Slovenia, March 2020: case report. Epi 
Inf 148: 1-3. (Brlek et al., June 16, 2020).
Bulfone, TC et al., (2020, November 29). Outdoor Transmission of 
SARS-CoV-2 and Other Respiratory Viruses: A Systematic Review. 
(2020). The Journal of Infectious Diseases 223: 550-561, https://doi.org/10.1093/infdis/jiaa742. (Bulfone et al., November 29, 2020).
Byambasuren, O et al., (2020, December 11). Estimating the extent of 
asymptomatic COVID-19 and its potential for community transmission: 
Systematic review and meta-analysis. Official Journal of the 
Association of Medical Microbiology and Infectious Disease Canada. 
5(4): 223-234 doi: 10.3138/jammi-2020-0030. (Byambasuren et al., 
December 11, 2020).
Centers for Disease Control and Prevention (CDC). (2020, March 12). 
What healthcare personnel should know about caring for patients with 
confirmed or possible coronavirus disease 2019 (COVID-19). https://www.cdc.gov/coronavirus/2019-ncov/hcp/caring-for-patients-H.pdf. 
(CDC, March 12, 2020).
Centers for Disease Control and Prevention (CDC). (2020, May 17). 
Hand hygiene recommendations: Guidance for healthcare providers 
about hand hygiene and COVID-19. https://www.cdc.gov/coronavirus/2019-ncov/hcp/hand-hygiene.html. (CDC, May 17, 2020).
Centers for Disease Control and Prevention (CDC). (2021, February 
23). Interim Infection Prevention and Control Recommendations for 
Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) 
Pandemic. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html. (CDC, February 23, 2021).
Centers for Disease Control and Prevention (CDC). (2021, April 5). 
Science Brief: SARS-CoV-2 and Surface (Fomite) Transmission for 
Indoor Community Environments. https://www.cdc.gov/coronavirus/2019-ncov/more/science-and-research/surface-transmission.html. (CDC, 
April 5, 2021).
Centers for Disease Control and Prevention (CDC). (2021, May 5). 
SARS-CoV-2 Variant Classifications and Definitions. https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/variant-surveillance/variant-info.html. (CDC, May 5, 2021).
Centers for Disease Control and Prevention (CDC). (2021, May 7). 
Scientific Brief: SARS-CoV-2 Transmission. https://www.cdc.gov/coronavirus/2019-ncov/science/science-briefs/sars-cov-2-transmission.html. (CDC, May 7, 2021).
Centers for Disease Control and Prevention (CDC). (2021, May 14) 
Nationwide Commercial Laboratory Seroprevalence Survey. https://covid.cdc.gov/covid-data-tracker/#national-lab. (CDC, May 14, 2021).
Centers for Disease Control and Prevention (CDC). (2021, May 24). 
Demographic Trends of COVID-19 cases and deaths in the US reported 
to CDC: Cases by age group. https://covid.cdc.gov/covid-data-tracker/#demographics. (CDC, May 24, 2021).
Census Bureau. (2020, June 25). Annual Estimates of the Resident 
Population for Selected Age Groups by Sex for the United States: 
April 2010 to July 1, 2019. https://www2.census.gov/programs-surveys/popest/tables/2010-2019/national/asrh/nc-est2019-agesex.xlsx. (Census Bureau, June 25, 2020).
Cevik, M et al., (2020, October 23) Virology, transmission, and 
pathogenesis of SARS-CoV-2 BMJ 2020; 371: m3862 doi: https://doi.org/10.1136/bmj.m3862. (Cevik et al., October 23, 2020).
Choi, S et al., (2017, September 25). High reproduction number of 
Middle East respiratory syndrome coronavirus in nosocomial 
outbreaks: Mathematical modelling in Saudi Arabia and South Korea. J 
Hos Inf 99: 162-168. (Choi et al., September 25, 2017).
Chu, DK et al., (2020, June 27). Physical Distancing, Face Masks, 
and Eye Protection to Prevent Person-to-Person Transmission of SARS-
CoV-2 and COVID-19: A systematic review and meta-analysis. Lancet 
395: 1973-1987. (Chu et al., June 27, 2020).
Cummings et al., (2020, July 9). Risk factors for healthcare 
personnel infection with endemic coronaviruses (HKU1, OC43, NL63, 
229E): Results from the respiratory protection effectiveness 
clinical trial (REPECT). Clin Infect Dis doi: 10.1093/cid/ciaa900. 
(Cummings et al., July 9, 2020).
Delamater, PL et al., (2019). Complexity of the basic reproduction 
number (R0). Emerging Infectious Disease 25(1): 1-4. https://doi.org/10.3201/eid2501.171901. (Delamater et al., 2019).
Doung-ngern, P et al., (2020, September 14). Case-control Study of 
Use of Personal Protective Measures and Risk for SARS Coronavirus 2 
Infection, Thailand. Emerg In Dis 26, 11: 2607-2616. (Doung-ngern et 
al., September 14, 2020).
Fennelly, K. (2020, July 24). Particle sizes of infectious aerosols: 
Implications for infection control. Lancet Respir Med 2020; 8: 914-
24. https://doi.org/10.1016/S2213-2600(20)30323-4. (Fennelly, July 
24, 2020).
Gunther, T et al., (2020, October 27). SARS-CoV-2 outbreak 
investigation in a German meat processing plant. EMBO Mol Med (2020) 
12: .e13296. doi.org/10.15252/emmm.202013296. (Gunther et al., 
October 27, 2020).
Harding, H, Broom, A, Broom, J. (2020, June 1). Aerosol-generating 
procedures and infective risk to healthcare workers from SARS-CoV-2: 
the limits of the evidence. J Hosp Infect. 2020; 105(4): 717-725. 
doi: 10.1016/j.jhin.2020.05.037. (Harding et al., June 1, 2020).
Harvard Chan School of Public Health. (2020, February 26). 
Visualizing COVID-19's Effective Reproduction Number (Rt). http://metrics.covid19-analysis.org/. (Harvard Chan School of Public 
Health, February 26, 2020).
Heinzerling, A et al., (2020, April 17). Transmission of COVID-19 to 
Health Care Personnel During Exposures to a Hospitalized Patient--
Solano County, California, February 2020. MMWR Morb Mortal Wkly Rep 
2020; 69: 472-476. DOI: http://dx.doi.org/10.15585/mmwr.mm6915e5. 
(Heinzerling et al., April 17, 2020).
Honein, MA, Christie, A, Rose, DA et al., (2020, December 11). 
Summary of Guidance for Public Health Strategies to Address High 
Levels of Community Transmission of SARS-CoV-2 and Related Deaths, 
December 2020. MMWR Morb Mortal Wkly Rep 2020; 69: 1860-1867. DOI: 
http://dx.doi.org/10.15585/mmwr.mm6949e2. (Honein et al., December 
11, 2020).
Howard, J. (2021, May 22). ``Response to request for an assessment 
by the National Institute for Occupational Safety and Health, 
Centers for Disease Control and Prevention, U.S. Department of 
Health and Human Services, of the current hazards facing healthcare 
workers from Coronavirus Disease-2019 (COVID-19).'' (Howard, May 22, 
2021).
Johansson, MA et al., (2021, January 7). SARS-CoV-2 transmission 
from people without COVID-19 symptoms. JAMA Network Open. 4(1): 
e2035057. doi: 10.1001/jamanetworkopen.2020.35057. (Johansson et 
al., January 7, 2021).
Klompas, M et al., (2021, February 9). A SARS-CoV-2 Cluster in an 
Acute Care Hospital. Annals of Internal Medicine [Epub ahead of 
print 9 February 2021]. doi:10.7326/M20-7567. (Klompas et al., 
February 9, 2021).
Kwon, KS et al., (2020, November 23). Evidence of Long-Distance 
Droplet Transmission of SARS-CoV-2 by Direct Air Flow in a 
Restaurant in Korea. J Korean Med Sci 35(46): e415. (Kwon et al., 
November 23, 2020).
Lednicky, JA et al., (2020, September 11). Viable SARS-CoV-2 in the 
air of a hospital room with COVID-19 patients. Int J Infect Dis 100: 
476-482. (Lednicky et al., September 11, 2020).
Leong, YC et al., (2020, December). Clinical considerations for out-
of-hospital cardiac arrest management during COVID-19. Resuscitation 
Plus. 100027-100027. https://doi.org/10.1016/j.resplu.2020.100027. 
(Leong et al., December 2020).
Li, Y et al., (2020, October 22).The temporal association of 
introducing and lifting non-pharmaceutical interventions with the 
time varying reproduction number (R) of SARS-CoV-2: A modeling study 
across 131 countries. Lancet Infect Dis 21: 193-202. (Li et al., 
October 22, 2020).
Li, H et al., (2020, November 3). Dispersion of Evaporating Cough 
Droplets in Tropical Outdoor Environment. Phys

Fluids 32, 113301. https://doi.org/10.1063/5.0026360. (Li et al., 
November 3, 2020).
Nishiura, H et al., (2020, March 4). Serial interval of novel 
coronavirus (COVID-19) infections. Int J Infect Dis. 2020 Apr; 93: 
284-286. doi: 10.1016/j.ijid.2020.02.060. Epub 2020 Mar 4. PMID: 
32145466; PMCID: PMC7128842. (Nishiura et al., March 4, 2020).
Nolte, KB et al., (2020, December 14). Design and Construction of a 
Biosafety Level-3 Autopsy Laboratory. Arch Path Lab Med. doi: 
10.5858/arpa.2020-0644-SA. (Nolte et al., December 14, 2020).
Payne, D and Peache, M. (2021, February 4). Aerosol-generating 
procedures in home care. Br J Community Nurs. 26 (2): 76-80. https://dx.doi.org/10.12968/bjcn.2021.26.2.76. (Payne and Peache, February 
4, 2021).
Pluim, JME et al., (2018, June 6). Aerosol production during 
autopsies: the risk of sawing in bone. Forensic Science 
International 289: 260-267. https://doi.org/10.1016/j.forsciint.2018.05.046. (Pluim et al., June 6, 2018).
Riddell, S et al., (2020, October 7). The effect of temperature on 
persistence of SARS-CoV-2 on common surfaces. Virol J 17:145 DOI: 
https://doi.org/10.1186/s12985-020-01418-7. (Riddell et al., October 
7, 2020).
Riou, J and Althaus, CL. (2020, January 30). Pattern of early human-
to-human transmission of Wuhan 2019 novel coronavirus (2019-nCoV), 
December 2019 to January 2020. Eurosurveillance 25(4): pii=2000058. 
https://doi.org/10.2807/1560-7917.ES.2020.25.4.2000058. (Riou and 
Althaus, January 30, 2020).
Sagami, R et al., (2021, January). Aerosols Produced by Upper 
Gastrointestinal Endoscopy: A Quantitative Evaluation. The American 
journal of gastroenterology. 116 (1): 202-205. https://doi.org/10.14309/ajg.0000000000000983. (Sagami et al., January 2021).
Sanche, S et al., (2020, April 7). High contagiousness and rapid 
spread of severe acute respiratory syndrome coronavirus 2. Emerg Inf 
Dis 26(7): 1470-1477. (Sanche, April 7, 2020).
Schoen, LJ. (2020, May). Guidance for building operations during the 
COVID-19 pandemic. ASHRAE Journal 72-72. https://www.ashrae.org/file%20library/technical%20resources/ashrae%20journal/2020journaldocuments/72-74_ieq_schoen.pdf. (Schoen, May 2020).
Shi, A et al., (2021, May 18). COVID-19 Spread Mapper: Table of 
metrics for May 18, 2021. http://metrics.covid19-analysis.org/?_inputs_&map_metric=%22rt%22&compare_sel_countries=null&show_ci=%22No%22&Rt_table_search=%22%22&map_date=%222021-05-18%22&compare_metric=%5B%22rt%22%2C%22case_rate%22%2C%22death_rate%22%5D&compare_submit=0&table_select_resolution=%22subnat_USA%22&table_date=%222021-05-18%22&select_resolution=%22auto%22&compare_sel_states=null&compare_sel_counties=null. (Shi et al., May 18, 2021).
Siegel, JD, Rhinehart, E, Jackson, M, Chiarello, L, and the 
Healthcare Infection Control Practices Advisory Committee. (2007). 
2007 Guideline for Isolation Precautions: Preventing Transmission of 
Infectious Agents in Healthcare Settings. Centers for Disease 
Control and Prevention. https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html. (Siegel et al., 2007)
Teng, M et al., (2020, September 16) Endoscopy during COVID-19 
pandemic: An overview of infection control measures and practical 
application. World J Gastrointest Endosc. 12 (9): 256-265. https://dx.doi.org/10.4253/wjge.v12.i9.256. (Teng et al, September 16, 
2020).
Tindale, LC et al., (2020, June 22). Evidence for transmission of 
COVID-19 prior to symptom onset. Elife. 2020; 9: e57149. Published 
2020 Jun 22. doi: 10.7554/eLife.57149. (Tindale et al., June 22, 
2020).
Tran, K et al., (2012, April 26). Aerosol generating procedures and 
risk of transmission of acute respiratory infections to healthcare 
care: A systematic review. PLOSONE 7(4): e35797. doi: 10.1371/
journal.pone.0035797. (Tran et al., April 26, 2012).
van Doremalen, N et al., (2020, April 16). Aerosol and Surface 
Stability of SARS-CoV-2 as Compared with SARS-CoV-1. N Engl J Med. 
2020 Apr 16; 382(16): 1564-1567. doi: 10.1056/NEJMc2004973. (van 
Doremalen et al., April 16, 2020).
Wang, Y et al., (2020, May 11). Reduction of secondary transmission 
of SARS-CoV-2 in households by face mask use, disinfection and 
social distancing: A cohort study in Beijing, China. BMJ Glob 
Health. 2020; 5(5): e002794. doi: 10.1136/bmjgh-2020-002794. (Wang 
et al., May 11, 2020).
World Health Organization (WHO). (2003, May). Consensus document on 
the epidemiology of severe acute respiratory syndrome (SARS). WHO/
CDS/CSR/GAR/2003.11. https://apps.who.int/iris/bitstream/handle/10665/70863/WHO_CDS_CSR_GAR_2003.11_eng.pdf?sequence=1&isAllowed=y. 
(WHO, May 2003)
c. The Effect of Vaccines on the Grave Danger Presented by SARS-CoV-2
    The development of safe and highly effective vaccines and the on-
going nation-wide distribution of these vaccines are encouraging 
milestones in the nation's response to COVID-19. Although there was 
initial uncertainty attached to the performance of authorized vaccines 
outside of clinical trials, vaccines have been in use for several 
months and they have proven effective in reducing transmission as well 
as the severity of COVID-19 cases. Data now available clearly establish 
that fully-vaccinated persons (defined as two weeks after the second 
dose of the mRNA vaccines or two weeks after the single dose vaccine) 
have a greatly reduced risk compared to unvaccinated individuals. This 
includes reductions in deaths, severe infections requiring 
hospitalization, and less severe symptomatic infections. The 
combination of data from clinical trials and data from mass vaccination 
efforts points increasingly to a significantly lower risk in settings 
where all workers are fully vaccinated and are not providing direct 
care for individuals with suspected or confirmed COVID-19. OSHA has 
therefore determined that there is insufficient evidence in the record 
to support a grave danger finding for employees in non-healthcare 
workplaces (or discrete segments of workplaces) where all employees are 
vaccinated. However, in healthcare settings where workers are 
vaccinated, as discussed below, the best available evidence establishes 
a grave danger still exists, given the greater potential for 
breakthrough cases in light of the greater frequency of exposure to 
suspected and confirmed COVID-19 patients in those settings (Birhane et 
al., May 28, 2021). In addition, the best available evidence shows that 
vaccination has not eliminated the grave danger in mixed healthcare 
workplaces (i.e., those where some workers are fully vaccinated and 
some are unvaccinated) or in those healthcare workplaces where no one 
has yet been vaccinated.
The Effectiveness of Authorized Vaccines
    There are currently three vaccines for the prevention of COVID-19 
that have received EUAs from the FDA, allowing for their distribution 
in the U.S.: The Pfizer-BioNTech COVID-19 vaccine, the Moderna COVID-19 
vaccine, and the Janssen COVID-19 vaccine. Pfizer-BioNTech and Moderna 
are mRNA vaccines that require two doses administered three weeks and 
one month apart, respectively. Janssen is a viral vector vaccine that 
requires a single dose (CDC, April 2, 2021). The vaccines were shown to 
greatly exceed minimum efficacy standards in preventing COVID-19 in 
clinical trial participants (FDA, December 11, 2020; FDA, December 18, 
2020; FDA, February 26, 2021). Data from clinical trials for all three 
vaccines and observational studies for the two mRNA vaccines clearly 
establish that fully vaccinated persons have a greatly reduced risk of 
SARS-CoV-2 infection compared to unvaccinated individuals. This 
includes severe infections

requiring hospitalization and those resulting in death, as well as less 
severe symptomatic infections.
    As stated above, the three authorized vaccine were shown to be 
highly efficacious in clinical trials. Clinical trial results are 
commonly considered a best case scenario (e.g., conducted in relatively 
young and healthy populations), while evidence from follow-up 
observational studies provides insight on a more diverse population. 
This essential data from observational studies in populations who were 
vaccinated outside of clinical trials is emerging and shows that the 
mRNA vaccines are highly effective. At this time, observational studies 
for the single dose, viral vector vaccine are not available. Some of 
the studies for mRNA vaccines examined high-risk populations, such as 
healthcare workers. Thus, the degree of protection in these studies can 
be extrapolated to a wide range of workplace settings in healthcare. 
The results from these studies are very encouraging.
    A study of 3,950 health care personnel, first responders, and other 
essential workers who completed weekly SARS-CoV-2 testing for 13 
consecutive weeks reported 90% effectiveness (95% confidence interval 
[CI] = 68%-97%) after full vaccination with either mRNA vaccine 
(Thompson et al., April 2, 2021). Still, 22.9% of PCR-confirmed 
infections required medical care; these included two hospitalizations 
but no deaths. A study of more than 8,000 individuals in the U.S. 
general population found that two doses of either mRNA vaccine were 
88.7% effective in preventing SARS-CoV-2 infection (Pawlowski et al., 
February 27, 2021). Similar to the above results in essential workers, 
although breakthrough infection occurred, vaccinated patients in this 
study who were subsequently diagnosed with COVID-19 had significantly 
lower 14-day hospital admission rates than matched unvaccinated 
participants (3.7% vs. 9.2%). Hall et al., (April 23, 2021), in a study 
of U.K. healthcare workers with bi-weekly testing, documented an 85% 
effectiveness of the Pfizer-BioNTech vaccine, though those authors 
required only one week after dose two for classification as fully 
vaccinated. Research from Israel provides additional evidence of high 
effectiveness for the Pfizer-BioNTech vaccine (Dagan et al., February 
24, 2021).
    Data available regarding vaccine efficacy against some SARS-CoV-2 
variants of concern illustrate that the vaccines remain effective at 
reducing symptomatic infections. Two doses of the Pfizer-BioNTech 
COVID-19 vaccine was highly effective (85-86%) against SARS-CoV-2 
infection and symptomatic COVID-19 during a period when B.1.1.7 was the 
predominant circulating strain in the UK (Hall et al., April 23, 2021). 
In Israel, the Pfizer-BioNTech vaccine was 92% effective even with the 
proportion of cases due to the B.1.1.7 becoming the dominant virus in 
circulation towards the end of the evaluation period (Dagan et al., 
February 24, 2021). Another study testing the Pfizer-BioNTech COVID-19 
vaccine found that it was equally capable of neutralizing the notable 
variants from the United Kingdom and South Africa (Xie et al., February 
8, 2021). This finding was then reflected in a Qatari study that found 
that the Pfizer-BioNTech vaccine was not only effective at preventing 
disease in people infected by those variants, but was observed as 100% 
effective in preventing fatalities from COVID-19 (Abu-Raddad et al., 
May 5, 2021). The Janssen vaccine clinical trial was conducted during a 
time in which SARS-CoV-2 variants were circulating in South Africa 
(B.1.351 variant) and Brazil (P.2 variant). At 28 or more days past 
vaccination, efficacy against moderate to severe/critical disease was 
72% in the United States; 68% in Brazil; 64% in South Africa (FDA, 
February 26, 2021). Although some studies have reported antibodies to 
be less effective against the B.1.351 variant, antibody activity in 
serum from vaccinated persons was generally higher than activity from 
serum of persons who recovered from COVID-19 (CDC, April 2, 2021).
    A major question not fully addressed in the original clinical 
trials is whether vaccinated individuals can become infected and shed 
virus, even if they are asymptomatic. Thompson et al., (April 2, 2021), 
reported that 11% of the PCR-confirmed breakthrough infections in their 
essential worker population were asymptomatic, indicating a concern for 
asymptomatic transmission. However, this concern is based on studies 
indicating asymptomatic transmission among unvaccinated individuals and 
it is not known if this phenomena occurs in infected vaccinated 
individuals. In the Moderna clinical trial, reverse transcription 
polymerase chain reaction (RT-PCR) testing was performed on 
participants at their second vaccination visit; asymptomatic positives 
in the vaccinated group were less than half those in the placebo group 
(Baden et al., December 30, 2020, supplemental files Table s18). In a 
Mayo clinic study, an 80% reduction in risk of positive pre-procedural 
screening tests was observed in patients tested after their second 
vaccine dose (Tande et al., March 10, 2021). A study of more than 
140,000 healthcare workers and their almost 200,000 household members 
reported a 30% reduction in risk of documented COVID-19 cases in the 
household members after the healthcare provider was fully vaccinated 
(Shah et al., March 21, 2021). In the Israeli general population, the 
estimated vaccine effectiveness for the asymptomatic infection proxy 
group (infection without documented symptoms, which could have included 
undocumented mild symptoms) was 90% at 7 or more days after the second 
dose (Dagan et al., February 24, 2021). Preliminary data from Israel 
suggest that people vaccinated with the Pfizer-BioNTech COVID-19 
vaccine who develop COVID-19 have a four-fold lower viral load than 
unvaccinated people (Levine-Tiefenbrun, February 8, 2021). As noted by 
CDC (April 2, 2021), this observation may indicate reduced 
transmissibility, because viral load is thought to be a major factor in 
transmission (Marks et al., February 2, 2021).
    The CDC has acknowledged that a ``growing body of evidence suggests 
that fully vaccinated people are less likely to have asymptomatic 
infection or transmit SARS-CoV-2 to others'' (CDC, April 2, 2021). The 
decreased risk for infection, especially serious infection, combined 
with decreased risk of transmission to others has allowed the CDC to 
relax some recommendations for individuals who are in community or 
public settings and who are fully vaccinated with one of the three FDA 
authorized vaccines, as follows.
     Quarantine is no longer required for fully vaccinated 
individuals who remain asymptomatic following exposure to a COVID-19 
infected person (CDC, May 13, 2021).
     Testing following a known exposure is no longer needed for 
a fully vaccinated person, as long as the individual remains 
asymptomatic and is not in specific settings such as healthcare (CDC, 
April 27, 2021a), non-healthcare congregate facilities (e.g., 
correctional and detention facilities, homeless shelters) or high-
density workplaces (e.g., poultry processing plants) (CDC, May 13, 
2021).
    In non-healthcare settings, fully vaccinated people no longer need 
to wear a mask or physically distance, except where required by 
federal, state, local, tribal, or territorial laws, rules, and 
regulations, including local business and workplace guidance (CDC, May 
13, 2021). In healthcare settings, the picture is more mixed. While the

CDC still recommends source controls for vaccinated healthcare workers 
to protect unvaccinated people, it has relaxed several NPIs for health 
care providers (HCP) in some circumstances. CDC has stated that ``fully 
vaccinated HCP could dine and socialize together in break rooms and 
conduct in-person meetings without source control or physical 
distancing'' (CDC, April 27, 2021a). The CDC also recommends that fully 
vaccinated HCP no longer need to be restricted from work after a high-
risk exposure, as long as they remain symptom-free (CDC, April 27, 
2021a). Perhaps more significantly, while acknowledging the growing 
body of evidence against SARS-CoV-2 transmission from vaccinated people 
to unvaccinated people, the CDC has not identified evidence of a 
substantial risk of such transmission even in healthcare settings. 
Therefore, pending additional evidence of such transmission, the risk 
of transmission from vaccinated healthcare workers to unvaccinated co-
workers does not appear to be high enough to warrant OSHA's imposition 
of mandatory controls through an ETS to protect unvaccinated workers 
from exposure to vaccinated workers.
    On the other hand, HCP treating suspected and confirmed COVID-19 
patients are expected to have higher exposures to the SARS-CoV-2 virus 
than others in the workforce, because such work involves repeated 
instances of close contact with infected patients (Howard, May 22, 
2021). Exposure can be even higher in aerosol generating activities. 
Indeed, one study reported higher infection rates among vaccinated HCWs 
during a regional COVID-19 surge (Keehner et al., Mar. 23, 2021). Thus, 
the CDC has not relaxed infection control practices or PPE intended to 
protect HCP, including respirator use. (CDC, April 27, 2021a). NIOSH 
has stated that the ``available evidence shows that healthcare workers 
are continuing to become infected with SARS-CoV-2 . . . including both 
vaccinated and unvaccinated workers, and the conditions for the 
transmission of the virus exist at healthcare workplaces'' (Howard, May 
22, 2021). The CDC has also indicated that it will continue ``to 
evaluate the impact of vaccination; the duration of protection, 
including in older adults; and the emergence of novel SARS-CoV-2 
variants on healthcare infection prevention and control 
recommendations'' (CDC, April 27, 2021a). OSHA, too, will continue to 
monitor this issue and revise the ETS as appropriate.
Grave Danger Exists in Healthcare Workplaces Where Unvaccinated Workers 
Are Present
    The evidence shows that the advent of vaccines does not eliminate 
the grave danger from exposure to SARS-CoV-2 in healthcare workplaces 
where less than 100% of the workforce is fully vaccinated. Unvaccinated 
workers can transmit the virus to each other and can become infected as 
a result of exposure to persons with COVID-19 who enter the healthcare 
facility. An outbreak of COVID-19 due to an unvaccinated, symptomatic 
HCP was recently reported in a skilled nursing facility in which 90.4% 
of residents had been vaccinated (Cavanaugh, April 30, 2021). The 
outbreak, due to the R.1 variant, caused attack rates that were three 
to four times higher in unvaccinated residents and HCPs as among those 
who were vaccinated. Additionally, unvaccinated persons were 
significantly more likely to experience symptoms or require 
hospitalization. Therefore, unvaccinated employees at these workplaces 
remain at grave danger of infection, along with the serious health 
consequences of COVID-19, as discussed in the remainder of this 
section.
    Although the risk appears to be lower, breakthrough infections of 
vaccinated individuals do occur, but the potential for secondary 
transmission remains not fully substantiated. For instance, a small yet 
significant portion of the population does not respond well to 
vaccinations (Agha et al., April 7, 2021; Boyarsky et al., May 5, 2021; 
Deepak et al., April 9, 2021; ACI, April 28, 2021) and may be as 
vulnerable as unvaccinated individuals. These individuals could 
potentially transmit the SARS-CoV-2 infection to unvaccinated 
employees. In a California study, seven out of 4,167 fully vaccinated 
health care workers experienced breakthrough infections (Keehner et 
al., May 6, 2021). A similar study from the Mayo Clinic, included 
44,011 fully vaccinated individuals with 30 breakthrough infections 
being recorded (Swift et al., April 26, 2021). Of those breakthrough 
cases, 73% were symptomatic. Secondary transmission was not evaluated 
in the study. A nursing facility in Chicago found 22 possible 
breakthrough cases of SARS-COV-2 infection among fully vaccinated staff 
and residents (Teran et al., April 30, 2021). Of those cases, 36% were 
symptomatic. However, no secondary transmission was observed in the 
facility. The lack of secondary transmission was likely due to the 
facility's implementation of non-pharmaceutical interventions and high 
vaccination rates. The authors concluded that to ensure outbreaks do 
not occur from breakthrough infections in workplaces with vaccinated 
and unvaccinated workers that the facilities need to maintain high 
vaccine coverage and non-pharmaceutical interventions. While these 
breakthrough events appear to be uncommon, it is important to remember 
how quickly a few cases can result in an outbreak in unvaccinated 
populations.
    Moreover, even though the U.S. is approaching the time where there 
is sufficient vaccine supply for the entire U.S. population, 
administering the vaccine throughout the country will still take more 
time. As of May 24, 2021, CDC statistics show that 43% of the 
population between 18 and 65 has been fully vaccinated (CDC, May 24, 
2021a). To this end, there is still a need to strengthen confidence in 
the safety and effectiveness of the vaccines for significant portions 
of the population, including workers, to reduce vaccine hesitancy. Even 
in the healthcare industry, where distribution has enabled entire 
worker populations to be completely vaccinated by now, some workers 
exhibited reluctance to getting vaccinated. On January 4, 2021, a study 
of 1,398 U.S. emergency department health care personnel found that 95% 
were offered the vaccine, with 14% declining (Schrading et al., 
February 19, 2021). In February of 2021, the CDC released a study of 
initial vaccine efforts at skilled nursing facilities offering long-
term care (Gharpure et al., February 5, 2021). The study found that 
only 37.5% of eligible staff were vaccinated, leaving a potentially 
significant population vulnerable to SARS-CoV-2 infections and capable 
of transmission.
    An anonymous survey of employees across the Yale Medicine and Yale 
New Haven Health system was used to estimate the prevalence of and 
underlying reasons for COVID-19 vaccine hesitancy. The survey was sent 
to about 33,000 employees and medical staff across the Yale healthcare 
system and included clinical staff and those who support the critical 
infrastructure without direct patient contact (e.g., food service 
staff). Out of 3,523 responses (an 11% response rate), 85% of 
respondents stated they were ``extremely likely'' or ``somewhat 
likely'' to receive the COVID-19 vaccine. Of that 85%, 12% expressed 
mild hesitancy by stating they would get it within the next 6 months. 
But 14.7% of overall respondents expressed reluctance by responding 
``neither likely nor unlikely,'' ``somewhat unlikely,'' or ``extremely 
unlikely'' to receive the COVID-19 vaccine. Overall, 1 in 6 personnel 
in this health system survey expressed at least

some reluctance to get vaccinated (Roy et al., December 29, 2020).
    Findings in more recent surveys of the general working population 
from 18 to 65 years old show similar rates of people who stated they 
would not, probably would not, or would only if required get vaccinated 
(18.2%) (Census Bureau, May 5, 2021); 17-26% (KFF, April 22, 2021). In 
March 2021, a survey found that healthcare employees reported some of 
the highest vaccination percentages of any sector (78.3% and 67.7%, 
respectively; King et al., April 24, 2021). However, future growth of 
vaccination may be a concern with vaccine hesitation in those sectors 
reported as 14.1% and 15.9%, respectively.
    That unvaccinated healthcare workers remain in grave danger is 
emphasized by the fact that thousands of new hospital admissions still 
occur each day (CDC, May 24, 2021b) in the midst of significant 
distribution of over three hundred million effective vaccine doses. 
These factors indicate that transmission remains robust and significant 
portions of the population remain vulnerable to COVID-19. Spread of the 
disease within the healthcare workforce may start with a worker 
becoming ill through community transmission or an ill patient seeking 
treatment. The rate of new cases, hospitalizations, and deaths peaked 
in January 2021, just before vaccines became more widely available 
outside of healthcare settings. The January to February decline, 
however, is likely not attributable in large part to the new vaccines 
alone, because only a small portion of the population had received 
them. During this time, variants of concern, such as B.1.1.7, that are 
more transmissible and may result in worse health outcomes, have become 
the majority source of infection (CDC, May 24, 2021c). Hundreds of 
people each day are still dying of COVID-19 in early May 2021, many of 
them working-age adults (May 24, 2021d).
    OSHA will continue to monitor trends as more of the population 
becomes vaccinated and the post-vaccine evidence base continues to 
grow. If and when OSHA finds a grave danger from the virus no longer 
exists for covered healthcare workplaces (or some portion thereof), or 
new information necessitates a change in measures necessary to address 
the grave danger, OSHA will update the rule as appropriate.
    In summary, the availability and use of safe and effective vaccines 
for COVID-19 is a critical milestone that has led to a marked decrease 
in risk for healthcare employees generally, but grave danger still 
remains for those whose jobs require them to work in settings where 
patients with suspected or confirmed COVID-19 receive care. CDC has 
determined that the remaining risk for fully vaccinated persons outside 
of healthcare settings is low enough to justify foregoing other layers 
of controls for settings where all persons are fully vaccinated and 
asymptomatic (CDC, April 27, 2021), but the CDC continues to recommend 
respirators and PPE for fully vaccinated healthcare employees in 
settings where patients with suspected or confirmed COVID-19 receive 
care. Based on CDC guidance and the best available evidence, OSHA finds 
a grave danger in healthcare for vaccinated and unvaccinated HCP 
involved in the treatment of COVID-19 patients.
References
Abu-Raddad, LJ et al., (2021, May 5). Effectiveness of the BNT162b2 
Covid-19 Vaccine against the B.1.1.7 and B.1.351 Variants. NEJM DOI: 
10.1056/NEJMc2104974 (Abu-Raddad et al., May 5, 2021).
Agency for Clinical Innovation (ACI). (2021, April 28). Evidence 
check: Immunocompromised patients and COVID-19 vaccines. https://aci.health.nsw.gov.au/__data/assets/pdf_file/0009/645750/Evidence-check-Immunocompromised-patients-COVID-19-vaccines.pdf. (ACI, April 
28, 2021).
Agha et al., (2021, April 7). Suboptimal response to COVID-19 mRNA 
vaccines in hematologic malignancies patients. medRxiv 
2021.04.06.21254949. https://doi.org/10.1101/2021.04.06.21254949. 
(Agha, et al., April 7, 2021).
Baden, L et al., (2021, December 30). Efficacy and safety of the 
mRNA-1273 SARS-CoV-2 Vaccine. The New England Journal of Medicine, 
384(5), 403-416. https://doi.org/10.1056/NEJMoa2035389. (Baden et 
al., December 30, 2020).
Birhane, M et al., (2021, May 28). COVID-19 Vaccine Breakthrough 
Infections Reported to CDC--United States, January 1-April 30, 2021. 
MMWR 70: 792-793. http://dx.doi.org/10.15585/mmwr.mm7021e3. (Birhane 
et al., May 28, 2021).
Boyarsky, BJ et al., (2021, May 5). Antibody Response to 2-Dose 
SARS-CoV-2 mRNA Vaccine Series in Solid Organ Transplant Recipients. 
JAMA. 2021 May 5. doi: 10.1001/jama.2021.7489. PMID: 33950155. 
(Boyarsky et al., May 5, 2021).
Cavanaugh, AM et al., (2021, April 30). COVID-19 outbreak associated 
with a SARS-CoV-2 R.1 lineage variant in a skilled nursing facility 
after vaccination program--Kentucky, March 2021. MMWR 70: 639-643. 
http://dx.doi.org/10.15585/mmwr.mm7017e2. (Cavanaugh et al., April 
30, 2021).
Census Bureau. (2021, May 5). Household Pulse Survey COVID-19 
Vaccination Tracker. https://www.census.gov/library/visualizations/interactive/household-pulse-survey-covid-19-vaccination-tracker.html. (Census Bureau, May 5, 2021).
Centers for Disease Control and Prevention (CDC). (2021, April 2). 
Science brief: Background rationale and evidence for public health 
recommendations for fully vaccinated people. https://www.cdc.gov/coronavirus/2019-ncov/science/science-briefs/fully-vaccinated-people.html. (CDC, April 2, 2021).
Centers for Disease Control and Prevention (CDC). (2021a, April 27). 
Updated healthcare infection prevention and control recommendation 
in response to COVID-19 vaccination. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-after-vaccination.html. 
(CDC, April 27, 2021a).
Centers for Disease Control and Prevention (CDC). (2021b, April 27). 
Domestic travel during COVID-19. https://www.cdc.gov/coronavirus/2019-ncov/travelers/travel-during-covid19.html. (CDC, April 27, 
2021b).
Centers for Disease Control and Prevention (CDC). (2021, May 13). 
Interim public health recommendations for fully vaccinated people. 
https://www.cdc.gov/coronavirus/2019-ncov/vaccines/fully-vaccinated-guidance.html. (CDC, May 13, 2021).
Centers for Disease Control and Prevention (CDC). (2021a, May 24). 
Demographic Trends of People Receiving COVID-19 Vaccinations in the 
United States. https://covid.cdc.gov/covid-data-tracker/?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fcases-updates%2Fcas%E2%80%A6#vaccination-demographic. (CDC, 
May 24, 2021a).
Centers for Disease Control and Prevention (CDC). (2021b, May 24). 
COVID data tracker. New Admissions of Patients with Confirmed COVID-
19, United States. https://covid.cdc.gov/covid-data-tracker/#new-hospital-admissions. (CDC, May 24, 2021b).
Centers for Disease Control and Prevention (CDC). (2021c, May 24). 
Variant Proportions. https://covid.cdc.gov/covid-data-tracker/#variant-proportions. (CDC, May 24, 2021c).
Centers for Disease Control and Prevention (CDC). (2021d, May 24). 
COVID-19 Weekly Deaths per 100,000 Population by Age by Age, Race/
Ethnicity, and Sex. https://covid.cdc.gov/covid-data-tracker/#demographicsovertime. (CDC, May 24, 2021d).
Dagan, N et al., (2021, February 24). BNT162b2 mRNA COVID-19 vaccine 
in a nationwide mass vaccination setting. N Engl J Med. 384(15): 
1412-1423. doi: 10.1056/NEJMoa2101765. Epub 2021 Feb 24. PMID: 
33626250; PMCID: PMC7944975. (Dagan et al., February 24, 2021).
Deepak, et al., (2021, April 7). Glucocorticoids and B Cell 
Depleting Agents Substantially Impair Immunogenicity of mRNA 
Vaccines to SARS-CoV-2. medRxiv 2021.04.05.21254656. https://doi.org/10.1101/2021.04.05.21254656. (Deepak et al., April 7, 2021).

Food and Drug Administration (FDA). (2020, December 11). Emergency 
use authorization for an unapproved product review memorandum 
(Pfizer-BioNTech COVID-19 vaccine/BNT 162b2 mRNA-1273). https://www.fda.gov/emergency-preparedness-and-response/coronavirus-disease-2019-covid-19/pfizer-biontech-covid-19-vaccine. (FDA, December 11, 
2020).
Food and Drug Administration (FDA). (2020, December 18). Emergency 
use authorization for an unapproved product review memorandum 
(Moderna COVID-19 vaccine/mRNA-1273). https://www.fda.gov/emergency-preparedness-and-response/coronavirus-disease-2019-covid-19/moderna-covid-19-vaccine. (FDA, December 18, 2020).
Food and Drug Administration (FDA). (2021, February 26). Janssen 
COVID-19 vaccine. Vaccines and Related Biological Products Advisory 
Committee, February 26, 2021 Meeting Briefing Document. https://www.fda.gov/media/146219/download. (FDA, February 26, 2021).
Gharpure, R et al., (2021, February 5). Early COVID-19 first-dose 
vaccination coverage among residents and staff members of skilled 
nursing facilities participating in the pharmacy partnership for 
long-term care program--United States, December 2020-January 2021. 
MMWR 2021; 70: 178-182. DOI: http://dx.doi.org/10.15585/mmwr.mm7005e2. (Gharpure et al., February 5, 2021).
Hall, VJ et al., (2021, April 23). COVID-19 vaccine coverage in 
health-care workers in England and effectiveness of BNT162b2 mRNA 
vaccine against infection (SIREN): A prospective, multicentre, 
cohort study. Lancet. 2021 Apr 23: S0140-6736(21)00790-X. doi: 
10.1016/S0140-6736(21)00790-X. Online ahead of print. PMID: 
33901423. (Hall et al., April 23, 2021).
Howard, J. (2021, May 22). ``Response to request for an assessment 
by the National Institute for Occupational Safety and Health, 
Centers for Disease Control and Prevention, U.S. Department of 
Health and Human Services, of the current hazards facing healthcare 
workers from Coronavirus Disease-2019 (COVID-19).'' (Howard, May 22, 
2021).
Keehner et al., (2021, May 6). SARS-CoV-2 infection after 
vaccination in health care workers in California. New England 
Journal of Medicine 384(18). (Keehner et al., May 6, 2021).
KFF. (2021, April 22). KFF COVID-19 Vaccine Monitor https://www.kff.org/coronavirus-covid-19/dashboard/kff-covid-19-vaccine-monitor-dashboard/. (KFF, April 22, 2021).
King, WC et al., (2021, April 24). COVID-19 vaccine hesitancy 
January-March 2021 among 18-64 year old US adults by employment and 
occupation. medRxiv; https://www.medrxiv.org/content/10.1101/2021.04.20.21255821v3. (King et al., April 24, 2021).
Levine-Tiefenbrun, M et al., (2021, February 8). Decreased SARS-CoV-2 viral load following vaccination. medRxiv. 2021; https://www.medrxiv.org/content/10.1101/2021.02.06.21251283v1.full.pdf. 
(Levine-Tiefenbrun, February 8, 2021).
Marks, M et al., (2021, February 2). Transmission of COVID-19 in 282 
clusters in Catalonia, Spain: A cohort study. Lancet Infect Dis. 
21(5): 629-636. doi: 10.1016/S1473-3099(20)30985-3. Epub 2021 Feb 2. 
PMID: 33545090; PMCID: PMC7906723. (Marks et al., February 2, 2021).
Pawlowski, C et al., (2021, February 27). FDA-authorized COVID-19 
vaccines are effective per real-world evidence synthesized across a 
multi-state health system. medRxiv [Preprint posted online February 
27, 2021]. https://www.medrxiv.org/content/10.1101/2021.02.15.21251623v3. (Pawlowski et al., February 27, 2021).
Roy, B et al., (2020, December 29). Health care workers' reluctance 
to take the COVID-19 vaccine: A consumer-marketing approach to 
identifying and overcoming hesitancy. https://catalyst.nejm.org/doi/full/10.1056/CAT.20.0676. (Roy et al., December 29, 2020).
Schrading, WA et al., (2021, February 19). Vaccination rates and 
acceptance of SARS-CoV-2 vaccination among U.S. emergency department 
health care personnel. Acad Emerg Med 28: 455-458. (Schrading et 
al., February 19, 2021).
Shah, ASV et al., (2021, March 21). Effect of vaccination on 
transmission of COVID-19: an observational study in healthcare 
workers and their households. medRxiv. 2021 https://www.medrxiv.org/content/10.1101/2021.03.11.21253275v1. (Shah et al., March 21, 
2021).
Swift, MD et al., (2021, April 26). Effectiveness of mRNA COVID-19 
vaccines against SARS-CoV-2 infection in a cohort of healthcare 
personnel. Clinical Infectious Diseases DOI: https://doi.org/10.1093/cid/ciab361. (Swift et al., April 26, 2021).
Tande, AJ et al., (2021, March 10). Impact of the COVID-19 Vaccine 
on asymptomatic infection among patients undergoing pre-procedural 
COVID-19 molecular screening. Clin Infect Dis. 2021 Mar 10: ciab229. 
doi: 10.1093/cid/ciab229. Epub ahead of print. PMID: 33704435; 
PMCID: PMC7989519. (Tande et al., March 10, 2021).
Teran, RA et al., (2021, April 30). Postvaccination SARS-CoV-2 
infections among skilled nursing facility residents and staff 
members--Chicago, Illinois, December 2020-March 2021. MMWR 70(17): 
632-638. (Teran et al., April 30, 2021).
Thompson, MG et al., (2021, April 2). Interim estimates of vaccine 
effectiveness of BNT162b2 and mRNA-1273 COVID-19 vaccines in 
preventing SARS-CoV-2 infection among health care personnel, first 
responders, and other essential and frontline workers--eight U.S. 
locations, December 2020-March 2021. MMWR 70: 495-500. DOI: http://dx.doi.org/10.15585/mmwr.mm7013e3. (Thompson et al., April 2, 2021).
Xie, X et al., (2021, February 8). Neutralization of SARS-CoV-2 
spike 69/70 deletion, E484K and N501Y variants by BNT162b2 vaccine 
elicited sera. Nature Medicine. DOI: https://doi.org/10.1038/s41591-021-01270-4. (Xie et al., February 8, 2021).
III. Impact on Healthcare Employees
    Data on SARS-CoV-2 infections, illnesses, and deaths among 
healthcare employees supports OSHA's finding that COVID-19 poses a 
grave danger to these employees. Even fairly brief exposure (i.e., 15 
minutes during a 24-hour period) can lead to infection, which in turn 
can cause death or serious impairment of health. Employees in 
healthcare settings include healthcare employees, who provide direct 
patient care (e.g., nurses, doctors, and emergency medical technicians 
(EMTs)), and healthcare support employees, who provide services that 
support the healthcare industry and may have contact with patients 
(e.g., janitorial/housekeeping, laundry, and food service employees). 
Employees who perform autopsies are also considered to work in 
healthcare. Most employees who work in healthcare perform duties that 
put them at elevated risk of exposure to SARS-CoV-2.
    SARS-CoV-2 is introduced into healthcare settings by infected 
patients, other members of the public, or employees. Workers in 
healthcare settings that provide treatment to patients with suspected 
or confirmed COVID-19 face a particularly elevated risk of contracting 
SARS-CoV-2 (Howard, May 22, 2021). Once the virus is introduced into 
the worksite, the virus can be transmitted from person-to-person at 
close contact through inhalation of respiratory droplets. In limited 
scenarios, it might also be transmitted through inhalation of aerosols, 
which consists of small droplets and particles that can linger in the 
air, especially in enclosed spaces with inadequate ventilation (CDC, 
May 7, 2021). Less frequently, transmission is also possible when 
someone touches a contaminated item or surface and then touches their 
nose, mouth, or eyes (CDC, April 5, 2021).
    A 2021 cross-sectional study of 6,510 healthcare employees from the 
Northwestern HCW SARS-CoV-2 Serology Cohort Study (conducted May 28-
June 30, 2020 in Illinois) shows that infections among healthcare 
workers were not limited to doctors and nurses; healthcare 
administrators had similar rates of seropositivity compared to 
physicians, and support services had the highest seroprevalence (this 
group included healthcare facility workers in

food service, environmental services, security, and patient access/
registration) (Wilkins et al., 2021). A meta-analysis published in the 
American Journal of Epidemiologists compared data from 97 separate 
studies and found evidence that COVID-19 infections were both common 
(11% of the tested cohort of healthcare employees) and spread among 
different healthcare worker occupations. In this study, however, nurses 
had the highest rate of seroprevalence while most of the COVID-19-
positive medical personnel were working in hospital nonemergency wards 
during screening (Gomez-Ochoa et al., January 2021).
    Healthcare employees who provide direct patient care are at high 
risk of exposure to SARS-CoV-2 because they have close and sometimes 
prolonged contact with patients who are infected or potentially 
infected with SARS-CoV-2. This contact occurs when conducting physical 
examinations and providing treatment and medical support. The risk can 
be amplified when examining or treating a COVID-19 patient who has 
symptoms such as coughing and difficulty breathing (leading to more 
forceful inhalation and exhalation), both of which can result in the 
release of more droplets that can be propelled further. Healthcare 
employees who conduct, or provide support during, aerosol-generating 
procedures on persons with suspected or confirmed COVID-19 also face a 
greater risk of infection (Heinzerling et al., April 17, 2020). 
Examples of procedures that can produce aerosols include intubation, 
suctioning airways, use of high-speed tools during dental work, and use 
of power saws during autopsies. A complete list of aerosol-generating 
procedures, as defined by this ETS, is included in 29 CFR 1910.502(b). 
Employees in healthcare are also at risk of exposure to SARS-CoV-2 if 
they have close contact with co-workers while providing patient care or 
performing other duties in enclosed areas such as a nursing station, 
laundry room, or kitchen. Based on the biological mechanisms of SARS-
CoV-2 transmission, there is no doubt that some employees in healthcare 
are at risk of exposure to SARS-CoV-2. Healthcare employees are 
performing some job tasks that create an expectation of exposure to 
people or human remains infected with COVID-19. The nature of caring 
for a patient known to have COVID-19 or performing on autopsy on 
someone who had COVID-19 increases the risk to employees performing 
that task.
    This section summarizes recent studies about U.S. employees in 
healthcare that illustrate the impact of COVID-19 in several types of 
settings. Because the pandemic is recent and the evidence generated is 
on the frontiers of science, studies are not available for every type 
of employee in every type of healthcare setting. The peer-reviewed 
scientific journal articles, government reports, and journal pre-print 
articles described below establish the widespread prevalence of COVID-
19 among healthcare employees. OSHA's findings are based primarily on 
the evidence from peer-reviewed scientific journal articles and 
government reports. However, peer review for scientific journal 
articles and the assembly of information for government reports and 
other official sources of information take time, and therefore those 
sources do not always reflect the most up-to-date information (Chan et 
al, December 14, 2010). This is critical in the context of the COVID-19 
pandemic, where new information is emerging daily. Therefore, OSHA has 
supplemented peer-reviewed data and government reports with additional 
information on occupational outbreaks contained in other sources of 
media (e.g., newspapers). The reported information from newspapers can 
provide further evidence of the impact of an emerging and changing 
disease, especially for certain workers in healthcare and associated 
occupations (e.g., laundry workers, janitors) that are not well 
represented in the peer-reviewed scientific literature, and assist OSHA 
in protecting these employees from the grave danger posed by 
transmission of SARS-CoV-2. OSHA did not make findings based solely on 
non-peer-reviewed sources such as pre-prints and news articles, but the 
agency found that those sources sometimes provided useful information 
when considered in context with more robust sources. Together, these 
sources of information represent the best available evidence of the 
impact on employees of the pandemic thus far.
    The peer-reviewed literature, government reports and, in a limited 
number of cases, non-peer-reviewed articles illustrate a significant 
number of infections among healthcare employees, but the types of 
workplaces or conditions described are not the only ones in which a 
grave danger exists. However, the studies add to the evidence that any 
healthcare employee is at risk of exposure if they have close contact 
with others who are suspected or confirmed to have COVID-19. The 
studies also provide evidence that once SARS-CoV-2 is introduced into 
the healthcare workplace (e.g., through an infected patient, other 
member of the public, or employee), unvaccinated employees in that 
workplace are at risk of exposure.
a. General Investigations of Workers or Workplaces
    The Washington State Department of Health and the Washington State 
Department of Labor and Industries collaborated on a report evaluating 
COVID-19 cases and their occupational history (WSDH and WLNI, November 
10, 2020). They identified 30,895 confirmed cases of COVID-19 in 
Washington State with occupational data, including healthcare settings, 
through September 13, 2020. They reported infection rates for 22 
occupational groups, and reported that healthcare and social assistance 
were among the industry sectors with the highest incidence of 
infections (WSDH and WLNI, November 10, 2020). The report states that 
some occupations increase the risk to workers of exposure to SARS-CoV-
2, but the data does not demonstrate that all the cases reported 
resulted from occupational exposure.
    These data were also used to determine how work activities were 
related to COVID-19. Zhang used information from a previous Washington 
State report with an earlier cutoff date (through June 11, 2020; 10,850 
cases) and cross-referenced it with information available from O*NET (a 
Department of Labor database that contains detailed occupational 
information for more than 900 occupations across the U.S.) to determine 
occupation-specific COVID-19 risks (Zhang, November 18, 2020). Zhang 
created a model using the O*NET descriptors and correlated it to the 
case reports from Washington State to develop a predictive model for 
COVID-19 cases. The model found that among O*NET's 57 physical and 
social factors related to work, the two predictive variables of COVID-
19 risk were frequency of exposure to diseases and physical proximity 
to other people. The author found that healthcare professions in 
general had the highest predicted risk for COVID-19. This finding 
provides additional evidence that during an active pandemic, healthcare 
employees can be exposed to a grave danger during sustained periods in 
workspaces where they are working in proximity to others, including 
patients with COVID-19.
    The Oregon Health Authority (OHA) publishes a weekly report 
detailing outbreaks directly related to work settings. OHA 
epidemiologists consider cases to be part of a workplace outbreak when 
clusters form with respect to space and time unless their

investigation uncovers an alternative source for the outbreak. In their 
May 19, 2021, COVID-19 Weekly Report, OHA reported 71 active clusters, 
including at three separate hospitals (OHA, May 19, 2021).
    In a May 21, 2021 report, the Tennessee Department of Health 
reported 238 active clusters (i.e., 2 or more confirmed cases of COVID-
19 linked by the same location of exposure or exposure event that is 
not considered a household exposure), with 6 occurring in assisted care 
facilities, 37 in nursing homes, and 3 in other healthcare settings 
(Tennessee Department of Health, May 21, 2021).
    A study on SARS-CoV-2 testing in Los Angeles from mid-September 
through October 2020 evaluated 149,957 symptomatic and asymptomatic 
positive cases associated with an occupation (Allan-Blitz et al., 
December 11, 2020). Infection rates were found to be particularly high 
for healthcare personnel and first responders.
    A Morbidity and Mortality Weekly Report (MMWRs) (a weekly 
epidemiological digest published by the CDC) reported on the 
occupational status of COVID-19 cases in Colorado. In the Colorado 
study, 1,738 COVID-19 cases from nine Colorado counties were evaluated; 
these cases occurred before the state lockdown that began on March 26, 
2020 (Marshall et al., June 30, 2020). Half of the individuals were 
exposed in a workplace setting, with the greatest number of COVID-19-
positive employees coming from healthcare (38%).
    Chen et al., (January 22, 2021) analyzed records of deaths 
occurring on or after January 1, 2016 in California and found that 
mortality rates in working aged adults (18-65 years) increased 22% 
during the COVID-19 pandemic (March through October 2020) compared to 
pre-pandemic periods. Relative to pre-pandemic periods, healthcare or 
emergency workers were one occupational group that experienced excess 
and statistically significant mortality compared to pre-pandemic 
periods (19% increase). The study authors concluded that essential work 
conducted in person is a likely avenue of infection transmission.
    Hawkins et al., (January 10, 2021) examined death certificates of 
individuals who died in Massachusetts between March 1 and July 31, 
2020. An age-adjusted mortality rate of 16.4 per 100,000 employees was 
determined from 555 death certificates that had useable occupation 
information. Employees in healthcare support, personal care services, 
and social services had particularly high mortality rates. The study 
authors noted that occupation groups expected to have frequent contact 
with sick people, close contact with the public, and jobs that are not 
practical to do from home had particularly elevated mortality rates.
    The impact of COVID-19 across diverse healthcare sectors is not 
limited to the United States. The European Centre for Disease 
Prevention and Control investigated clusters in occupational settings 
throughout Europe (ECDC, August 11, 2020). The Centre reviewed 1,376 
occupational clusters from 16 European countries from March through 
July of 2020. Indoor settings contributed to 95% of reported clusters. 
Hospitals and long-term care facilities accounted for many of the 
clusters.
References
Allan-Blitz, L et al., (2020, December 11). High frequency and 
prevalence of community-based asymptomatic SARS-CoV-2 Infection. 
medRxix. https://doi.org/10.1101/2020.12.09.20246249. (Allan-Blitz 
et al., December 11, 2020).
Centers for Disease Control and Prevention (CDC). (2021, April 5). 
Science Brief: SARS-CoV-2 and Surface (Fomite) Transmission for 
Indoor Community Environments. https://www.cdc.gov/coronavirus/2019-ncov/more/science-and-research/surface-transmission.html. (CDC, 
April 5, 2021).
Centers for Disease Control and Prevention (CDC). (2021, May 7). 
Scientific Brief: SARS-CoV-2 Transmission. https://www.cdc.gov/coronavirus/2019-ncov/more/scientific-brief-sars-cov-2.html. (CDC, 
May 7, 2021).
Chan, E et al., (2010, December 14). Global capacity for emerging 
infectious disease detection. Proceedings of the National Academy of 
Sciences of the United States of America, 107(50), 21701-21706. 
https://doi.org/10.1073/pnas.1006219107. (Chan et al, December 14, 
2010).
Chen, Y et al., (2021, January 22). Excess mortality associated with 
the COVID-19 pandemic among Californians 18-65 years of age, by 
occupational sector and occupation: March through October 2020. 
MedRxiv. doi: 10.1101/2021.01.21.21250266. (Chen et al., January 22, 
2021).
European Centre for Disease Prevention and Control (ECDC). (2020, 
August 11). COVID-19 clusters and outbreaks in occupational settings 
in the EU/EEA and the UK. (ECDC, August 11, 2020).
G[oacute]mez-Ochoa, SA et al., (2021, January). COVID-19 in health-
care workers: a living systematic review and meta-analysis of 
prevalence, risk factors, clinical characteristics, and outcomes. 
American journal of epidemiology. 2021 Jan; 190(1): 161-75. (Gomez-
Ochoa et al., January 2021).
Hawkins, D et al., (2020, December 21). COVID-19 deaths by 
occupation, Massachusetts, March 1-July 31, 2020. American Journal 
of Industrial Medicine 64(4): 238-244. DOI: 10.1002/ajim.23227. 
(Hawkins et al., December 21, 2021).
Heinzerling, A et al., (2020, April 17). Transmission of COVID-19 to 
Health Care Personnel During Exposures to a Hospitalized Patient--
Solano County, California, February 2020. MMWR Morb Mortal Wkly Rep 
2020; 69: 472-476. DOI: http://dx.doi.org/10.15585/mmwr.mm6915e5. 
(Heinzerling et al., April 17, 2020).
Howard, J. (2021, May 22). ``Response to request for an assessment 
by the National Institute for Occupational Safety and Health, 
Centers for Disease Control and Prevention, U.S. Department of 
Health and Human Services, of the current hazards facing healthcare 
workers from Coronavirus Disease-2019 (COVID-19).'' (Howard, May 22, 
2021).
Marshall, K et al., (2020, June 30). Exposure before issuance of 
stay-at-home orders among persons with laboratory-confirmed COVID-
19--Colorado, March 2020. MMWR: 69(26): 847-9. (Marshall et al., 
June 30, 2020).
Oregon Health Authority (OHA). (2021, May 19). COVID-19 weekly 
outbreak report. https://www.oregon.gov/oha/covid19/Documents/DataReports/COVID-19-Weekly-Outbreak-Report-2021-1-13-FINAL.pdf. 
(OHA, May 19, 2021).
Tennessee Department of Health. (2021, May 21). COVID-19 critical 
indicators. (Tennessee Department of Health. May 21, 2021).
Washington State Department of Health (WSDH) and Washington State 
Department of Labor and Industries (WLNI). (2020, November 10). 
COVID-19 confirmed cases by industry sector. Publication Number 421-
002. https://www.doh.wa.gov/Portals/1/Documents/1600/coronavirus/IndustrySectorReport.pdf. (WSDH and WLNI, November 10, 2020).
Wilkins, JT et al., (2021). Seroprevalence and correlates of SARS-
CoV-2 antibodies in health care workers in Chicago. Open Forum 
Infectious Diseases. 8(1): ofaa582. https://doi.org/10.1093/ofid/ofaa582. (Wilkins et al., 2021).
Zhang, M. (2020, November 18). Estimation of differential 
occupational risk of COVID-19 by comparing risk factors with case 
data by occupational group. American Journal of Industrial Medicine 
64(1):39-47. doi: 10.1002/ajim.23199. (Zhang, November 18, 2020).
b. Studies Focusing on Employees in Healthcare
General Surveillance and Surveys Across the U.S.
    Burrer et al., (2020) reported surveillance data on COVID-19 cases 
and deaths among ``healthcare personnel'' between February 12 and April 
9, 2020. ``Healthcare personnel'' were defined as ``paid and unpaid 
persons serving in healthcare settings who have the potential for 
direct or indirect exposure to patients or

infectious materials.'' \9\ Although only 16% of all surveillance forms 
indicated whether the case was healthcare personnel, 19% of the 
reported cases occurred in healthcare personnel. Twelve states 
indicated whether the case was healthcare personnel for at least 80% of 
all reported cases. An estimated 11% of COVID-19 cases from those 12 
states were healthcare personnel. Based on reported known contact with 
confirmed COVID-19 cases in the 14 days before illness onset, work 
exposures likely caused 55% of those infections. Between 8% and 10% of 
infected employees were hospitalized, 2%-5% of the infected employees 
were admitted to the ICU, and 0.3%-0.6% of those employees died.
---------------------------------------------------------------------------

    \9\ The term ``healthcare personnel'' is consistent with OSHA's 
use of the terms ``healthcare employees'' and ``healthcare workers'' 
to include healthcare support workers.
---------------------------------------------------------------------------

    CDC continues to provide general updates for COVID-19 cases and 
deaths among healthcare personnel. However, information on healthcare 
personnel status was reported for only 18.21% of total cases and death 
status reported for only 79.57% of healthcare personnel cases as of May 
24, 2021 (CDC, May 24, 2021a). CDC reports 491,816 healthcare personnel 
cases (10% of the 4,856,885 cases that included information on 
healthcare personnel status) and 1,611 fatalities (0.4% of healthcare 
employee cases) as of May 24, 2021 (CDC, May 24, 2021a). Independent 
reporting by Kaiser Health News and the Guardian in their ongoing 
investigative reporting database found 3,607 fatalities among 
healthcare personnel in the United States as of April 2021(Kaiser 
Health News and the Guardian, April 2021; February 23, 2021). The 
reporters for this effort consider even their own count--which is 
higher than the official CDC count--to be an undercount due to various 
reporting issues, such as a lack of reporting requirements for long-
term care employees for a significant portion of the initial COVID-19 
surge.
    Hartmann et al., (2020) analyzed case interview data from February 
through May 2020 to assess the burden of COVID-19 on healthcare 
employees in Los Angeles County, CA, where it is mandated that all 
positive cases be reported to the County Department of Public Health, 
and all cases are interviewed. Healthcare employees were defined as any 
person working or volunteering in healthcare settings including 
hospitals and skilled nursing facilities, medical offices, mental 
health facilities, and emergency medical services (EMS). The definition 
also includes healthcare employees providing care in non-healthcare 
settings such as schools, senior living facilities, and correctional 
facilities. Healthcare employees included both staff who interacted 
directly with patients and staff who do not provide direct clinical 
care to patients. Through May 31, 2020, 5,458 COVID-19 cases among 
healthcare employees were reported to the County Health Department, 
representing 9.6% of all cases during this time period. Of those 
healthcare employees, 46.6% worked in a long-term care setting, 27.7% 
worked in a hospital, and 6.9% worked in medical offices. Healthcare 
employees from all other settings represented less than 4% of total 
healthcare employee cases. Nurses represented 49.4% of all healthcare 
employee cases; no other group of healthcare employees represented more 
than 6% of the total reported healthcare employee cases. Of note is 
that some healthcare associated employees who are expected to have less 
close contact with patients represented a greater percentage of cases 
than some healthcare employee that are expected to have close and 
direct patient contact. For example, employees in administration 
(4.3%), environmental services (3.2%), and food services (2.9%) 
represented a higher percentage of infected healthcare employees than 
physicians (2.7%). When asked about known exposures, 44% of those who 
tested positive reported exposure to a COVID-19-positive patient or co-
worker in their health facility, 11% reported exposure to a COVID-19-
positive friend or family member or recent travel, and 45.1% had 
unknown exposures. At the time of the interviews, 5.3% of COVID-19-
positive healthcare employees in Los Angeles County reported requiring 
hospitalization because of COVID-19, and as of May 31, 2020 there were 
40 (0.7%) deaths.
    Fell et al., (October 30, 2020) reviewed exposure and infection 
data for healthcare personnel in Minnesota between March and July of 
2020. After the first confirmed case of COVID-19 in Minnesota (on March 
6, 2020), the Minnesota Department of Health (MDH) requested that 
healthcare facilities provide a list of exposed healthcare personnel. 
Healthcare personnel included EMS personnel, nurses/nursing assistants, 
physicians, technicians, therapists, phlebotomists, pharmacists, 
students and trainees, contractors, and those who do not provide direct 
patient care but could be exposed to infectious agents in a healthcare 
setting (e.g., clerical, food services, environmental services, 
laundry, security, engineering and facilities management, 
administrative, billing, and volunteer personnel). Cases in laboratory 
personnel are also reported. The facilities were asked to determine if 
each exposure was high-risk, defined as when the healthcare personnel 
has close, prolonged contact with a confirmed COVID-19 case or their 
secretions/excretions while not wearing PPE, or close, prolonged 
contact with persons with COVID-19 in their household or community. MDH 
and the 1,217 participating healthcare facilities assessed 17,200 
healthcare personnel for 21,406 exposures to COVID-19 cases, of which 
5,374 (25%) were classified as higher-risk. It was reported that 373 of 
5,374 personnel (6.9%) with high-risk exposures tested positive for 
COVID-19 within 14 days of the exposure. The report stated that only 
symptomatic personnel were encouraged to get tested for COVID-19, and 
therefore it is possible that asymptomatic cases occurred and were not 
detected. Of those 373 personnel who tested positive for COVID-19, 242 
were exposed to a patient, resident of a congregate setting, in a 
congregate setting outbreak, or to another healthcare personnel. 
Twenty-one percent of exposures to a confirmed COVID-19 case took place 
in acute or ambulatory care settings, 24% of exposures were to 
residents in congregate living or long-term care settings, and 25% of 
exposures were in congregate setting outbreaks. An additional 25% of 
exposures to confirmed COVID-19 cases were exposures to co-workers, and 
5% were exposures to household/social contacts.
    The Fell study (October 30, 2020) also demonstrated that high risk 
exposures can occur to healthcare employees in positions throughout the 
healthcare facility. Available data for 4,669 (87%) of the higher risk 
exposures in the Fell et al., study indicated that the highest 
percentages of high-risk exposures were in nursing assistants or 
patient care aides (1,857; 40%) and nursing staff (1,416; 30%). The 
proportion of high-risk exposures represented by personnel such as 
administrators (247; 5%) and environmental services staff (155; 3%) 
were similar to those reported by medical providers, such as physicians 
or nurse practitioners (220; 5%). Healthcare personnel working in 
congregate living or long-term care settings, including skilled 
nursing, assisted living, and group home facilities, were more likely 
to receive a positive COVID-19 test result within 14 days of a higher-
risk exposure than were healthcare personnel working in acute care 
settings. The study authors note the

potential for employee transmission by cautioning that, in contrast to 
the recognized risk associated with patient care, healthcare employees 
might have failed to recognize the risk associated with interacting 
with co-workers in areas such as breakrooms and nursing stations. 
Physical distancing and PPE may therefore not have been used as 
consistently in those situations.
    The authors of a different study concluded that nurses and EMTs 
were, respectively, 26% and 33% more likely to contract COVID-19 than 
attending physicians. Nurses and EMTs' job duties require more intense, 
close contact with patients compared to physicians, as well as higher 
frequency and duration of patient contact. Firew et al., (October 21, 
2020) conducted a cross-sectional survey of healthcare employees in May 
of 2020 across 48 states, the District of Columbia, and U.S. 
territories. The 2,040 respondents who completed at least 80% of the 
survey were included in the study. Among included participants, 31.1% 
were attending physicians, 26.8% were nurses, 13% were EMTs, 8.82% were 
resident physicians or fellows, 3.97% were physician assistants, and 
16.32% were other healthcare employees. A total of 598 respondents 
(29.3%) reported SARS-CoV-2 infections.
    In a prospective study of over 2 million community members and 
99,795 frontline healthcare workers that was performed in the U.S. and 
UK from March through April 2020, healthcare workers were 3.4 times as 
likely to self-report a positive COVID-19 test as the general public, 
after adjusting for the increased likelihood of healthcare personnel 
receiving a COVID-19 test (Nguyen et al., 2020). In the U.S. alone, 
healthcare workers were almost two times more likely to report a 
positive test after adjusting for greater likelihood of testing.
Detection of SARS-CoV-2 in Healthcare Employees
    OSHA reviewed a number of studies that included hospital employees. 
Many hospitals provide short-term and/or long-term care for COVID-19 
patients who have symptoms that are severe enough to require 
hospitalization. Therefore, close contact with COVID-19 patients is 
expected in hospital settings, putting hospital employees at risk of 
developing COVID-19. Examples of employees who work in hospitals 
include healthcare practitioners, who generally have either licensure 
or credentialing requirements (e.g., doctors, nurses, pharmacists, 
physical therapists, massage therapists) for the purpose of promoting, 
maintaining, monitoring, or restoring health. Individuals who provide 
healthcare support services also work at hospitals. Examples of 
employees who provide healthcare support services and may have close 
contact with COVID-19 patients in some circumstances include patient 
intake/admission, patient food services, chaplain services, equipment 
and facility maintenance, housekeeping services, healthcare laundry 
services, and medical waste handling services. As noted above, hospital 
employees are at risk from close contact with patients.
    Some of the studies reviewed below were done in employees of 
healthcare systems that included both hospitals and ambulatory care 
centers such as physician offices, medical clinics (including urgent 
care and retail-based clinics), outpatient surgical centers, and 
outpatient cancer treatment centers. Although this ETS does not cover 
non-hospital ambulatory care settings where all non-employees are 
screened prior to entry and people with suspected or confirmed COVID-19 
are not permitted to enter, it was not possible to separate out results 
for hospital versus ambulatory care employees. Also it is not known to 
what extent those ambulatory care centers in the studies reviewed by 
OSHA performed screening to identify suspected or confirmed COVID-19. 
Risk of exposure and transmission of SARS-CoV-2 is expected to be lower 
in ambulatory healthcare settings that perform screening to exclude 
persons with suspected or confirmed COVID-19. However some types of 
ambulatory medical facilities (e.g., family practice; pediatrics 
clinic; urgent care) may choose to test patients for COVID-19 or 
examine and treat COVID-19 patients on site. Therefore, healthcare 
employees and healthcare support employees in some ambulatory care 
centers who do not conduct health screening to identify and exclude 
suspected or confirmed COVID-19 patients are at risk of infection due 
to close contact with patients who could potentially have COVID-19.
    Barrett et al., (2020) conducted a prospective cohort study of 
healthcare employees and non-healthcare employees with no known 
previous SARS-CoV-2 infection who were recruited and tested for SARS-
CoV-2 from March 24 through April 7, 2020 at Rutgers University and two 
of its affiliated university hospitals in New Jersey. As of July 2020, 
New Jersey was one of the hardest hit areas, with less than 3% of the 
U.S. population but 8.5% of all known U.S. cases. Healthcare employees 
were defined as individuals who worked at least 20 hours per week in a 
hospital, had occupations with regular patient contact, and were 
expected to have contact with at least three patients per shift over 
the following three months. Occupations included residents, fellows, 
attending physicians, dentists, nurse practitioners, physician 
assistants, registered nurses, technicians, respiratory therapists, and 
physical therapists. Non-healthcare employees included faculty, staff, 
trainees, or students working at Rutgers for at least 20 hours a week 
and who had no patient contact. The study reported that 7.3% of 
healthcare employees (40 of 546) and 0.4% of non-healthcare employees 
(1 of 283) tested positive for SARS-CoV-2 infection. Even after the 
authors conducted sensitivity analyses to exclude individuals with 
symptoms at baseline and those who had exposure to someone with COVID-
19 or COVID-19 symptoms outside of work, differences between infection 
rates in healthcare employees and non-healthcare employees continued to 
be observed. OSHA finds this suggests that healthcare employees were 
more likely than non-healthcare employees to have developed COVID-19 
from a workplace exposure during the early months of the pandemic in 
the United States. The study authors concluded that the potential for 
workplace exposure is further supported by the fact that only 8% of 
infected study subjects reported contact with someone having COVID-19 
symptoms outside of work. In addition, higher rates of infection were 
observed in healthcare employees who worked in the hospital that had 
more COVID-19 patients and was located in the community that had higher 
rates of SARS-CoV-2 infections. The study authors noted that because 
that hospital was overwhelmed, it was not always possible to separate 
COVID-19 vs. non-COVID-19 patients, which may have led to additional 
exposures among staff. Among healthcare employees, nurses had the 
highest rate of observed infections (11.1% tested positive), and 
attending physicians had the lowest rate of observed infection (1.8% 
positive). Resident and fellow physicians had a 3.1% positivity rate 
and other groups of healthcare employees had a 9% positivity rate. 
Increased risk of infection was associated with spending greater 
proportions of work time in patients' rooms and higher reported 
exposures to patients with suspected or diagnosed COVID-19.
    Mani et al., (November 15, 2020) reported results from SARS-CoV-2 
testing of 3,477 symptomatic employees in the University of Washington

Medical system and its affiliated organizations in Seattle, WA, between 
March 12 and April 23, 2020. During that period, 185 (5.3%) employees 
tested positive. Prevalence (i.e., proportion) of SARS-CoV-2 in 
frontline healthcare employees (those with face-to-face contact with 
patients) was 5.2% and prevalence in non-frontline staff was 5.5%. Some 
staff who were asymptomatic also underwent screening as part of 
outbreak investigations, and 9 of 151 (6%) tested positive. When 
findings from symptomatic and asymptomatic staff were combined, SARS-
CoV-2 prevalence was 5.3% in frontline healthcare employees and 5.3% 
among all employees. Of the 174 employees who tested positive and were 
followed, six (3.2%) reported COVID-related hospitalization, and one 
employee was admitted to the ICU. No deaths were reported. The study 
authors suspected that community transmission likely played a major 
role in infection among healthcare employees early in the local 
epidemic and that similar percentages of infections in frontline and 
non-frontline healthcare employees support the PPE protocols 
implemented for frontline workers at the institution. In addition, 
positive cases were likely underestimated due to the focus on testing 
symptomatic employees.
    Vahidy et al., (2020) studied asymptomatic infection rates among 
staff from a medical center consisting of seven hospitals in Texas and 
members of the surrounding community in March through April of 2020. 
Healthcare jobs with possible exposure to COVID-19 patients were 
classified into five categories, with varying levels of patient 
exposure: (1) Nursing (e.g., nurses/nurses aids, emergency medical 
technicians), (2) clinicians (e.g., physicians, nurse practitioners), 
(3) allied healthcare workers (e.g., therapists, social workers), (4) 
support staff (e.g., security, housekeeping), and (5) administrative or 
research staff (e.g., managers, research assistants). A total of 2,872 
asymptomatic individuals, including 2,787 healthcare personnel and 85 
community residents, were tested for SARS-CoV-2 infection. Among the 
healthcare personnel tested, the prevalence of SARS-CoV-2 infection was 
5.4% among the 1,992 patient-facing staff treating COVID-19 patients 
and 0.6% among the 625 patient-facing staff not treating COVID-19 
patients. No cases were seen among the 170 nonclinical healthcare staff 
that did not interact with patients or in the 85 community residents 
(Vahidy et al., 2020). The nonclinical healthcare staff worked in 
buildings with separate heating, ventilation, and air conditioning 
systems, and with lower population density because of remote work when 
compared to clinical healthcare staff. In the different healthcare 
categories that cared for COVID-19 patients, prevalence of infection 
ranged from 3.6% to 6.5%, with no significant differences in the 
different categories of healthcare workers. Therefore, the study 
indicates that healthcare workers providing both direct and indirect 
care to COVID-19 patients are at risk.
    Nagler et al., (June 28, 2020), reported the results of SARS-CoV-2 
testing in employees from the New York Langone Health system, an 
academic medical center encompassing four hospital campuses and over 
250 ambulatory sites, with approximately 43,000 employees. Between 
March 25 and May 18, 2020, the health system tested employees who were 
symptomatic (4,150), were asymptomatic but exposed to COVID-19 (4,362), 
and asymptomatic employees who were returning to work after their 
services had been suspended during the peak of the epidemic (6,234). 
Among symptomatic employees, the COVID-19 positivity rate across the 
duration of the study was 33%. Among asymptomatic employees with self-
reported exposure, the COVID-19 positivity rate was 8%. In asymptomatic 
employees returning to work, COVID-19 positivity rate was 3%. In all 
groups, the positivity rate in the first week of testing was 
substantially higher than in the last week of testing, which occurred 
more than a month after the first week. The study authors noted a 
temporal correlation of COVID-19 case declines in healthcare employees 
and the community, despite continued workplace exposure, and suggested 
that infections in healthcare employees may reflect importance of 
community transmission and efficacy of stringent infection control and 
PPE standards that remained largely unchanged since the start of the 
pandemic in March 2020. OSHA finds that the study demonstrates the 
potential for COVID-19 to be introduced into the workplace from 
uncontrolled community spread and that the effective use of infection 
control practices and PPE most likely prevented transmission to 
healthcare employees.
    Misra-Hebert et al., (September 1, 2020) conducted a retrospective 
cohort study to obtain data on rates of COVID-19 and risk factors for 
severe disease in healthcare employees and non-healthcare employees 
(neither category defined) who were tested for SARS-CoV-2, and listed 
in a registry at the Cleveland Clinic Health System, between March 8 
and June 9, 2020. The data was drawn from healthcare employees from 
different segments of the country. Ninety percent of the healthcare 
employees and 75% of non-healthcare employees were from Ohio, and the 
remainder were from Florida. Although more healthcare employees than 
non-healthcare employees reported exposures to COVID-19 (72% vs. 17%), 
similar, and not significantly different, proportions of employees 
tested positive for COVID-19 in each group: 9% (551/6145) of healthcare 
employees and 6.5% (4353/66,764) of non-healthcare employees. OSHA 
finds it difficult to draw conclusions regarding this finding because 
the nature of the exposure (e.g., whether it was at close contact) was 
not explained. In fact, patient-facing healthcare employees (those 
having direct contact with patients) were 1.6 times more likely than 
non-patient-facing healthcare employees to test positive. The study 
authors suggested that the finding represents an increased risk of 
infection with work exposure, however they were not able to confirm if 
the exposure occurred 14 days prior to testing or if PPE was worn 
during the exposure. Positive cases peaked in early-to-mid April for 
both healthcare employees and non-healthcare employees (16% and 12%, 
respectively, as estimated from figure 2 of the study), and then 
decreased concurrently with the implementation of preventive measures, 
such as masking and physical distancing, over the course of the study. 
Of those who tested positive, 6.9% of healthcare employees and 27.7% of 
non-healthcare employees were hospitalized, and 1.8% and 10.8% 
respectively, were admitted to the intensive care unit. The study noted 
that the lower rates of hospitalization for the healthcare employee 
group could be explained on the basis that the healthcare employee 
population was younger and had fewer co-morbidities.
Serology Testing in Employees in Hospitals.
    Although most of the studies described in this section relied on 
polymerase chain reaction (PCR) tests to detect cases of COVID-19, a 
number of studies conducted serology testing to determine how many 
individuals had been infected by the SARS-CoV-2 virus in the past. 
Serology tests determine if antibodies that respond to the SARS-CoV-2 
virus are present in samples of blood serum. Seroprevalence is the 
percentage of individuals in a population who have antibodies. Terms 
such as seropositive or seroconversion are often used to describe 
persons who have tested positive for the SARS-CoV-2 antibody. Most of 
the serology tests

conducted looked at a type of antibody known as Immunoglobulin G (IgG). 
Seroprevalence studies provide a more complete picture of how many 
individuals in a population may have been infected because many 
individuals who were infected were not tested for current infections 
for reasons such as lack of symptoms and lack of available testing. 
Indeed, many individuals who were asymptomatic may be unaware that they 
were exposed to SARS-CoV-2 or had COVID-19 (CDC, July 6, 2020). The 
studies described below were conducted before vaccination began, and it 
is therefore unlikely that the studies are detecting antibodies 
produced as a result of vaccination.
    Venugopal et al., (2020) conducted a cross-sectional study of 
healthcare employees across all hospital services (including 
physicians, nurses, ancillary services, and ``others'') who worked at a 
level one trauma center in the South Bronx, NY between March 1 and May 
1, 2020. The period of analysis included the first few weeks of March, 
when New York City experienced a surge of infections that resulted in 
strained resources and supplies such as PPE. This hospital was so 
highly impacted that it was considered ``the epicenter of the 
epicenter.'' Participants were tested for IgG antibodies. They were 
also tested for SARS-CoV-2. Of the 500 out of 659 healthcare employees 
who completed serology testing, 137 (27%) were positive for SARS-CoV-2 
IgG antibodies. Seroprevalence was similar across the different types 
of healthcare employees (25% to 28%). The study authors indicated that 
seroprevalence in healthcare employees was higher than in the 
community, and that seroprevalence likely reflected healthcare and 
community exposures.
    Sims et al., (November 5, 2020) conducted a prospective cohort 
serology study at Beaumont Health, which includes eight hospitals 
across the Detroit, MI metropolitan area. In April of 2020, during the 
peak of the pandemic's first wave, Michigan had the third highest 
number of cases in the U.S. and most cases were in the Detroit 
metropolitan area. All 43,000 hospital employees were invited to 
participate and seroprevalence was analyzed in 20,614 of them between 
April 13 and May 28, 2020. A total of 1,818 (8.8%) of participants were 
seropositive. However, when separated according to employees working at 
home (n=1,868) versus working in their normal manner, employees working 
at home were significantly less likely to be seropositive (5.6%) than 
those going into work (9.1%). The authors speculated that the 
seropositivity level for employees working at home was representative 
of the population sheltering at home and only leaving home when 
necessary. Participants involved with direct patient care had a higher 
seropositive rate (9.5%) than those who were not (7%). Healthcare 
employees with frequent patient contact (phlebotomy, respiratory 
therapy, and nursing) had a significantly higher seropositive rate 
(11%) than those with intermittent patient contact (physicians or 
clinical roles such as physical therapists, radiology technicians, 
etc.), who on average had a seropositive rate of 7.4%. The study 
authors speculated that the differences in these two groups may have 
been based on differences in both duration and proximity of exposure to 
patients. Another notable observation is that support personnel such as 
facilities/security and administrative support employees had 
seropositivity rates of approximately 7% to 8%, which were similar to 
rates in physicians (values estimated from Figure 2B). Participants 
reporting frequent contact with either 1) non-COVID-19 patients, or 2) 
physicians or nurses but not patients, had higher rates of 
seropositivity (7.6%) than those reporting no significant contact with 
patients, physicians, or nurses (but who handled patient samples) 
(6.5%).
    Moscola et al., (September 1, 2020) reported the prevalence of 
SARS-CoV-2 antibodies in healthcare employees from the Northwell Health 
System in the greater New York City area. The healthcare employees were 
offered free, voluntary testing at each of the system's 52 sites 
between April 20 and June 23, 2020. The analysis included 40,329 of the 
system's 70,812 employees and found that 5,523 (13.7%) were 
seropositive. The prevalence of SARS-CoV-2 antibodies was similar to 
that found in randomly-tested adults in New York State at that time 
(14%). Analysis of seropositivity by job type reported the highest 
levels of seropositivity (20.9%) in service maintenance staff 
(including housekeepers, groundskeepers, medical assistants, and 21 
others), followed by 13.1% in nurses, 12.6% in administrative and 
clerical staff (including non-clinical professionals such as employees 
in information technology, human resources, medical records, and 
billing); 11.6% in allied health professionals (including clinical 
professionals such as physician assistants, physical therapists/
occupational therapists, social workers, mental health professionals, 
pharmacists, and laboratory technicians), and 8.7% in physicians. 
Seropositivity rates were highest in employees from the emergency 
department and non-ICU hospital units (approximately 17% each), 
followed by ``other'' non-specified areas (12.1%), and ICUs (9.9%).
    Wilkins et al., (2021) conducted a cross-sectional study to examine 
seropositivity rates in 6,510 healthcare workers from a Chicago 
healthcare system consisting of hospitals, immediate care centers, and 
outpatient practices. Blood samples were collected through July 8, 
2020. The study authors then compared the seropositivity rate of 
different occupational groups of workers, using administrators as the 
referent group to reflect exposure consistent with non-healthcare 
workers. Overall seropositivity for all study participants was 4.8%. 
Before adjusting for demographics and self-reported out-of-hospital 
exposure to COVID-19, the study found that a number of healthcare 
occupations had a higher crude prevalence rate than the administrator 
group, including: 10.4% for support service healthcare workers; 10.1% 
for medical assistants; 9.3% for respiratory technicians; 7.6% for 
nurses; and 3.8% for administrators. After adjustment for demographics 
and self-reported out-of-hospital exposure to COVID-19, the only type 
of healthcare workers that continued to be significantly more likely to 
be seropositive than administrators were nurses, who were 1.9 times 
more likely to be seropositive. The study authors concluded that the 
higher work-related risk in nurses likely occurred as a result of 
frequent and close contact with patients. The study also compared 
seropositivity rates for different occupational tasks and found that 
adjusted seropositivity rates were higher for workers participating in 
the care of COVID-19 patients when compared with those who did not 
report participating in the care of COVID-19 patients. Being exposed to 
patients receiving high-flow oxygen therapy and hemodialysis was 
significantly associated with 45% and 57% higher odds for seropositive 
status, respectively.
Comparison of Healthcare Worker Serology and the Surrounding Community
    Although some serology studies suggest that infections are more 
correlated to community transmission than job designation (Jacob et 
al., March 10, 2021; Carter et al., May 2021), these studies do not 
undermine the robust evidence that healthcare employees with potential 
workplace exposure to patients with suspected or confirmed COVID-19 are 
exposed to an elevated risk of contracting COVID-19 compared

to the general population. Carter et al., (May 2021) found that 
healthcare worker infection rates varied from region to region, noting 
the importance of community transmission as a factor in infection 
rates. In Jacob et al., (March 10, 2021), health care workers' serology 
results were compared to residence location, job designation, and other 
characteristics to identify risk factors. The study authors found that 
community transmission was a significant factor in acquiring 
infections, but were not able to tie in any specific job designation 
resulting in increases in infection risk. The authors note, however, 
that the study did not show that workplace exposures did not increase 
risk; rather it showed that the levels of community transmission 
observed may be a greater driver of transmission. It should also be 
noted that the non-pharmaceutical interventions for each job 
classification are different, so a direct comparison of non-clinical 
and clinical personnel may result in conclusions with limited 
application.
    One might expect that a full shift with fully and properly 
implemented non-pharmaceutical interventions should result in lower 
infection rates. This appeared evident in a study comparing infection 
rates between first and second COVID-19 outbreak surges in Norway 
(Magnusson et al., January 6, 2021). For instance, during the first 
wave from February 26, 2020 to July 17, 2020, nurses were almost three 
times more likely to be infected than those in a similar age range (20 
to 70 years old). However, during the second wave from July 18, 2020 to 
December 18, 2020, infection rates for nurses were largely 
indistinguishable from the population at large of a similar age. The 
authors suggested that the decrease in the odds ratio was potentially 
due to the implementation of appropriate infection control practices 
that were previously lacking.
Studies Examining Risks After Known Exposures
    Heinzerling et al., (April 17, 2020) examined the development of 
COVID-19 in 120 healthcare employees who were unknowingly exposed to a 
patient with COVID-19. The patient was later identified as one of the 
first U.S. community cases of COVID-19, and Heinzerling et al., (April 
17, 2020) concluded that the ``investigation presented a unique 
opportunity to analyze exposures associated with SARS-CoV-2 
transmission in a healthcare setting without recognized community 
exposures.'' Of the 120 healthcare employees who were exposed, 43 
developed symptoms within 14 days of exposure and were tested for 
COVID-19. Three of those employees (7% of those tested) were positive 
for COVID-19. Although those three employees represent 2.5% of the 
total exposed, it is possible that more employees might have developed 
COVID-19 because asymptomatic employees were not tested. The healthcare 
employees who became infected, when compared to those who were not 
infected, were more commonly present during two aerosol-generating 
procedures (nebulizer treatment (67% vs. 9%) and non-invasive 
ventilation (67% vs. 12%); more commonly performed physical 
examinations of the patient (100% vs. 24%); and were exposed to the 
patient for longer durations of time (median 120 minutes vs. 25 
minutes). None of the exposed healthcare employees had been wearing the 
complete set of PPE recommended for contact with COVID-19 patients.
Long-Term Care Facilities
    Long-term care facilities include nursing homes, skilled nursing 
facilities, and assisted living facilities. They provide both medical 
and personal care services to people unable to live independently. 
Because long-term care facilities are a congregate living situation, 
infections such as COVID-19 can spread rapidly between patients or 
residents and the healthcare staff who care for them. Therefore, 
employees who work at these facilities have an elevated risk of 
exposure and infection. Like employees who work at hospitals, employees 
who work at long-term care facilities include both healthcare 
practitioners, who may have direct and close contact with patients and 
residents, as well as healthcare support staff who could also be 
exposed to patients and residents. See the section on ``Detection of 
SARS-CoV-2 in Healthcare Employees'' above for a description of the 
types of employees who may work at these facilities.
    McMichael et al., (March 27, 2020) investigated a COVID-19 outbreak 
affecting patients, employees, and visitors at a long-term care 
facility in King County, Washington in February of 2020. SARS-CoV-2 
infections were identified in 129 persons, including 81 residents, 34 
of 170 staff (20%), and 14 visitors. None of the employees died, but 2 
of the 34 infected employees (5.9%) had symptoms severe enough to 
require hospitalization. The median age of the employees was 42.5 years 
(range 22-79 years). Job titles reported for the employees that were 
infected included physical therapist, occupational therapist assistant, 
environmental care worker, nurse, certified nursing assistant, health 
information officer, physician, and case manager. The study authors 
noted that infection prevention procedures at the facility were 
insufficient, and they concluded that introduction of SARS-CoV-2 into 
long-term care facilities will result in high attack rates among 
residents, staff, and visitors.
    Weil et al., (September 1, 2020) reported a cross-sectional study 
of skilled nursing facilities in the Seattle area between March 29 and 
May 13, 2020. Testing was performed by Public Health of Seattle and 
King County (testing of both residents and staff) or the Seattle Flu 
Study (testing of only employees). The authors described the period of 
the study to be at the peak of the pandemic, but the skilled nursing 
facilities were not experiencing outbreaks at the time of the study. 
Testing of employees for SARS-CoV-2 was voluntary, and 1,583 employees 
at 16 skilled nursing facilities were tested. Eleven of the 16 skilled 
nursing facilities had at least one resident or employee who tested 
positive. Forty-six (2.9%) employees had positive or inconclusive 
testing for SARS-CoV-2. Of 1208 residents tested, 110 (9.1%) were 
positive. Study authors noted shortages in PPE.
    Yi et al., (September 7, 2020) evaluated surveillance data on 
COVID-19 for assisted living facilities in 39 states (representing 44% 
of the total long-term care facilities in the U.S.). The states began 
reporting data at various periods ranging from February 27 to April 30, 
2020. As of October 15, 2020, 6,440 of 28,623 (22%) assisted living 
facilities had at least one COVID-19 case among residents or staff 
(ranging from 1.3% of assisted living facilities in Iowa to 92.8% of 
assisted living facilities in Connecticut). In 22 states, 17,799 cases 
of COVID-19 were reported in staff (total number of staff not 
specified). In 9 states, 46 of 7,128 (0.6%) employees with COVID-19 
died.
    Bagchi et al., (2021) reported on the CDC's National Healthcare 
Safety Network (NHSN) surveillance of nursing homes, which began on 
April 26, 2020. As of May 25, 2020, the Centers for Medicare & Medicaid 
Services (CMS) began requiring nursing homes to report COVID-19 cases 
in residents and staff. The authors analyzed data in residents, nursing 
home staff, and facility personnel that was reported from May 25 
through November 22, 2020 in all 50 states, the District of Columbia, 
Guam, and Puerto Rico. Staff members and facility personnel were 
defined as ``all persons working or volunteering in the facility, 
including contractors,

temporary staff members, resident caregivers, and staff members who 
might work at multiple facilities.'' The study authors reported that 
``case count data were aggregated weekly, and resident-weeks were 
calculated as the total number of occupied beds on the day data were 
reported.'' Data on number of staff members employed were not 
collected, and therefore ``resident weeks'' was used as ``a closest 
best estimate of the at-risk denominator for staff members.'' The study 
authors indicated that ``cases per 1,000 resident-week were calculated 
for residents and staff members using the number of COVID-19 cases 
reported in a week over the corresponding 1,000 resident-weeks.'' 
COVID-19 cases in staff members increased during June and July (10.9 
cases per 1,000 resident-weeks reported in the week of July 26); 
declined during August and September (6.3 per 1,000 resident-weeks in 
the week of September 13); and increased again by late November (21.3 
cases per 1,000 resident-weeks in the week of November 22). The study 
authors noted that COVID-19 rates among nursing home staff followed 
similar trends in nursing home residents and the surrounding 
communities, thereby indicating a possible association between COVID-19 
rates in nursing homes and nearby communities.
    Terebuh et al., (September 20, 2020) investigated COVID-19 clusters 
in 45 congregate living facilities in Ohio, from March 7 to May 15, 
2020. Most of the facilities investigated were healthcare worksites. 
More than half of the clusters occurred at medical facilities (51% at 
nursing homes, 11% at assisted living facilities, 7% at treatment 
facilities, and 2% at intermediate care facilities). The remaining 
clusters occurred at corrections facilities (7%), group homes (20%), 
and shelters (2%). Of the combined 598 residents and healthcare 
employees who were either confirmed to have COVID-19 or identified as a 
probable case based on symptoms and close contact with a confirmed 
case, healthcare employees represented 167 (28%) of the confirmed and 
37 (6%) of the probable cases of COVID-19. None of the healthcare 
employees died. The study authors were able to identify the index case 
in 25 of the clusters, and 88% of the index cases were determined to be 
healthcare employees.
Studies Focusing on Healthcare Support Services
    Healthcare support services employees, such as personnel that 
provide food, laundry, or waste-handling services, are at risk of 
exposure to patients with SARS-CoV-2 and contracting COVID-19. 
Employees who provide healthcare support services usually have less 
direct contact with patients, but they can have close contact with 
COVID-19 patients or contaminated materials when performing tasks such 
as cleaning patient rooms, removing waste or dirty laundry from patient 
rooms, delivering food and picking up used food trays and utensils, or 
repairing equipment in the patient's room. In addition, healthcare 
support employees can have close and prolonged contact with their co-
workers while performing their duties.
    One study discussed above (Sims et al., November 5, 2020), shows an 
infection rate among healthcare support services employees that is 
similar to healthcare employees, such as physicians, who have some 
patient contact. As noted, support personnel such as facilities/
security and administrative support employees had seropositivity rates 
of approximately 7% to 8%, which were similar to rates in physicians 
(values estimated from Figure 2B). Both healthcare support employees 
and physicians had seropositivity rates that were higher than the rates 
among employees working from home.
    Hale and Dayot (2020) examined an outbreak of COVID-19 among food 
service employees that occurred in an academic medical center before 
masking and physical distancing requirements were implemented. After an 
employee in the food and nutrition department tested positive, 280 
asymptomatic staff were tested. The entire food and nutrition 
department that was actively working was considered exposed because 
employees shared a common locker room and break area. Therefore, 
testing was not limited to employees who worked near the index case as 
part of their duties. Ten staff members in the department (including 
the index case) tested positive during the investigation. At least 
seven of the cases were thought to result from transmission from the 
index case.
    Outbreaks for support services have not been well documented and 
may be encapsulated with incidents for the entire hospital. Local 
newspaper reports have identified potential incidents in laundry 
facilities that handle linens contaminated with SARS-CoV-2. In a New 
Jersey unionized laundry facility, representatives noted that eight 
employees had been infected with SARS-CoV-2 and demanded improvements 
in infectious disease control implementation (Davalos, December 21, 
2020). In Canada, a Regina hospital laundry plant was connected with an 
18-employee outbreak (Martin, August 10, 2020). The cause of the 
outbreak was not determined.
Emergency Medical Services (EMS)
    A limited number of studies have examined the impact of COVID-19 on 
employees who provide EMS (e.g., EMTs, paramedics), who are considered 
healthcare personnel under this standard. The studies that address EMS 
often address personnel such as EMTs along with other types of 
emergency responders such as firefighters, who are not considered 
healthcare personnel under this standard. EMTs and similar occupations, 
such as paramedics, have close contact with patients who are or could 
be infected with SARS-CoV-2 when they provide medical care or transport 
those patients. The medical care they provide includes intubation and 
cardiopulmonary resuscitation, which could generate aerosols and put 
them at particularly high risk when performing those procedures on 
someone with confirmed or suspected COVID-19.
    Prezant et al., (2020) reviewed paid medical leave data for EMS 
providers and firefighters using New York City fire department 
electronic medical records from October 1, 2017 through May 31, 2020. 
The study authors found that as of May 31, 2020, 1,792 of 4,408 EMS 
providers (40.7%) had been on leave for suspected or confirmed COVID-
19. When compared with the medical leave data from before the 
pandemic--including months during influenza periods in prior years--the 
authors found that medical leave for EMS providers was 6.8% above 
baseline in March 2020 and peaked at 19.3% above baseline in April 
2020. The authors determined that COVID-19 was responsible for this 
increase. The medical leave levels for EMS providers were above those 
for firefighters. Among firefighters, the data showed that 34.5% had 
been on leave for suspected or confirmed COVID-19 as of May 31, 2020, 
and there was a peak in medical leave at 13.0% above baseline in April 
2020. A total of 66 (1.2%) firefighters and EMS providers with COVID-19 
were hospitalized and 4 died. Despite EMS providers having been given 
the same PPE (not further specified) as firefighters, EMS providers had 
higher rates of COVID-19. The study authors concluded that higher rates 
in EMS providers were attributable to greater exposure to COVID-19 
patients while administering medical care.
    Weiden et al., (January 25, 2021) investigated risk factors for 
SARS-CoV-2 infection and severe disease (hospitalization or death) in 
New York City first responders (EMS and

firefighters) from March 1 through May 31, 2020, based on medical 
records. The study had a total of 14,290 participants (3,501 EMS 
personnel and 10,789 firefighters). From March 1 to May 31, 2020, 9,115 
(63.8%) responders had no COVID-19 diagnosis, 5,175 (36.2%) were 
confirmed or suspected COVID-19 cases, and 62 (0.4%) were hospitalized. 
Three participants died in a hospital, and one died at home. 
Researchers found that EMS respondents had more cases of severe COVID-
19 than firefighters (42/3501 [1.2%] vs. 21/10,789 [0.19%]). The SARS-
CoV-2 infection rate among New York City first responders overall was 
15 times the New York City rate. EMS personnel had a 4-fold greater 
risk of severe disease and 26% increased risk of confirmed COVID-19 
cases when compared with firefighters. Both firefighters and EMS 
personnel responded to the pandemic-related emergency medical calls and 
followed the same PPE protocols. However, EMS personnel had greater 
COVID-19 exposure than firefighters due to greater COVID-19-related 
call volume and being solely responsible for patient transport, 
nebulization of bronchodilators, and intubation.
    Tarabichi et al., (October 30, 2020) recruited first responders 
(from EMS and fire departments) to participate in a study in the 
Cleveland, Ohio area. The authors conducted a first serologic survey 
and virus test in the period between April 20 through May 19, 2020 and 
a second between May 18 and June 2, 2020. A total of 296 respondents 
completed a first visit and 260 completed the second visit. Seventy-one 
percent of respondents reported exposure to SARS-CoV-2 and 16 (5.4%) 
had positive serological testing. No subject had a positive virus test. 
Fifty percent (8/16) of those who tested positive were either 
asymptomatic or mildly symptomatic. Based on responses to questions 
about suspected contacts (it does not appear that the time period of 
exposure was considered), the study author concluded that likely 
sources of transmission in participants who tested positive were 
patients or co-workers.
    In a study examining COVID-19 antibodies in employees from public 
service agencies in the New York City area from May through July of 
2020, 22.5% of participants were found to have COVID-19 antibodies 
(Sami et al., March 2021). The percentages of EMTs and paramedics found 
to have antibodies (38.3 and 31.1%) were among the highest levels 
observed in all the occupations. The study authors noted that risk of 
exposures may be increased for employees who provide emergency medical 
services because those services are provided in uncontrolled, 
unpredictable environments, where space is limited (e.g., ambulances) 
and quick decisions must often be made. Both emergency technicians and 
paramedics perform procedures such as airway management that involve a 
high risk of exposure. In fact, the proportions of employees who had 
antibodies were found to be increased with increasing frequency of 
aerosol-generating procedures.
In-Home Healthcare Providers
    In-home healthcare workers provide medical or personal care 
services, similar to those provided in long-term care facilities, 
inside the homes of people unable to live independently. Patients 
receiving in-home care could receive services from different types of 
healthcare providers (e.g., a nurse administering medical care, a 
physical therapist assisting with exercise, a personal care services 
provider assisting with daily functions such as bathing). In addition, 
a number of workers may provide services to the same patient, while 
working in shifts over the course of the day. In-home healthcare 
providers have a high risk of infection from working close to patients 
and possibly their family members or other caregivers in enclosed 
spaces (e.g., performing a physical examination, helping the patient 
bathe).
    The impact of COVID-19 on in-home healthcare workers is not well 
studied. In-home healthcare workers might be included in reports of 
COVID-19 cases and deaths in healthcare workers, but those reports do 
not indicate if any of the affected healthcare workers provided home 
care. One report from the UK indicated that an occupational category of 
``social care'' which included ``care workers and home carers'' 
experienced significantly increased rates of death involving COVID-19 
(50.1 deaths per 100,000 men and 19.1 deaths per 100,000 women) from 
March through May of 2020 (Windsor-Shellard et al., June 26, 2020). And 
in a related study from March through December of 2020, it was reported 
that nearly three in four deaths involving COVID-19 in social care 
operations were in ``care workers and home carers,'' with 109.9 deaths 
per 100,000 men and 47.1 deaths per 100,000 women (Windsor-Shellard et 
al., January 25, 2021).
Conclusion
    The representative studies OSHA described in this section on 
healthcare provide examples of the pervasive impact that SARS-CoV-2 
exposures have had on employees in those industries before vaccines 
were available. Even since vaccines have become widely available, 
approximately 20 to 30% of healthcare workers remained unvaccinated as 
of March 2021 (King et al., April 24, 2021), and breakthrough cases 
among vaccinated healthcare employees are evident. The evidence is 
consistent with OSHA's determination that SARS-CoV-2 poses a grave 
danger to healthcare employees. Cases or outbreaks in settings such as 
hospitals, long-term care facilities, and emergency services 
departments have had a clear impact on employees in those types of 
workplaces. The evidence establishes that employees in those settings, 
whether they provide direct patient care or supporting services, have 
been infected with SARS-CoV-2 and have developed COVID-19. Some of 
these employees have died and others have become seriously ill. 
Employees in healthcare are at elevated risk for transmission in the 
workplace. Employees in these industry settings are exposed to these 
forms of transmission through in-person interaction with patients and 
co-workers in settings where individuals with suspected or confirmed 
COVID-19 receive care. In many cases, close contact with people who are 
suspected or confirmed to have COVID-19 is required of personnel in 
these types of workplaces, and such close contact usually occurs 
indoors. These employees, who form the backbone of the nation's medical 
response to the COVID-19 public health emergency, clearly require 
protection under this ETS.
References
Bagchi, S et al., (2021). Rates of COVID-19 among residents and 
staff members in nursing homes--United States, May 25-November 22, 
2020. MMWR 70: 52-55. http://dx.doi.org/10.15585/mmwr.mm7002e2. 
(Bagchi et al., 2021).
Barrett, ES et al., (2020). Prevalence of SARS-CoV-2 infection in 
previously undiagnosed health care workers in New Jersey, at the 
onset of the US COVID-19 pandemic. BMC infectious diseases 20(1): 1-
0. doi: 10.1101/2020.04.20.20072470. (Barrett et al., 2020).
Burrer, SL et al., (2020). Characteristics of health care personnel 
with COVID-19--United States, February 12-April 9, 2020. MMWR 
69(15): 477-481. https://www.cdc.gov/mmwr/volumes/69/wr/mm6915e6.htm. (Burrer et al., 2020).
Carter, RE et al., (2021, March 26). Prevalence of SARS-CoV-2 
Antibodies in a Multistate Academic Medical Center. Mayo Clin Proc. 
2021 May; 96(5): 1165-1174. doi: 10.1016/j.mayocp.2021. 03.015. 
PMID: 33958053; PMCID:

PMC7997730. (Carter et al., March 26, 2021).
Centers for Disease Control and Prevention (CDC). (2020, July, 6). 
About serology surveillance. https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/about-serology-surveillance.html. (CDC, July 6, 
2020).
Centers for Disease Control and Prevention (CDC). (2021a, May 24). 
Cases & Deaths among Healthcare Personnel. https://covid.cdc.gov/covid-data-tracker/#health-care-personnel. (CDC, May 24, 2021a).
Davalos, J. (2020, December 21). Hospital laundry workers fear their 
infection risk is rising. Bloomberg. https://www.bloomberg.com/news/articles/2020-12-21/hospital-laundry-workers-say-every-day-at-work-risks-covid-infection. (Davalos, December 21, 2020).
Fell, A et al., (2020, October 30). SARS-CoV-2 exposure and 
infection among health care personnel--Minnesota, March 6-July 11, 
2020. MMWR 69(43): 1605-1610. https://www.cdc.gov/mmwr/volumes/69/wr/mm6943a5.htm?s_cid=mm6943a5_x. (Fell et al., October 30, 2020).
Firew, TS et al., (2020). Protecting the front line: A cross-
sectional survey analysis of the occupational factors contributing 
to healthcare workers' infection and psychological distress during 
the COVID-19 pandemic in the USA. BMJ Open 10(10). doi: 10.1136/
bmjopen-2020-042752. (Firew et al., 2020).
Hale, M and Dayot, A. (2020). Outbreak investigation of COVID-19 in 
hospital food service workers. American Journal of Infection Control 
49(3): 396-397. https://doi.org/10.1016/j.ajic.2020.08.011. (Hale 
and Dayot, 2020).
Hartmann, S et al., (2020). Coronavirus 2019 (COVID-19) Infections 
among healthcare workers, Los Angeles County, February-May 2020. 
Clinical Infectious Diseases. doi: 10.1093/cid/ciaa1200. (Hartmann 
et al., 2020).
Heinzerling, A et al., (2020, April 17). Transmission of COVID-19 to 
health care personnel during exposures to a hospitalized patient--
Solano County, California, February 2020. MMWR 69(15): 472-476. 
https://www.cdc.gov/mmwr/volumes/69/wr/mm6915e5.htm. (Heinzerling, 
et al., April 17, 2020).
Jacob, JT et al., (2021, March 10). Risk Factors Associated With 
SARS-CoV-2 Seropositivity Among US Health Care Personnel. JAMA Netw 
Open. 2021; 4(3): e211283. doi: 10.1001/jamanetworkopen.2021.1283. 
(Jacob et al., March 10, 2021).
Kaiser Health News and the Guardian. (2021, February 23). Lost on 
the Frontline. The Guardian. https://www.theguardian.com/us-news/ng-interactive/2020/aug/11/lost-on-the-frontline-covid-19-coronavirus-us-healthcare-workers-deaths-database. (Kaiser Health News and the 
Guardian, February 23, 2021).
Kaiser Health News and the Guardian. (2021, April). Lost on the 
Frontline. The Guardian. https://www.theguardian.com/us-news/ng-interactive/2020/aug/11/lost-on-the-frontline-covid-19-coronavirus-us-healthcare-workers-deaths-database. (Kaiser Health News and the 
Guardian, April 2021).
King, WC et al., (2021, April 24). COVID-19 vaccine hesitancy 
January-March 2021 among 18-64 year old US adults by employment and 
occupation. medRxiv; https://www.medrxiv.org/content/10.1101/2021.04.20.21255821v3. (King et al., April 24, 2021).
Magnusson, K et al., (2021, January 6). Occupational risk of COVID-
19 in the 1st and 2nd wave of infection. medRxiv https://doi.org/10.1101/2020.10.29.20220426. (Magnussen et al., January 6, 2021).
Mani, NS et al., (2020, November 15). Prevalence of COVID-19 
infection and outcomes among symptomatic healthcare workers in 
Seattle, Washington. Clin Infectious Disease 71(10): 2702-2707. doi: 
10.1093/cid/ciaa761. (Mani et al., November 15, 2020).
Martin, A. (2020, August 10). Outbreak at Regina's K-Bro Linens: 18 
employees test positive. Regina Leader-Post. https://leaderpost.com/news/local-news/outbreak-at-reginas-k-bro-linens-18-employees-test-positive. (Martin, August 10, 2020).
McMichael, TM et al., (2020, March 27). Epidemiology of Covid-19 in 
a long-term care facility in King County, Washington. New England 
Journal of Medicine 382(21): 2005-2011. doi: 10.1056/NEJMoa2005412. 
(McMichael et al., March 27, 2020).
Misra-Hebert, AD et al., (2020, September 1). Impact of the COVID-19 
pandemic on healthcare workers' risk of infection and outcomes in a 
large, integrated health system. Journal of General Internal 
Medicine 35: 3293-3301. https://doi.org/10.1007/s11606-020-06171-9. 
(Misra-Hebert et al., September 1, 2020).
Moscola, J et al., (2020, September 1). Prevalence of SARS-CoV-2 
antibodies in health care personnel in the New York City Area. JAMA 
324(9): 893-895. doi: 10.1001/jama.2020.14765. (Moscola et al., 
September 1, 2020).
Nagler, AR et al., (2020, June 28). Early results from SARS-CoV-2 
PCR testing of healthcare workers at an academic medical center in 
New York City. Clinical Infectious Diseases 72(7): 1241-1243. doi: 
10.1093/cid/ciaa867. (Nagler et al., June 28, 2020).
Nguyen, LH et al., (2020). Risk of COVID-19 among front-line health-
care workers and the general community: a prospective cohort study. 
The Lancet Public Health 5(9): e475-e483. https://doi.org/10.1016/S2468-2667(20)30164-X. (Nguyen et al., 2020).
Prezant, DJ et al., (2020). Medical leave associated with COVID-19 
among emergency medical system responders and firefighters in New 
York City. JAMA Netw Open 3(7). https://doi.org/10.1001/jamanetworkopen.2020.16094. (Prezant et al., 2020).
Sami, S et al., (2021, March). Prevalence of SARS-CoV-2 antibodies 
in first responders and public safety personnel, New York City, New 
York, USA, May-July 2020. Emerging Infectious Diseases 27(3). 
https://doi.org/10.3201/eid2703.204340. (Sami et al., March 2021).
Sims, MD et al., (2020). COVID-19 seropositivity and asymptomatic 
rates in healthcare workers are associated with job function and 
masking. Clinical Infectious Diseases. doi: 10.1093/cid/ciaa1684. 
(Sims et al., November 5, 2020).
Tarabichi, Y et al., (2020, October 30). SARS-CoV-2 infection among 
serially tested emergency medical services workers. Prehospital 
Emergency Care 25(1): 39-45. https://doi.org/10.1080/10903127.2020.1831668. (Tarabichi et al., October 30, 2020).
Terebuh et al., (2020, September 20). Characterization of community-
wide transmission of SARS-CoV-2 in congregate living settings and 
local public health-coordinated response during the initial phase of 
the COVID-19 pandemic. Influenza Other Respir Viruses. doi: 10.1111/
irv.12819. (Terebuh et al., September 20, 2020).
Vahidy, FS et al., (2020) Prevalence of SARS-CoV-2 infection among 
asymptomatic health care workers in the greater Houston, Texas, 
area. JAMA Network Open 3(7): e2016451. https://doi.org/10.1001/jamanetworkopen.2020.16451. (Vahidy et al., 2020).
Venugopal, U et al., (2020, January). SARS-CoV-2 seroprevalence 
among health care workers in a New York City hospital: A cross-
sectional analysis during the COVID-19 pandemic. International 
Journal of Infectious Diseases 102: 63-69. https://doi.org/10.1016/j.ijid.2020.10.036. (Venugopal et al., January 2020).
Weiden, M et al., (2021, January 25). Pre-COVID-19 lung function and 
other risk factors for severe COVID-19 in first responders. ERJ open 
research 7(1): 00610-2020. https://doi.org/10.1183/23120541.00610-2020. (Weiden et al., January 25, 2021).
Weil, A et al., (2020, September 1). Cross-sectional prevalence of 
SARS-CoV-2 among skilled nursing facility employees and residents 
across facilities in Seattle. J Gen Intern Med 35: 11. doi: 10.1007/
s11606-020-06165-7. (Weil et al., September 1, 2020).
Wilkins, JT et al., (2021). Seroprevalence and correlates of SARS-
CoV-2 antibodies in health care workers in Chicago. Open Forum 
Infectious Diseases 8(1). https://doi.org/10.1093/ofid/ofaa582. 
(Wilkins et al., 2021).
Windsor-Shellard, B and Butt, A. (2020, June 26). Coronavirus 
(COVID-19) related deaths by occupation, England and Wales: deaths 
registered between 9 March and 25 May 2020. https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/causesofdeath/bulletins/coronaviruscovid19relateddeathsbyoccupationenglandandwales/deathsregisteredbetween9marchand25may2020.

(Windsor-Shellard and Butt, June 26, 2020).
Windsor-Shellard, B and Nasir, R. (2021, January 25). Coronavirus 
(COVID-19) related deaths by occupation, England and Wales: deaths 
registered between 9 March and 28 December 2020. https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/causesofdeath/bulletins/coronaviruscovid19relateddeathsbyoccupationenglandandwales/deathsregisteredbetween9marchand28december2020. (Windsor-Shellard 
and Nasir, January 25, 2021).
Yi, H et al., (2020, September 7). Health equity considerations in 
COVID-19: geospatial network analysis of the COVID-19 outbreak in 
the migrant population in Singapore. J Travel Med. DOI: 10.1093/jtm/
taaa159. (Yi et al., September 7, 2020).
IV. Conclusion
    OSHA finds that healthcare employees face a grave danger from 
exposure to SARS-CoV-2 in the United States.\10\ OSHA's determination 
is based on three separate manifestations of incurable, permanent, or 
non-fleeting health consequences of exposure to the virus, each of 
which is independently supported by substantial evidence in the record. 
The danger to healthcare employees is further supported by powerful 
lines of evidence demonstrating the transmissibility of the virus in 
the workplace and the prevalence of infections in employee populations 
where individuals with suspected or confirmed COVID-19 receive care.
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    \10\ The determination that COVID-19 presents a grave danger to 
healthcare employees is not based on a determination that workplace 
protections previously adopted by any particular employer to address 
the risk of infection are necessarily inadequate. As discussed in 
the Feasibility section, many such workplace protections are 
consistent with the uniform nationwide requirements set forth in the 
ETS. The purpose of the ETS is to ensure sufficient protections for 
workers are consistently implemented across the country.
---------------------------------------------------------------------------

    First, with respect to the grave health consequences of exposure to 
SARS-CoV-2, OSHA has found that regardless of where and how exposure 
occurs, COVID-19 can result in death. The risk of death from COVID-19 
is especially high for employees who have underlying health conditions, 
older employees, and employees who are members of racial and ethnic 
minority groups, who together make up a significant proportion of the 
working population. Second, even for those who survive a SARS-CoV-2 
infection, the virus often causes serious, long-lasting, and 
potentially permanent health effects. Serious cases of COVID-19 require 
hospitalization and dramatic medical interventions, and might leave 
employees with permanent and disabling health effects. Third, even mild 
or moderate cases of COVID-19 that do not require hospitalization can 
be debilitating and require medical care and significant time off from 
work for recovery and quarantine. People who initially appear to have 
mild cases can suffer health effects that continue months after the 
initial infection. Furthermore, racial and ethnic minority groups are 
at increased risk of SARS-CoV-2 infection, as well as hospitalization 
and death from COVID-19.
    Each of these categories of health consequences independently poses 
a grave danger to individuals exposed to the virus. That danger is 
amplified for healthcare employees because of the high potential for 
transmission of the virus in healthcare settings where individuals with 
suspected or confirmed COVID-19 receive care. The best available 
evidence on the science of transmission of the virus makes clear that 
SARS-CoV-2 is transmissible from person to person in these settings, 
which can result in large-scale clusters of infections. Transmission is 
most prevalent in healthcare settings where individuals with suspected 
or confirmed COVID-19 receive care, and can be exacerbated by, for 
example, poor ventilation, close contact with potentially infectious 
individuals, and situations where aerosols containing SARS-CoV-2 
particles are likely to be generated. Importantly, while older 
employees and those with underlying health conditions face a higher 
risk of dying from COVID-19 once infected, fatalities are certainly not 
limited to that group. Every healthcare workplace exposure or 
transmission has the potential to cause severe illness or even death, 
particularly in unvaccinated healthcare workers in settings where 
patients with suspected or confirmed COVID-19 receive care. Taken 
together, the multiple, severe health consequences of COVID-19 and the 
evidence of its transmission in environments characteristic of the 
healthcare workplaces where this ETS requires worker protections 
demonstrate that exposure to SARS-CoV-2 represents a grave danger to 
employees in these workplaces throughout the country.\11\
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    \11\ Note that OSHA has made no determination regarding the 
significance of the risk to employees from exposure to SARS-CoV-2, 
as would be required in a permanent rulemaking under section 6(b)(5) 
of the OSH Act, 29 U.S.C. 655(b)(5). OSHA has only considered 
whether exposure to SARS-CoV-2 poses a grave danger, as required for 
promulgation of a permanent standard under section 6(c)(1)(A), 29 
U.S.C. 655(c)(1)(A).
---------------------------------------------------------------------------

    The existence of a grave danger to employees from SARS-CoV-2 is 
further supported by the toll the pandemic has already taken on the 
nation as a whole. Although OSHA cannot estimate the total number of 
healthcare workers in our nation who contracted COVID-19 at work and 
became sick or died, COVID-19 has killed 587,342 people in the United 
States as of May 24, 2021 (CDC, May 24, 2021a). That death toll 
includes 91,351 people who were 18 to 64 years old (CDC, May 24, 
2021b). Current mortality data shows that unvaccinated people of 
working age have a 1 in 217 chance of dying when they contract COVID-
19. As of May 24, 2021, more than 32 million people in the United 
States have been reported to have infections, and thousands of new 
cases were being identified daily (CDC, May 24, 2021c). One in ten 
reported cases of COVID-19 becomes severe and requires hospitalization. 
Moreover, public health officials agree that these numbers fail to show 
the full extent of the deaths and illnesses from this disease, and 
racial and ethnic minority groups are disproportionately represented 
among COVID-19 cases, hospitalizations, and deaths (CDC, December 10, 
2021; CDC, May 26, 2021; Escobar et al., 2021; Gross et al., 2020; 
McLaren, 2020). Given this context, OSHA is confident in its finding 
that exposure to SARS-CoV-2 poses a grave danger to the healthcare 
employees covered by the protections in this ETS.
    The above analysis fully satisfies the OSH Act's requirements for 
finding a grave danger. Although OSHA usually performs a quantitative 
risk assessment before promulgating a health standard under section 
6(b)(5) of the OSH Act, 29 U.S.C. 655(b)(5), that type of analysis is 
not necessary in this situation. OSHA has most often invoked section 
6(b)(5) authority to regulate exposures to chemical hazards involving 
much smaller populations, many fewer cases, extrapolations from animal 
evidence, long-term exposure, and delayed effects. In those situations, 
mathematical modelling is necessary to evaluate the extent of the risk 
at different exposure levels. The gravity of the danger presented by a 
disease with acute effects like COVID-19, on the other hand, is made 
obvious by a straightforward count of deaths and illnesses caused by 
the disease, which reach sums not seen in a century. The evidence 
compiled above amply support OSHA's finding that SARS-CoV-2 presents a 
grave danger in to the healthcare employees covered by the protections 
in this ETS. In the context of ordinary 6(b) rulemaking, the Supreme 
Court has said

that the OSH Act is not a ``mathematical straitjacket,'' nor does it 
require the agency to support its findings ``with anything approaching 
scientific certainty,'' particularly when operating on the ``frontiers 
of scientific knowledge.'' Indus. Union Dep't, AFL-CIO v. Am. Petroleum 
Inst., 448 U.S. 607, 656, 100 S. Ct. 2844, 2871, 65 L. Ed. 2d 1010 
(1980). This is true a fortiori here in the current national crisis 
where OSHA must act to ensure employees are adequately protected from 
the new hazard presented by the COVID-19 pandemic (see 29 U.S.C 
655(c)(1)).
    Having made the determination of grave danger, as well as the 
determination that an ETS is necessary to protect these employees from 
exposure to SARS-CoV-2 (see Need for the ETS, in Section IV.B. of this 
preamble), OSHA is required to issue this standard to protect these 
employees from getting sick and dying from COVID-19 acquired at work. 
See 29 U.S.C. 655(c)(1).
References
Centers for Disease Control and Prevention (CDC). (2020, December 
10). COVID-19 racial and ethnic health disparities. https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/racial-ethnic-disparities/index.html. (CDC, December 10, 2020).
Centers for Disease Control and Prevention (CDC). (2021, May 26). 
Health disparities: race and Hispanic origin. https://www.cdc.gov/nchs/nvss/vsrr/covid19/health_disparities.htm. (CDC, May 26, 2021).
Centers for Disease Control and Prevention (CDC). (2021a, May 24). 
COVID data tracker.Trends in number of COVID-19 cases and deaths in 
the US reported to CDC, by state/territory: Trends in Total COVID-19 
Deaths in the United States Reported to CDC. https://covid.cdc.gov/covid-data-tracker/#trends_dailytrendscases. (CDC, May 24, 2021a).
Centers for Disease Control and Prevention (CDC). (2021b, May 24). 
Demographic Trends of COVID-19 cases and deaths in the US reported 
to CDC: Deaths by age group. https://covid.cdc.gov/covid-data-tracker/#demographics. (CDC, May 24, 2021b).
Centers for Disease Control and Prevention (CDC). (2021c, May 24). 
COVID data tracker.Trends in number of COVID-19 cases and deaths in 
the US reported to CDC, by state/territory: Trends in Total COVID-19 
Cases in the United States Reported to CDC. https://covid.cdc.gov/covid-data-tracker/#trends_dailytrendscases.(CDC, May 24, 2021c).
Escobar, GJ et al., (2021, February 9). Racial disparities in COVID-
19 testing and outcomes. Annals of Internal Medicine. doi: 10.7326/
M20-6979. (Escobar et al., February 9, 2021).
Gross, CP et al., (2020, October). Racial and ethnic disparities in 
population-level COVID-19 mortality. Journal of General Internal 
Medicine 35(10): 3097-3099. doi: 10.1007/s11606-020-06081-w. (Gross 
et al., October 2020).
McLaren, J. (2020, June). Racial disparity in COVID-19 deaths: 
Seeking economic roots with Census data. NBER Working Paper Series. 
Working Paper 27407. doi: 10.3386/w27407. (McLaren, June 2020).

B. Need for the ETS

    This ETS is necessary to protect the healthcare workers with the 
highest risk of contracting COVID-19 at work. Healthcare workers face a 
particularly elevated risk of contracting COVID-19 in settings where 
patients with suspected or confirmed COVID-19 receive treatment, 
especially those healthcare workers providing direct care to patients. 
The ETS is necessary to protect these workers through requirements 
including patient screening and management, respirators and other 
personal protective equipment (PPE), limiting exposure to aerosol-
generating procedures, physical distancing, physical barriers, 
cleaning, disinfection, ventilation, health screening and medical 
management, access to vaccination, and anti-retaliation provisions and 
medical removal protection.
I. Events Leading to the ETS
    Since January 2020, OSHA has received numerous petitions and 
supporting letters from members of Congress, unions, advocacy groups, 
and one group of large employers urging the agency to take immediate 
action by issuing an ETS to protect healthcare employees from exposure 
to the virus that causes COVID-19 (Scott and Adams, January 30, 2020; 
NNU, March 4, 2020; AFL-CIO, March 6, 2020; Wellington, March 12, 2020; 
DeVito, March 12, 2020; Carome, March 13, 2020; Murray et al., April 
29, 2020; Solt, April 28, 2020; Public Citizen, March 13, 2020; 
Pellerin, March 19, 2020; Yborra, March 19, 2020; Owen, March 19, 2020; 
ORCHSE, October 9, 2020). These petitions and supporting letters 
asserted that many employees have been infected because of workplace 
exposures to the virus that causes COVID-19 and immediate, legally 
enforceable action is necessary for protection. OSHA quickly began 
issuing detailed guidance documents and alerts beginning in March 2020 
that helped employers determine employee risk levels of COVID-19 
exposure and made recommendations for appropriate controls.
    On March 18, 2020, then-OSHA Principal Deputy Assistant Secretary 
Loren Sweatt responded to an inquiry from Congressman Robert C. 
``Bobby'' Scott, Chairman of the House Committee on Education and 
Labor, regarding OSHA's response to the COVID-19 outbreak (OSHA, March 
18, 2020). In the letter, she stated that OSHA had ``a number of 
existing enforcement tools'' it was using to address COVID-19, 
including existing standards such as Personal Protective Equipment 
(PPE), Respiratory Protection, and Bloodborne Pathogens, as well as the 
General Duty Clause, 29 U.S.C. 654(a)(1). She also stated that OSHA was 
working proactively to assist employers by developing guidance 
documents. And, given the existing enforcement tools, ``we currently 
see no additional benefit from an ETS in the current circumstances 
relating to COVID-19,'' and ``OSHA can best meet the needs of America's 
workers by being able to rapidly respond in a flexible environment.'' 
However, she noted that OSHA would continue to monitor ``this quickly 
evolving situation and will take appropriate steps to protect workers 
from COVID-19 in coordination with the overall U.S. government response 
effort.''
    Shortly after OSHA's announcement that it did not intend to pursue 
an ETS at that time, the American Federation of Labor and Congress of 
Industrial Organizations (AFL-CIO), the country's largest federation of 
labor unions, filed an emergency petition with the U.S. Court of 
Appeals for the D.C. Circuit, for a writ of mandamus to compel OSHA to 
issue an ETS for COVID-19, arguing that OSHA's failure to issue legally 
enforceable COVID-19-specific rules endangered workers (AFL-CIO, May 
18, 2020). On May 29, 2020, OSHA denied the AFL-CIO's pending March 6 
petition to OSHA for an ETS \12\ and simultaneously filed a response 
brief with the D.C. Circuit, arguing the AFL-CIO was not entitled to a 
writ of mandamus (DOL, May 29, 2020). The agency stated that the union 
had not clearly and indisputably demonstrated that an ETS was necessary 
and expressed its view that an ETS was not necessary at that time 
because of the agency's two-pronged strategy for addressing COVID-19 in 
the workplace:

Enforcement of existing standards and section 5(a)(1) of the OSH Act 
(the General Duty Clause), as well as development of rapid guidance to 
provide a flexible response to new and evolving information about the 
virus. On June 11, 2020, the U.S. Court of Appeals for the D.C. Circuit 
issued a one paragraph per curiam order denying the AFL-CIO's petition, 
finding that OSHA's ``decision not to issue an ETS is entitled to 
considerable deference,'' and ``[i]n light of the unprecedented nature 
of the COVID-19 pandemic, as well as the regulatory tools that the OSHA 
has at its disposal to ensure that employers are maintaining hazard-
free work environments, . . . OSHA reasonably determined that an ETS is 
not necessary at this time.'' In re Am. Fed'n of Labor & Cong. of 
Indus. Orgs., No. 20-1158, 2020 WL 3125324 (AFL-CIO, June 11, 2020), 
rehearing en banc denied (AFL-CIO, July 28, 2020).\13\
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    \12\ The AFL-CIO had petitioned OSHA on March 6 to issue an ETS 
to protect working people from occupational exposure to infectious 
diseases broadly, including COVID-19 (AFL-CIO, March 6, 2020). In 
OSHA's May 29, 2020 denial, the agency concluded that it lacked 
compelling evidence to find that an undefined category of infectious 
diseases generally posed a grave danger for which an ETS was 
necessary (OSHA, May 29, 2020). With respect to COVID-19 
specifically, the agency made no conclusion as to whether the 
disease posed a grave danger to workers, but concluded, as it had in 
the earlier March 18, 2020 response to congressional inquiry, that a 
COVID-19 ETS was not necessary at that time (id.).
    \13\ On October 29, 2020, a group of petitioners including the 
American Federation of Teachers (AFT), the American Federation of 
State, County and Municipal Employees, the Washington State Nurses 
Association, and the United Nurses Association of California/Union 
of Health Care Professionals filed a separate petition for a writ of 
mandamus from the U.S. Court of Appeals for the Ninth Circuit to 
compel OSHA to issue a permanent standard to protect healthcare 
workers from the risks of infectious diseases (AFT, October 29, 
2020). On December 31, 2020, OSHA filed a response brief asserting 
that the petitioners were not entitled to the requested writ of 
mandamus (DOL, December 31, 2020). OSHA explained that, while the 
agency has been considering the need for an infectious disease 
standard for healthcare workers since at least 2009, it has not yet 
made a final determination on the necessity of such a standard, and 
that the agency's limited resources at this time are best directed 
toward responding to the broader COVID-19 crisis. The Ninth Circuit 
granted the parties' request to stay the case because OSHA now 
intends to prioritize the infectious disease rulemaking.
---------------------------------------------------------------------------

    Following OSHA's decision in May 2020 not to issue an ETS, some 
states and local health departments determined enforceable regulation 
was necessary, leading to the adoption of a variety of state and local 
executive orders and emergency regulations with specific worker 
protection requirements. Virginia, Oregon, California, Michigan, and 
Washington have issued their own ETSs, (see Section VII, Additional 
Requirements, for a full discussion of OSHA-approved State Plans), and 
many additional states and localities have issued other kinds of 
requirements, guidelines, and protective ordinances for workers. Other 
states and localities have not. The resulting patchwork of state and 
local regulations led to inadequate and varying levels of protection 
for workers across the country, and has caused problems for many 
employees and businesses. As a result, on October 9, 2020, ORCHSE 
Strategies, LLC (since acquired by the National Safety Council (NSC))--
a group of more than 100 large (mostly Fortune 500) companies in over 
28 industries--petitioned OSHA to issue an ETS, recognizing that OSHA 
had provided ``very well prepared and thoughtful'' guidance, but 
concluding an ETS is still needed and that the lack of a uniform 
response has caused confusion and unnecessary burden on already 
struggling workplaces (ORCHSE, October 9, 2020).
    Notwithstanding the patchwork efforts at the state and local level, 
the country experienced a significant increase in COVID-19 deaths and 
infections. When OSHA decided not to promulgate an ETS in May 2020, the 
COVID-19 death toll in the United States was reaching 100,000 (CDC, May 
28, 2020). Since then, an additional 500,000 Americans have died from 
COVID-19 (CDC, May 24, 2021a). Despite a decrease in recent weeks, the 
death rate remains high (7-day moving average death rate of 500 on May 
23, 2021) (CDC, May 24, 2021b), and thousands of Americans are 
hospitalized with COVID-19 every day (CDC, May 24, 2021c).
    As of May 23, 2021, the agency had issued 689 citations for COVID-
19-related violations of existing OSHA requirements, primarily of 
healthcare facilities including nursing homes. Violations have 
included, among other things, failure to properly develop written 
respiratory protection programs; failure to provide a medical 
evaluation, respirator fit test, training on the proper use of a 
respirator, and personal protective equipment; failure to report an 
injury, illness, or fatality; failure to record an injury or illness on 
OSHA recordkeeping forms; and failure to comply with the General Duty 
Clause of the OSH Act. In addition, OSHA issued over 230 Hazard Alert 
Letters (HALs), including over 100 HALs to employers in healthcare 
settings (e.g., hospitals, ambulatory care, and nursing and residential 
care facilities), where it found COVID-19-related hazards during 
workplace inspections, but did not believe it had sufficient basis to 
cite the employer for violating an existing OSHA standard or the 
General Duty Clause.
    On January 21, 2021, President Biden issued Executive Order 13999, 
entitled ``Protecting Worker Health and Safety'' (86 FR 7211). In it, 
he declared that:

    Ensuring the health and safety of workers is a national priority 
and a moral imperative. Healthcare workers and other essential 
workers, many of whom are people of color and immigrants, have put 
their lives on the line during the coronavirus disease 2019 (COVID-
19) pandemic. It is the policy of my Administration to protect the 
health and safety of workers from COVID-19. The Federal Government 
must take swift action to reduce the risk that workers may contract 
COVID-19 in the workplace.

    He further directed OSHA to take a number of steps to better 
protect workers from the COVID-19 hazard, including issuing revised 
guidance on workplace safety, launching a national emphasis program to 
focus OSHA enforcement efforts on COVID-19, conduct a multilingual 
outreach program, and evaluate its COVID-19 enforcement policies (id.). 
In addition, the President directed OSHA to ``consider whether any 
emergency temporary standards on COVID-19, including with respect to 

masks in the workplace, are necessary, and if such standards are 
determined to be necessary, issue them by March 15, 2021'' (id.). OSHA 
began working on the issue at once, and shortly after Secretary Walsh 
took office on March 23, he ordered OSHA to ensure its analysis 
addressed the latest information regarding the state of vaccinations 
and virus variants (Rolfson and Rozen, April 6, 2021). In accordance 
with the executive order and Secretary Walsh's directive, OSHA has 
reviewed its May 2020 decision not to issue an ETS. For the reasons 
explained below, OSHA does not believe its prior approach--enforcement 
of existing standards and the General Duty Clause coupled with the 
issuance of nonbinding guidance--has proven over time to be adequate to 
``reduce the risk that workers may contract COVID-19'' in healthcare 
settings. Given the grave danger presented by the hazard, OSHA now 
finds that this standard is necessary to protect the healthcare 
employees who face the highest risk of contracting COVID-19 at work. 
See Nat'l Cable & Telecomm. Ass'n v. Brand X internet Svcs, 545 U.S. 
967, 981 (2005) (noting that an agency must ``consider the wisdom of 
its policy on a continuing basis . . . for example, in response to 
changed factual circumstances, or a change in administrations''); 
Asbestos Info. Ass'n, 727 F.2d at 423 (5th Cir. 1984) (``failure to act 
does not conclusively establish that a situation is not an emergency . 
. . [when there is a grave danger to workers,] to hold that because 
OSHA did not act previously it cannot do so now only compounds the 
consequences of the Agency's failure to act.'').
References
American Federation of Labor and Congress of Industrial 
Organizations. (2020, March 6). ``To Address the Outbreak of COVID-

19: A Petition for an OSHA Emergency Temporary Standard for 
Infectious Disease.'' (AFL-CIO, March 6, 2020).
American Federation of Labor and Congress of Industrial 
Organizations. (2020, May 18). Emergency Petition For A Writ Of 
Mandamus, and Request For Expedited Briefing And Disposition, No. 
19-1158. (AFL-CIO, May 18, 2020).
American Federation of Labor and Congress of Industrial 
Organizations, USCA Case #20-1158, Document #1846700. (2020, June 
11). (AFL-CIO, June 11, 2020).
American Federation of Labor and Congress of Industrial 
Organizations. Denial of Petition for Rehearing En Banc on Behalf Of 
American Federation of Labor and Congress of Industrial 
Organizations. USCA Case #20-1158, Document #1853761. (2020, July 
28). (AFL-CIO, July 28, 2020).
American Federation of Teachers, et al., Petition For A Writ Of 
Mandamus, No. 20-73203 (9th Cir., October 29, 2020). (2020, October 
29). (AFT, October 29, 2020).
Carome, M. (2020, March 13). ``Letter requesting an immediate OSHA 
emergency temporary standard for infectious disease.'' (Carome, 
March 13, 2020).
Centers for Disease Control and Prevention (CDC). (2021a, May 24). 
COVID data tracker.Trends in number of COVID-19 cases and deaths in 
the US reported to CDC, by state/territory: Trends in Total COVID-19 
Deaths in the United States Reported to CDC. https://covid.cdc.gov/covid-data-tracker/#trends_dailytrendscases. (CDC, May 24, 2021a).
Centers for Disease Control and Prevention (CDC). (2021b, May 24). 
COVID data tracker.Trends in number of COVID-19 cases and deaths in 
the US reported to CDC, by state/territory Daily Trends in Number of 
COVID-19 Deaths in the United States Reported to CDC. https://covid.cdc.gov/covid-data-tracker/#trends_dailytrendscases. (CDC, May 
24, 2021b).
Centers for Disease Control and Prevention (CDC). (2021c, May 24). 
COVID data tracker. New Admissions of Patients with Confirmed COVID-
19, United States. https://covid.cdc.gov/covid-data-tracker/#new-hospital-admissions. (CDC, May 24, 2021c).
Centers for Disease Control and Prevention (CDC). (2020, May 28). 
United States Coronavirus (COVID-19) Death Toll Surpasses 100,000. 
https://www.cdc.gov/media/releases/2020/s0528-coronavirus-death-toll.html. (CDC, May 28, 2020).
DeVito, J. (2020, March 12). ``Grant OSHA emergency standard for 
COVID-19 to protect frontline workers.'' (DeVito, March 12, 2020).
Murray, P, Brown, S, Heinrich, M, Brown, S, Blumenthal, R, Markey, 
EJ, Van Hollen, C, Durbin, RJ, Smith, T, Whitehouse, S, Wyden, R, 
King Jr., AS, Kaine, T, Reed, J, Menedez, R, Gillibrand, K, 
Duckworth, T, Warren, E, Hassan, MW, Casey Jr., RP, Sanders, B, 
Udall, T, Hirono, MK, Harris, KD, Feinstein, D, Klobuchar, A, 
Booker, CA, Shaheen, J, Cardin, B. (2020, April 29). ``COVID-19 ETS 
Petition.''(Murray et al., April 29, 2020).
National Nurses United (NNU). (2020, March 4). ``National Nurses 
United Petitions OSHA for an Emergency Temporary Standard on 
Emerging Infectious Diseases in Response to COVID-19.'' (NNU, March 
4, 2020).
Occupational Safety and Health Administration (OSHA). (2020, March 
18). Letter from Loren Sweatt to Congressman Robert C. ``Bobby'' 
Scott. (OSHA, March 18, 2020).
Occupational Safety and Health Administration (OSHA). (2020, May 
29). Letter from Loren Sweatt to AFL-CIO President Richard Trumka. 
(OSHA, May 29, 2020).
Owen, M. (2020, March 19). ``Grant OSHA emergency standard to 
protect frontline workers from COVID-19.'' (Owen, March 19, 2020) .
ORCHSE Strategies. (2020, October 9). ``Petition to the U.S. 
Department of Labor--Occupational Safety and Health Administration 
(OSHA) for an Emergency Temporary Standard (ETS) for Infectious 
Disease.'' (ORCHSE, October 9, 2020).
Pellerin, C. (2020). ``Grant OSHA emergency standard to protect 
frontline workers from COVID-19.'' (Pellerin, March 19, 2020).
Public Citizen. (2020, March 13). ``Support for AFL-CIO's Petition 
for an OSHA Emergency Temporary Standard for Infectious Disease to 
Address the Epidemic of Novel Coronavirus Disease.'' (Public 
Citizen, March 13, 2020).
Rolfson, B, Rozen, C. (2021, April 6). Labor Chief Walsh Puts Hold 
on OSHA Virus Rule for More Analysis. Bloomberg Law. https://news.bloomberglaw.com/safety/labor-chief-walsh-puts-hold-on-osha-virus-rule-for-more-analysis. (Rolfson and Rozen, April 6, 2021).
Scott, RC and Adams, AS. (2020, January 30). ``Prioritize OSHA's 
Work on Infectious Diseases Standard/Immediate Issue of Temporary 
Standard.'' (Scott and Adams, January 30, 2020).
Solt, BE. (2020). ``COVID-19 ETS Petition.'' (Solt, April 28, 2020).
United States Department of Labor (DOL). (2020, May 29). In Re: 
American Federation Of Labor And Congress Of Industrial 
Organizations. Department Of Labor's Response to the Emergency 
Petition for a Writ of Mandamus, No. 20-1158 (D.C. Cir., May 29, 
2020). (DOL, May 29, 2020).
United States Department of Labor (DOL). (2020, December 31). 
American Federation of Teachers, et al., Department of Labor's 
Opposition to the Petition for a Writ of Mandamus, No. 20-73203 (9th 
Cir., December 31, 2020). (DOL, December 31, 2020).
Wellington, M. (2020, March 12). ``Grant OSHA emergency standard for 
COVID-19 to protect front-line workers''. (Wellington, March 12, 
2020).
Yborra, G. (2020, March 19). ``Grant OSHA emergency standard to 
protect frontline workers from COVID-19.'' (Yborra, March 19, 2020).
II. No Other Agency Action Is Adequate To Protect Employees Against 
Grave Danger
    For the first time in its 50-year history, OSHA faces a ``new 
hazard'' so grave that it has killed almost 600,000 people in the 
United States in barely over a year, and infected millions more. COVID-
19 can be spread to employees whenever an infected person exhales. 
Those employees, once infected, could end up unable to breathe without 
ventilators or suffer from failure of multiple body organs, and are at 
risk of death or long-term debilitation. The COVID-19 pandemic has 
taken a particularly heavy toll on workers in healthcare providing 
frontline care to patients with suspected or confirmed COVID-19, 
creating the precise situation that section 6(c)(1) of the OSH Act was 
enacted to address. This ETS is necessary to protect these employees 
from the grave danger posed by COVID-19.
    When OSHA decided not to issue an ETS last spring, the agency had 
preliminarily determined that sufficient employee protection against 
COVID-19 could be provided through enforcement of existing workplace 
standards and the General Duty Clause of the OSH Act, coupled with the 
issuance of industry-specific, non-mandatory guidance. However, in 
doing so OSHA indicated that its conclusion that an ETS was not 
necessary was specific to the information available to the agency at 
that time, and that the agency would continue to monitor the situation 
and take additional steps as appropriate (see, e.g., OSHA, March 18, 
2020, Letter to Congressman Scott (stating ``[W]e currently see no 
additional benefit from an ETS in the current circumstances relating to 
COVID-19. OSHA is continuing to monitor this quickly evolving situation 
and will take the appropriate steps to protect workers from COVID-19 in 
coordination with the overall U.S. government response effort.'' 
(emphasis supplied); DOL May 29, 2020 at 20 (stating ``OSHA has 
determined this steep threshold [of necessity] is not met here, at 
least not at this time.'' (emphasis supplied))). OSHA's subsequent 
experience has shown that a new approach is needed to protect 
healthcare workers from the grave danger posed by the COVID-19 
pandemic.
    At the outset, employers do not have a reliance interest in OSHA's 
prior decision not to issue an ETS on May 29, 2020, which did not alter 
the status quo or require employers to change their behavior. See Dep't 
of Homeland Security v. Regents of the Univ. of

California, 140 S. Ct. 1891, 1913-14 (2020). As OSHA indicated when it 
made the decision, the determination was based on the conditions and 
information available to the agency at that time and was subject to 
change as additional information indicated the need for an ETS. In 
light of the agency's express qualifications and the surrounding 
context, any employer reliance would have been unjustified and cannot 
outweigh the countervailing urgent need to protect healthcare workers 
from the grave danger posed by COVID-19.
    Multiple developments support a change in approach. First, as noted 
above, although the rates of death and hospitalization from COVID-19 
have decreased in recent weeks as vaccines have become more widely 
available, COVID-19 continues to pose a grave danger to healthcare 
employees in settings where the risk of exposure to an infected person 
is elevated because of the nature of the work performed. In addition, 
some variability in infection rates in a pandemic is to be expected. 
While the curves of new infections and deaths can bend down after 
peaks, they often reverse course only to reach additional peaks in the 
future (Moore et al., April 30, 2020). Several new mutations--or 
variants--of the virus, preliminarily understood to be more contagious 
than the original, are now spreading in this country.
    Second, as discussed in more detail in Grave Danger (Section IV.A 
of this preamble), while vaccines have been authorized for use for 
several months, and the nationwide effort to fully vaccinate all 
Americans is ongoing, more work is needed to build confidence among 
Americans in the vaccines so that enough people are protected to bring 
the virus under control, and to ensure that employees can get 
vaccinated without the risk of losing their jobs or losing pay. The 
standard is therefore necessary to facilitate vaccination among 
healthcare workers by requiring employers to ``provid[e] reasonable 
time and paid leave . . . to each employee for vaccination and any side 
effects experienced following vaccination'' (paragraph (m)).
    The standard also further encourages vaccination by fully exempting 
``well-defined hospital ambulatory care settings where all employees 
are fully vaccinated'' and all non-employees are screened and denied 
entry if they are suspected or confirmed to have COVID-19 (paragraph 
(a)(2)(iv)) and ``home healthcare settings where all employees are 
fully vaccinated'' and all non-employees at that location are screened 
prior to employee entry so that people with suspected or confirmed 
COVID-19 are not present (paragraph (a)(2)(v)). In addition, the 
standard encourages vaccination by exempting fully vaccinated employees 
from the requirements for facemasks, physical distancing, and barriers 
``in well-defined areas where there is no reasonable expectation that 
any person with suspected or confirmed COVID-19 will be present'' 
(paragraph (a)(4)).
    Further, OSHA's actual enforcement experience over the past year--
which had only just begun when OSHA announced its previous views on the 
need for an ETS--has demonstrated that existing enforcement options do 
not adequately protect healthcare employees from the grave danger posed 
by COVID-19. As of May 23, 2021, OSHA and its State Plan partners have 
received more than 67,000 COVID-related complaints since March of 2020 
(OSHA, May 23, 2021). OSHA has received more complaints about 
healthcare settings than any other industry.\14\ Although the number of 
employee complaints has gone down in recent months since COVID-19 
vaccines have become more widely available, OSHA continues to receive 
hundreds of employee complaints every month, including many that 
concern healthcare settings, asking for investigations of workplaces 
where employees do not believe they are being adequately protected from 
COVID-19 and indicating that their employers do not follow the guidance 
issued by the agency and the CDC.
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    \14\ As a result of these complaints, federal OSHA has conducted 
2,305 inspections (State Plans have conducted 7,203 inspections) as 
of May 23, 2021. On March 12, 2021, OSHA issued a National Emphasis 
program to ensure that OSHA continues to devote a high percentage of 
its inspection resources to COVID-19, with a target of roughly 1,600 
inspections a year. These can be the result of complaints or 
programmed inspections targeted at high hazard industries. However, 
as described below, the effectiveness of the NEP will be hampered 
without the ETS given the inadequacy of OSHA's current enforcement 
tools.
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    The following narratives are just a few recent examples of the 
kinds of complaints OSHA continues to receive from healthcare employees 
on a regular basis:
     5/21/21 Doctor's office failed to remove employee with 
COVID-19 symptoms.
     5/21/21 Assisted living facility for the elderly failed to 
notify employees that they were exposed to residents with COVID-19.
     5/19/21 Doctor's office did not maintain distancing for 
employees, did not notify employees of exposure to COVID-19, and did 
not remove employees with COVID-19 symptoms from the workplace.
     5/19/21 Doctor's office did not ensure that technician 
wore gloves during COVID-19 treatment.
     5/10/21 Clinic did not follow guidance for patient 
screening or removal from the workplace of potentially infected 
employee.
     5/7/21 Psychiatric facility did not properly clean rooms 
of COVID-19 positive patients, did not train employees to properly 
remove infectious disease PPE when exiting COVID-19 positive areas to 
other areas of the facility, and allows employees who have tested 
positive for COVID-19 to continue to work at the workplace.
     5/6/21 Hospital failed to promptly remove employee with 
COVID-19 from the workplace, notify other employees of their exposure 
to the COVID-19, and did not require employees to wear facemasks.
     5/3/21 Doctor's office required employees to reuse 
isolation gowns to an extent not consistent with CDC guidance.
    This ETS addresses numerous issues raised in these complaints, 
including physical distancing, PPE, cleaning and disinfection, and 
measures to keep contagious co-workers away from the workplace.
    Based on its thorough review of OSHA's existing approach to 
protecting employees from COVID-19, OSHA finds that existing OSHA 
standards, the General Duty Clause, and non-mandatory guidance issued 
by OSHA are not adequate to protect healthcare employees from COVID-19. 
Similarly, the numerous guidance products published by other entities, 
such as CDC, are not sufficiently effective at protecting these 
employees because such guidance is not enforceable and there is no 
penalty for noncompliance. OSHA has determined that each of these 
tools, as well any combination of them, is inadequate to address COVID-
related hazards in the settings covered by this standard, thereby 
establishing the need for this ETS.
    This inadequacy has also been reflected in the number of states and 
localities that have issued their own mandatory standards in 
recognition that existing measures (including non-mandatory guidance, 
compliance assistance, and enforcement of existing standards) have 
failed to adequately protect workers from COVID-19. While these state 
and local requirements may have had positive effects where they have 
been implemented, they are no replacement for a national standard that 
would establish definitively that COVID-19 safety measures are no 
longer

voluntary for the workers covered by this standard. Without a national 
standard, the patchwork of inconsistent requirements has proven both 
ineffective at a national level and burdensome to employers operating 
across jurisdictions, increasing compliance costs and potentially 
limiting the ability to implement protective measures at scale (See 
ORCHSE, October 9, 2020). Congress has charged OSHA with protecting 
America's workforce, and an ETS is the only measure capable of 
providing adequate protection to the workers covered by this standard 
from the grave danger posed by COVID-19.
a. The Current Standards and Regulations Are Inadequate
    In updated enforcement guidance issued in March 2021 (OSHA, March 
12, 2021), OSHA identified a number of current standards and 
regulations that might apply when workers have occupational exposure to 
SARS-CoV-2 (Interim Enforcement Response Plan) (OSHA, March 12, 
2021).\15\ In addition to the standards listed there, OSHA has also 
cited the Hazard communication standard (29 CFR 1910.1200) during 
COVID-19 investigations. Accordingly, the complete list of potentially 
applicable standards and regulations follows:
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    \15\ The Interim Enforcement Response Plan also suggests that 
while OSHA's Bloodborne Pathogens standard (29 CFR 1910.1030) does 
not typically apply to respiratory secretions that may contain SARS-
CoV-2, the provisions of the standard offer a framework that may 
help control some sources of the virus, including exposures to body 
fluids (e.g., respiratory secretions) not covered by the standard. 
While this is true for some of the controls required by that 
standard, such as laundering and cleaning, it does not contain 
requirements to implement necessary controls to protect employees 
against airborne transmission of SARS-CoV-2, such as distancing, 
barriers, and ventilation. And in any event, it imposes no 
obligations unless blood or other potentially infectious materials 
(as defined in the standard) are present.
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     29 CFR part 1904, Recording and Reporting Occupational 
Injuries and Illnesses. This regulation requires certain employers to 
keep records of work-related fatalities, injuries, and illnesses and 
report them to the government in specific circumstances.
     29 CFR 1910.132, General requirements--Personal Protective 
Equipment (PPE). This standard requires that appropriate PPE, including 
PPE for eyes, face, head, and extremities, protective clothing, 
respiratory devices, and protective shields and barriers, be provided, 
used, and maintained in a sanitary and reliable condition.
     29 CFR 1910.134, Respiratory protection. This standard 
requires that employers provide, and ensure the use of, appropriate 
respiratory protection when necessary to protect employee health.
     29 CFR 1910.141, Sanitation. This standard applies to 
permanent places of employment and contains, among other requirements, 
general housekeeping and waste disposal requirements.
     29 CFR 1910.145, Specification for accident prevention 
signs and tags. This standard requires the use of biological hazard 
signs and tags, in addition to other types of accident prevention signs 
and tags.
     29 CFR 1910.1020, Access to employee exposure and medical 
records. This standard requires that employers provide employees and 
their designated representatives access to relevant exposure and 
medical records.
     29 CFR 1910.1200, Hazard communication. This standard 
requires employers to keep Safety Data Sheets (SDS) for chemical 
hazards, provide SDSs to employees and their representatives when 
requested, and train employees about those hazards. The standard does 
not apply to biological hazards, but hazard communication becomes an 
issue for the SARS-CoV-2 virus when chemicals are used to disinfect 
surfaces. OSHA notes that, when such chemicals are used in the 
workplace, the employer is required to comply with the hazard 
communication standard. The agency has not incorporated hazard 
communication requirements in the ETS, but has included related 
training and notification requirements. Section 1910.1200 compliance is 
only peripherally related to protection against SARS-CoV-2 hazards, 
employers are generally aware of those requirements, and the 
requirements of Sec.  1910.1200 are enforceable without being repeated 
in the ETS.
    Through its enforcement efforts to date, OSHA has encountered 
significant obstacles demonstrating that existing standards and 
regulations are inadequate to address the COVID-19 hazard for 
healthcare workers, and has determined that a COVID-19 ETS is necessary 
to address these inadequacies. As discussed in further detail below, 
OSHA has determined that some of the above-listed standards--including 
Sanitation at Sec.  1910.141--are in practice too difficult to apply to 
the COVID-19 hazard and have never been cited in COVID enforcement; 
other standards--such as Respiratory Protection at Sec.  1910.134 and 
general PPE at Sec.  1910.132--are more clearly applicable to the 
COVID-19 hazard, but for a variety of reasons have offered little 
protection to the vast majority of employees who are not directly 
caring for patients with suspected or confirmed COVID-19. Current CDC 
guidance does not indicate that respirators are generally needed 
outside of direct patient care, but CDC does support the protective 
measures the ETS would require for the workers it covers (Howard, May 
22, 2021).
    Finally, the remaining listed standards and regulations--for 
recordkeeping and reporting, accident prevention signs and tags, access 
to employee records, and hazard communication--while applicable to the 
COVID-19 hazard and important in the overall scheme of workplace 
safety, do not require employers to implement specific measures to 
protect workers from COVID-19. Further, as addressed in more detail 
below, even applicable regulations like the reporting requirements did 
not contemplate a hazard like COVID-19, and have proven to be difficult 
to apply to it. Thus, for the reasons elaborated in further detail 
below, OSHA has determined that its existing standards and regulations 
are insufficient to adequately address the grave danger posed by COVID-
19 to healthcare workers.
    First, most of the safety measures known to reduce the hazard of 
COVID-19 transmission are not explicitly required by existing 
standards: none expressly requires measures such as facilitating 
vaccination, facemasks, physical distancing, physical barriers, 
cleaning and disinfection (when appropriate), improved ventilation to 
reduce virus transmission, isolation of sick employees, minimizing 
exposures in the highest hazard settings such as aerosol-generating 
procedures on patients with suspected or confirmed COVID-19, patient 
screening and management, notification to employees potentially exposed 
to people with COVID-19, or training on these requirements. For 
example, although OSHA's existing Respiratory Protection and PPE 
standards require respirators and PPE such as gloves and face shields 
in some settings covered by the ETS, they do not require all of the 
other layers of protection required by the ETS that are necessary to 
mitigate the spread of COVID-19 in the workplace. See Need for Specific 
Provisions (Section V of the preamble).
    Similarly, while the Sanitation standard at Sec.  1910.141(a)(3) 
requires places of employment ``to be kept clean to the extent that the 
nature of the work allows,'' the standard does not require disinfection 
of potentially contaminated surfaces nor does it speak to the level or 
frequency with which cleaning is required to protect against an 
infectious

disease hazard like COVID-19. Accordingly, OSHA has not yet identified 
any instance in which the Sanitation standard could be applied in the 
agency's COVID-19 enforcement efforts. Thus, OSHA's efforts to enforce 
existing standards to address the COVID-19 hazard have been 
significantly hindered by the absence of any specific requirements in 
these standards related to some of the most important COVID-19-
mitigation measures. The COVID-19 ETS addresses this issue by clearly 
mandating each of these necessary protections.
    Second, because existing standards do not contain provisions 
specifically targeted at the COVID-19 hazard, it may be difficult for 
employers and employees to determine what particular COVID-19 safety 
measures are required by existing standards, or how the separate 
standards are expected to work together as applied to COVID-19. As 
explained in more detail in the Need for Specific Provisions (Section V 
of the preamble), the infection control practices required to address 
COVID-19 are most effective when used together, layering their 
protective impact. Because no such layered framework is currently 
enforced nationally, the existing standards leave large gaps in 
employee protection from COVID-19. An ETS with a national scope that 
contains provisions specifically addressing the COVID-19 hazards facing 
healthcare workers will provide clearer instructions to the average 
employer than the piecemeal application of existing standards. The ETS 
bundles all of the relevant requirements, providing a roadmap for 
employers and employees to use when developing a plan and implementing 
protections, so that employers and employees in the settings covered by 
this standard know what is required to protect employees from COVID-19. 
More certainty will lead to more compliance, and more compliance will 
lead to improved protection of employees.
    Third, requirements in some existing standards may be appropriate 
for other situations but simply do not contemplate COVID-19 hazards. 
For example, as noted above, the Sanitation standard at Sec.  1910.141 
requires employers to provide warm water, soap, and towels that can be 
used for hand washing, an important protective action against COVID-19, 
and generally requires that places of employment be kept ``clean,'' but 
it does not specify disinfection as a cleaning procedure, even though 
disinfection is an important precaution against COVID-19 transmission. 
Nor does it require the provision of hand sanitizer where hand washing 
facilities cannot be made readily available. Similarly, existing 
standards do not address facemasks for a hazard such as COVID-19, which 
protect other workers (source control) as well as provide some degree 
of protection to the wearer. The ETS, developed in direct response to 
the COVID-19 hazard and associated pandemic, provides this needed 
specificity so the employers covered by the ETS understand exactly what 
is required during this unprecedented public health emergency.
    Fourth, the existing recordkeeping and reporting regulations are 
not adequate to help the employer or the agency assess the full scope 
of COVID-19 workplace exposures. The recordkeeping regulations were not 
written with the nature of COVID-19 transmission or illness in mind. In 
order to adequately understand and thereby control the spread of COVID-
19 in the workplace, it is critical that the employer has a record of 
all cases of COVID-19 occurring among employees; however, such 
information is outside of the scope of OSHA's existing recordkeeping 
requirements, which are limited to injuries or illnesses that the 
employer knows to be work-related. The existing regulations are 
premised on the assumption that employers can easily identify injuries 
or illnesses that are work-related, but COVID-19 transmission can occur 
in the workplace, the community, or the household, and it can be 
difficult to identify the point of transmission. In numerous 
investigations, OSHA has identified employee illnesses or deaths from 
COVID-19 that were not reflected in the employer's required 
recordkeeping logs because the employer was not able to determine 
whether the illness or death was work-related. The COVID-19 log 
required by the ETS will provide a fuller picture of the prevalence of 
SARS-CoV-2 in the workplace by requiring employers to record employee 
cases without a work-relatedness determination.
    Furthermore, even where work-relatedness can be determined, the 
existing reporting regulations are also inadequate in ensuring OSHA has 
the full picture of the impact of COVID-19 in the settings covered by 
this standard because the regulations only require employers to report 
in-patient hospitalizations that occur within 24 hours of the work-
related incident and to report fatalities that occur within thirty days 
of the work-related incident. But many COVID-19 infections will not 
result in hospitalization or death until well after these limited 
reporting periods; consequently they are not required to be reported to 
OSHA, which limits the agency's ability to fully understand the impact 
of COVID-19 on the workforce. In order to adequately understand and 
thereby control the spread of COVID-19 in the workforce, it is critical 
that the employer has a record of all cases of COVID-19 occurring among 
employees and that OSHA is timely informed of all work-related COVID-19 
in-patient hospitalizations and fatalities.
    OSHA's existing recordkeeping and reporting requirements are also 
inadequate for addressing the COVID-19 hazard in the workplaces covered 
by the ETS because the current reporting structure does not require 
employers to notify employees of possible exposures in the workplace. 
While the recordkeeping requirements require employers to make illness 
and injury records available to employees, 29 CFR 1910.35(b)(2), they 
do not create an affirmative duty requiring employers to notify 
employees when they may have been exposed to another employee with the 
disease. Given the transmissibility of COVID-19, timely notification of 
an exposure is critical to curbing further spread of COVID-19 and 
protecting employees from the COVID-19 hazard.
    Thus, OSHA's existing recordkeeping and reporting requirements are 
not tailored to address hazards associated with COVID-19 in the 
workplaces covered by the ETS. As a result, they do not enable OSHA, 
employers, or employees to accurately identify and address such 
hazards. The ETS addresses that issue by requiring employers to record 
each instance identified by the employer in which an employee is COVID-
19 positive, regardless of whether the instance is connected to 
exposure to COVID-19 at work; requiring employers to report work-
related, COVID-19 in-patient hospitalizations and fatalities, 
regardless of when the exposure in the work environment occurred; and 
imposing an affirmative duty requiring employers to notify employees of 
COVID-19 exposure.
    In conclusion, OSHA's experience has demonstrated that existing 
standards alone are inadequate to address the COVID-19 hazard. The 
limitations and inadequacies explained above prevent OSHA from 
requiring all of the layers of controls necessary to protect employees 
from COVID-19 under these existing standards, even in situations that 
are clearly hazardous to employees. Thus, OSHA finds that its existing 
standards are not sufficient to protect employees from the grave danger 
posed by COVID-19.

b. The General Duty Clause Is Inadequate To Meet the Current Crisis
    Section 5(a)(1) of the OSH Act, or the General Duty Clause, 
provides the general mandate that each employer ``furnish to each of 
[its] employees employment and a place of employment which are free 
from recognized hazards that are causing or are likely to cause death 
or serious physical harm to his employees.'' 29 U.S.C. 654(a)(1). While 
OSHA has attempted to use the General Duty Clause to protect employees 
from COVID-19-related hazards, OSHA has found that there are 
significant challenges associated with this approach and therefore this 
ETS is necessary to protect the workers covered by this standard from 
the grave danger posed by COVID-19. While the General Duty Clause can 
be used in many contexts, in OSHA's experience over the past year, the 
clause falls short of the agency's mandate to protect employees from 
the hazards of COVID-19 in the settings covered by the standard. As 
explained more fully below, OSHA finds the ETS will more efficiently 
and effectively address those hazards. Cf. Bloodborne Pathogens, 56 FR 
64004, 64007, 64038 (Dec. 6, 1991) (bloodborne pathogens standard will 
more efficiently reduce the risk of the hazard than can enforcement 
under the general duty clause).
    As an initial matter, the General Duty Clause does not provide 
employers with specific requirements to follow or a roadmap for 
implementing appropriate abatement measures. The ETS, however, provides 
a clear statement of what OSHA expects employers to do to protect 
workers, thus facilitating better compliance. The General Duty Clause 
is so named because it imposes a general duty to keep the workplace 
free of recognized serious hazards; the ETS, in contrast, lays out 
clear requirements for COVID-19 plans, facemasks, distancing, barriers, 
cleaning, personal protective equipment, and training, among other 
things, and identifies the settings in which they are required. 
Conveying obligations as clearly and specifically as possible provides 
employers with enhanced notice of how to comply with their OSH Act 
obligations to protect workers from COVID-19 hazards. See, e.g., 
Integra Health Mgmt., Inc., 2019 WL 1142920, at *7 n.10 (OSHRC No. 13-
1124, 2019) (noting that standards ``give clear notice of what is 
required of the regulated community''); 56 FR 64007 (``because the 
standard is much more specific than the current requirements [general 
standards and the general duty clause], employers and employees are 
given more guidance in carrying out the goal of reducing the risks of 
occupational exposure to bloodborne pathogens'').
    Moreover, several characteristics of General Duty Clause 
enforcement actions limit how effectively OSHA can use the clause to 
address hazards associated with COVID-19. Most important, the General 
Duty Clause is not a good tool for requiring employers to adopt 
specific, overlapping, and complementary abatement measures, like those 
required by the ETS, and some important worker-protective elements of 
the ETS (such as payment for medical removal) would be virtually 
impossible for OSHA to require and enforce under the General Duty 
Clause. Second, OSHA's burden of proof for establishing a General Duty 
Clause violation is heavier than for standards violations.
    Third, the ETS will enable OSHA to issue more meaningful penalties 
for willful or egregious violations, thus facilitating better 
enforcement and more effective deterrence against employers who 
intentionally disregard their obligations under the Act or demonstrate 
plain indifference to employee safety. Fourth, the General Duty Clause 
does not provide complete protection to employees at multi-employer 
worksites, which are common situations in hospitals, where more than 
one employer controls hazards at the workplace. The ETS will permit 
more thorough enforcement in these situations. Each of these is 
discussed in more detail below.
General Duty Clause Citations Impose a Heavy Litigation Burden on OSHA
    For contested General Duty Clause citations to be upheld, OSHA must 
demonstrate elements of proof that are supplementary to, and can be 
more difficult to show than, the elements of proof required for 
violations of specific standards, where a hazard is presumed. 
Specifically, to prove a violation of the General Duty Clause, OSHA 
needs to establish--in each individual case--that: (1) An activity or 
condition in the employer's workplace presented a hazard to an 
employee; (2) the hazard was recognized; (3) the hazard was causing or 
was likely to cause death or serious physical harm; and (4) feasible 
means to eliminate or materially reduce the hazard existed. BHC Nw. 
Psychiatric Hosp., LLC v. Sec'y of Labor, 951 F.3d 558, 563 (D.C. Cir. 
2020).
    For the first element of a General Duty Clause case, OSHA must 
prove that there is a hazard, i.e., a workplace condition or practice 
to which employees are exposed, creating the potential for death or 
serious physical harm to employees. See SeaWorld of Florida LLC v. 
Perez, 748 F.3d 1202, 1207 (D.C. Cir. 2014); Integra Health Management, 
2019 WL 1142920, at *5. In the case of COVID-19, this means showing not 
just that the virus is a hazard as a general matter--a fairly 
indisputable point--but also that the specific conditions in the cited 
workplace, such as performing administrative tasks in a waiting room 
setting where patients are seeking treatment for suspected or confirmed 
COVID-19, create a hazard. In contrast, an OSHA standard that requires 
or prohibits specific conditions or practices establishes the existence 
of a hazard. See Harry C. Crooker & Sons, Inc. v. Occupational Safety & 
Health Rev. Comm'n, 537 F.3d 79, 85 (1st Cir. 2008); Bunge Corp. v. 
Sec'y of Labor, 638 F.2d 831, 834 (5th Cir. 1981). Thus, in enforcement 
proceedings under OSHA standards, as opposed to the General Duty 
Clause, ``the Secretary need not prove that the violative conditions 
are actually hazardous.'' Modern Drop Forge Co. v. Sec'y of Labor, 683 
F.2d 1105, 1114 (7th Cir. 1982). With OSHA's finding that the hazard of 
exposure to COVID-19 can exist in the workplaces covered by this 
standard (see Grave Danger, above), the ETS will eliminate the burden 
to repeatedly prove the existence of a COVID-19 hazard in each 
individual case under the General Duty Clause.
    One of the most significant advantages to standards like the ETS 
that establish the existence of the hazard at the rulemaking stage is 
that the Secretary can require specific abatement measures without 
having to prove that the cited workplace is hazardous.\16\ In contrast, 
under the General Duty Clause, the Secretary cannot require abatement 
before proving in the enforcement proceeding that an existing condition 
at the workplace is hazardous. For example, in a facial challenge to 
OSHA's Grain Handling Standard, which was promulgated in part to 
protect employees from the risk of fire and explosion from 
accumulations of grain dust, the Fifth Circuit acknowledged OSHA's 
inability to effectively protect employees from these hazards under the 
General Duty Clause in upholding, in large part, the standard.

See Nat'l Grain & Feed Ass'n v. Occupational Safety & Health Admin., 
866 F.2d 717, 721 (5th Cir. 1988) (noting Secretary's difficulty in 
proving explosion hazards of grain handling under General Duty Clause). 
Although OSHA had attempted to address fire and explosion hazards in 
the grain handling industry under the General Duty Clause, ``employers 
generally were successful in arguing that OSHA had not proved that the 
specific condition cited could cause a fire or explosion.'' Id. at 721 
& n.6 (citing cases holding that OSHA failed to establish a fire or 
explosion hazard under the General Duty Clause). In other words, the 
General Duty Clause was not an effective tool because OSHA could not 
prove that existing conditions at the cited workplace were hazardous. 
The Grain Handling Standard, in contrast, established specific limits 
on accumulations of grain dust based on its combustible and explosive 
nature, and the standard allowed OSHA to cite employers for exceeding 
those limits without the need to prove at the enforcement stage that 
each cited accumulation was likely to cause a fire or explosion. See 
id. at 725-26. The same logic applies to COVID-19 hazards. Given OSHA's 
burden under the General Duty Clause to prove that conditions at the 
cited workplace are hazardous, it is difficult for OSHA to ensure 
necessary abatement before employee lives and health are unnecessarily 
endangered by exposure to COVID-19. The ETS, on the other hand, allows 
OSHA to cite employers for each protective requirement they fail to 
implement without the need to prove in an enforcement proceeding that 
the particular cited workplace was hazardous at the time of citation 
without that particular measure in place.
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    \16\ ``The Act does not wait for an employee to die or become 
injured. It authorizes the promulgation of health and safety 
standards and the issuance of citations in the hope that these will 
act to prevent deaths and injuries from ever occurring.'' Whirlpool 
Corp, v. Marshall, 445 U.S. 1, 12 (1980); see also Arkansas-Best 
Freight Sys., Inc. v. Occupational Safety & Health Rev. Comm'n, 529 
F.2d 649, 653 (8th Cir. 1976) (noting that the ``[OSH] Act is 
intended to prevent the first injury'').
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    An additional limitation of the General Duty Clause is that it 
requires OSHA to show that there was a feasible and effective means of 
abating the hazard. To satisfy this element, OSHA is required to prove 
that there are abatement measures that will be effective in materially 
reducing the hazard. See Integra Health Management, 2019 WL 1142920, at 
*12. Proving the existence of feasible abatement measures that will be 
effective in materially reducing the hazard usually requires testimony 
from an expert witness, which limits OSHA's ability to prosecute these 
cases as broadly as needed to protect more workers. See, e.g., id. at 
*13 (requiring expert witness to prove proposed abatement measures 
would materially reduce hazard). In contrast, where an OSHA standard 
specifies the means of compliance, the agency has already made the 
necessary technical determinations in the rulemaking and therefore does 
not need to establish feasibility of compliance as part of its prima 
facie case in an enforcement proceeding; instead, the employer bears 
the burden of proving infeasibility as an affirmative defense. See, 
e.g., A.J. McNulty & Co. v. Sec'y of Labor, 283 F.3d 328, 334 (D.C. 
Cir. 2002); S. Colorado Prestress Co. v. Occupational Safety & Health 
Rev. Comm'n, 586 F.2d 1342, 1351 (10th Cir. 1978). Protecting as many 
workers as quickly as possible is especially critical in the context of 
COVID-19 because, as explained in Section IV.A, Grave Danger, it can 
spread so easily in the workplaces covered by this ETS.
The General Duty Clause Is Ill-Suited to Requiring Employers To Adopt a 
Comprehensive Set of Complementary Abatement Measures, Like Those 
Required by the ETS
    As explained in Section V. Need for the Specific Provisions of the 
ETS, effective infection control programs use a suite of overlapping 
controls in a layered approach to ensure that no inherent weakness in 
any one approach results in an infection incident. Each of the 
practices required by the ETS provides some protection from COVID-19 on 
its own, but the practices must be used together to ensure adequate 
worker protection. However, General Duty Clause enforcement poses key 
obstacles that prevent OSHA from requiring the types of overlapping 
controls necessary to address COVID-19 hazards. Because the General 
Duty Clause requires OSHA to establish the existence and feasibility of 
abatement measures that can materially reduce a hazard, it can be 
difficult for OSHA to use 5(a)(1) to require a full suite of 
overlapping or complementary control measures, or, in other words, to 
require additional abatement measures in situations where an employer 
is doing something, but not everything the ETS will require, to address 
COVID-19 hazards.
    In many cases over the past year where OSHA investigated COVID-19-
related complaints, the agency discovered that employers were following 
some minimal mitigation strategy while ignoring other crucial 
components of employee protection. In such instances, because the 
employer had taken some steps to protect workers, successfully proving 
a General Duty Clause citation would have required OSHA to show that 
additional missing measures would have further materially reduced the 
COVID-19 hazard. Although OSHA believes each measure required by this 
ETS materially reduces the COVID-19 hazard, there are key challenges 
inherent in trying to make such a showing in an individual case, such 
as the difficulty of pinpointing exactly when and how employees could 
become infected with COVID-19 and establishing the magnitude of the 
effect particular abatement measures would have on reducing infection 
in the specific conditions present in the employer's workplace. See, 
e.g., Pepperidge Farm, Inc., 17 OSH Cas. (BNA) 1993, 1997 WL 212599, at 
*51 (OSHRC No. 89-265, Apr. 26, 1997) (finding that additional feasible 
abatement measure established by the Secretary to address ergonomic 
hazard did not materially reduce the hazard in light of the other steps 
the employer had taken). The ETS cures this problem by imposing 
separate requirements for, and establishing the general effectiveness 
of, each necessary mitigation measure, thereby ensuring employers have 
an enforceable obligation to provide the full suite of workplace 
protections recommended by the CDC and other expert bodies.
    Consider a hospital setting where patients with suspected or 
confirmed COVID-19 receive treatment. The employer requires respirators 
for employees providing direct care to those patients but little else 
to protect those employees or other workers in those settings who are 
not directly involved in patient care. Under the ETS, OSHA can cite the 
employer for violating the specific requirements necessary to protect 
all workers in those settings, such as facemasks for workers who are 
not directly caring for patients, physical distancing or barriers 
between administrative employees and patients who have not yet been 
screened for suspected or confirmed COVID-19, work practice controls 
for employees performing aerosol-generating procedures on people with 
suspected or confirmed COVID-19, patient screening and management, paid 
leave for vaccination, and medical removal protection.
    Without the ETS, however, OSHA would have to cite the employer 
under the General Duty Clause for the much broader violation of failing 
to eliminate the recognized workplace hazard of COVID-19 infection. 
This would require OSHA to prove: (1) That the hazard of COVID-19 
infection was present and recognized for employees at this particular 
healthcare workplace, and (2) that additional abatement methods would 
materially reduce the hazard, over and above the reduction achieved by 
the use of respirators as already required under 29 CFR 1910.134 for

exposure to people with suspected or confirmed COVID-19. Both of these 
elements would likely require expert witness testimony specific to 
conditions in this particular workplace, and it may be difficult to 
establish that each layer of protection necessary to comprehensively 
protect employees would have materially reduced the hazard depending on 
the facts of the specific instance.
    Further, even where OSHA establishes a violation of the General 
Duty Clause, the employer is under no obligation to implement the 
precise feasible means of abatement proven by OSHA as part of its prima 
facie case. Cyrus Mines Corp., 11 OSH Cas. (BNA) 1063, 1982 WL 22717, 
at *4 (OSHRC No. 76-616, Dec. 17, 1983). Thus, even in cases where OSHA 
prevails, the employer need not necessarily implement the specific 
abatement measure(s) OSHA established would materially reduce the 
hazard. The employer could select alternative controls and then it 
would be up to OSHA, if it wished to cite the employer again, to 
establish that the recognized hazard continued to exist and that adding 
physical distancing or barriers, for example, could materially reduce 
the hazard even further.
    Finally, there are some crucial requirements in the ETS that OSHA 
would have difficulty enforcing under the General Duty Clause. Of 
particular note, OSHA is adopting provisions in the ETS that require 
paid time for vaccination and recovery from vaccine side effects, and 
removal of COVID-19-positive employees and other workers exposed to 
them from the workplace and payment of salary for employees who are 
removed (medical removal protection, or ``MRP''). These provisions are 
critical to protecting workers because they facilitate vaccination, 
which is the preferred means of protecting workers exposed to COVID-19 
hazards, and removal of infected employees and their close contacts as 
soon as the employer knows they have COVID-19. Additional discussion of 
the importance of these provisions can be found in Section V. Need for 
the Specific Provisions of the ETS. While it might be possible for OSHA 
to establish the value of vaccination as a protective measure and the 
need to remove known infected employees in a General Duty Clause case, 
it is highly unlikely that OSHA could require payment to those 
employees, or other measures to encourage employees to get vaccinated 
or to let their employers know when they test positive for COVID-19. 
Rather, paid leave for vaccination and MRP are measures better 
implemented through OSHA's statutory authority to promulgate standards. 
Standards are forward-looking and can be used to create a comprehensive 
network of required, and in this case of layered, worker safety 
protections. The ETS creates just such a network, and vaccination and 
MRP are important layers of that approach.
The ETS Will Permit OSHA To Achieve Meaningful Deterrence When 
Necessary To Address Willful or Egregious Failures To Protect Employees 
Against the COVID-19 Hazard
    As described above, in contrast to the broad language of the 
General Duty Clause, the ETS will clarify what exactly employers are 
required to do to protect employees from COVID-19-related hazards, 
making it easier for OSHA to determine whether an employer has 
intentionally disregarded its obligations or exhibited a plain 
indifference to employee safety or health. In such instances, OSHA can 
classify the citations as ``willful,'' allowing it to propose higher 
penalties, with increased deterrent effects. Early in the pandemic, 
shifting guidance on the safety measures employers should take to 
protect their employees from COVID-19 created ambiguity regarding 
employers' specific obligations. Thus, OSHA could not readily determine 
whether a particular employer had ``intentionally'' disregarded 
obligations that were not yet clear. And, even as the guidance began to 
stabilize, OSHA's ability to determine ``intentional disregard'' or 
``plain indifference'' was difficult, for example, when an employer 
took some, but not all, of the necessary steps to sufficiently address 
the COVID-19 hazard. Given the current understanding that multiple 
layers of protection are necessary to adequately protect workers from 
COVID-19, an ETS will ensure that employers have clearer notice of 
their obligations. This will allow the agency to take appropriate steps 
to redress the situation where an employer has intentionally 
disregarded the requirements necessary to protect employees from the 
COVID-19 hazard, or has acted with plain indifference to employee 
safety.
    Further, OSHA has adopted its ``egregious'' policy to impose 
sufficiently large penalties to achieve appropriate deterrence against 
bad actor employers who willfully disregard their obligation to protect 
their employees when certain aggravating circumstances are present, 
such as a large number of injuries or illnesses, bad faith, or an 
extensive history of noncompliance. (OSHA Directive CPL 02-00-080 
(October 21, 1990.)) Its purpose is to increase the impact of OSHA's 
enforcement ability. This policy uses OSHA's authority to issue a 
separate penalty for each instance of willful noncompliance with an 
OSHA standard, such as each employee lacking the same required 
protections, or each workstation lacking the same required controls. It 
can be more difficult to use this policy under the General Duty Clause 
because the Fifth Circuit and the Occupational Safety and Health Review 
Commission have held that OSHA may only cite a hazardous condition once 
under the General Duty Clause, regardless of its scope. Reich v. 
Arcadian Corp., 110 F.3d 1192, 1199 (5th Cir. 1997). Thus, even where 
OSHA finds that an employer willfully failed to protect a large number 
of employees from a COVID-19 hazard, OSHA likely could not cite the 
employer on a per-instance basis for failing to protect each of its 
employees. A COVID-19-specific ETS will clarify the permissible units 
of prosecution and thereby make clear OSHA's authority to separately 
cite employers for each instance of the employer's failure to protect 
employees and for each affected employee, where appropriate.
    By providing needed clarity, the ETS will facilitate ``willful'' 
and ``egregious'' determinations that are critical enforcement tools 
OSHA can use to adequately address violations by employers who have 
shown a conscious disregard for the health and safety of their workers 
in response to the pandemic. Without the necessary clarity, OSHA has 
been limited in its ability to impose penalties high enough to motivate 
the very large employers who are unlikely to be deterred by penalty 
assessments of tens of thousands of dollars, but whose noncompliance 
can endanger thousands of workers. Without a willful classification (or 
a substantially similar prior violation), the maximum penalty for a 
serious General Duty Clause violation is $13,653, regardless of the 
scope of the hazard.
The General Duty Clause Provides Incomplete Protection at Multi-
Employer Worksites
    Finally, the General Duty Clause has limited application to multi-
employer worksites like hospitals, as it cannot be used to cite an 
employer whose own employees were not exposed to a hazard even if that 
employer may have created, contributed to, or controlled the hazard. 
See Solis v. Summit Contractors, Inc., 558 F.3d 815, 818 (8th Cir. 
2009) (``Subsection (a)(1) [the General Duty Clause] creates a general 
duty running only to an employer's own employees,

while subsection (a)(2) creates a specific duty to comply with 
standards for the good of all employees on a multi-employer 
worksite.''). For example, if a janitorial services contractor were to 
send one employee who is COVID-19 positive into a healthcare setting 
and knowingly allow that employee to work around employees of other 
employers, the janitorial services contractor who created the hazard 
could not be issued a General Duty Clause citation because none of that 
employer's own employees would have been exposed to the hazard. This 
limitation of the General Duty Clause can prevent OSHA from citing the 
employer on a multi-employer worksite who may be the most responsible 
for an existing COVID-19 hazard or best positioned to mitigate that 
hazard.
    For all of the reasons described above, OSHA finds that the General 
Duty Clause is not an adequate enforcement tool to protect the 
employees covered by this standard from the grave danger posed by 
COVID-19.
c. OSHA and Other Entity Guidance Is Insufficient
    OSHA has issued numerous non-mandatory guidance products to advise 
employers on how to protect workers from SARS-CoV-2 infection. (See 
https://www.osha.gov/coronavirus) Even the most comprehensive guidance 
makes clear, as it must, that the guidance itself imposes no new legal 
obligations, and that its recommendations are ``advisory in nature.'' 
(See OSHA's online guidance, Protecting Workers: Guidance on Mitigating 
and Preventing the Spread of COVID-19 in the Workplace (January 29, 
2021); and OSHA's earlier 35-page booklet, Guidance on Preparing 
Workplaces for Covid-19 (March 9, 2020)). This guidance, as well as 
guidance materials issued by other government agencies and 
organizations, including the CDC, the Centers for Medicare & Medicaid 
Services (CMS), the Institute of Medicine (IOM), and the World Health 
Organization (WHO), help protect employees to the extent that employers 
voluntarily choose to implement the practices they recommend.\17\ 
Unfortunately, OSHA's experience shows that does not happen 
consistently or rigorously enough, resulting in inadequate protection 
for employees.
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    \17\ Although the Centers for Medicare & Medicaid Services (CMS) 
has issued regulations requiring healthcare employers that accept 
payment through Medicare and Medicaid to implement nationally 
recognized infection control practices (see 42 CFR Pts. 400-699), 
those regulations do not obviate the need for this ETS. As a 
preliminary matter, not all healthcare workplaces covered by the ETS 
accept Medicare and Medicaid, and those that do not are not required 
to comply with the CMS regulations. Furthermore, OSHA has important 
enforcement tools that CMS lacks: OSHA can enforce a standard by 
responding to complaints, conducting random unannounced inspections, 
and issuing citations with penalties, whereas compliance with CMS 
regulations is generally validated through periodic accreditation 
surveys. The joint effect of the CMS regulations and a new ETS would 
improve the breadth, quality and implementation of infection control 
programs in a manner that the CMS regulations cannot do, and have 
not done, alone. Indeed, that has been OSHA's experience in 
enforcing its existing standards against healthcare employers that 
overlap with CMS requirements, such as the Respirator, PPE, and 
Bloodborne Pathogens standards. Thus, the ETS is necessary to 
provide additional coverage and enforcement tools above and beyond 
the CMS regulations.
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    As documented in numerous peer-reviewed scientific publications, 
CDC, IOM, and WHO have recognized a lack of compliance with non-
mandatory recommended infection-control practices (Siegel et al., 2007; 
IOM, 2009; WHO, 2009). OSHA was aware of these findings when it 
previously concluded that an ETS was not necessary, but at the time of 
that conclusion, the agency erroneously believed that it would be able 
to effectively use the non-mandatory guidance as a basis for 
establishing the mandatory requirements of the General Duty Clause, and 
informing employers of their compliance obligations under existing 
standards. As explained above, that has not proven to be an effective 
strategy. Moreover, when OSHA made its initial necessity determination 
at the beginning of the pandemic, it made an assumption that given the 
unprecedented nature of the COVID-19 pandemic, there would be an 
unusual level of widespread voluntary compliance by the regulated 
community with COVID-19-related safety guidelines (see, e.g., DOL, May 
29, 2020 at 20 (observing that ``[n]ever in the last century have the 
American people been as mindful, wary, and cautious about a health risk 
as they are now with respect to COVID-19,'' and that many ``protective 
measures are being implemented voluntarily, as reflected in a plethora 
of industry guidelines, company-specific plans, and other sources'')).
    Since that time, however, developments have led OSHA to conclude 
that the same uneven compliance documented by CDC, IOM, and WHO is also 
occurring for the COVID-19 guidance issued by OSHA and other agencies. 
This was evidenced by a cross-sectional study performed from late 
summer to early fall of 2020 in New York and New Jersey that found non-
compliance and widespread inconsistencies in COVID-19 response programs 
(Koshy et al., February 4, 2021). Several other factors have also been 
found to contribute to uneven implementation of controls to prevent the 
spread of COVID-19. For example, there has been a reported rise of 
``COVID fatigue'' or ``pandemic fatigue''--i.e., a decrease in 
voluntary use of COVID-19 mitigation measures over time (Silva and 
Martin, November 14, 2020; Meichtry et al., October 26, 2020; Belanger 
and Leander, December 9, 2020). In addition, the fear of financial 
loss; skepticism about the danger posed by COVID-19; and even a simple 
human tendency, called ``psychological reactance,'' to resist curbs on 
personal freedoms, i.e., an urge to do the opposite of what somebody 
tells you to do, may also play a role in the uneven implementation of 
COVID-19 mitigation measures (Belanger and Leander, December 9, 2020; 
Markman, April 20, 2020).
    The high number of COVID-19-related complaints and reports also 
suggests a lack of widespread compliance with existing voluntary 
guidance. Although the number of employee complaints is declining, OSHA 
continues to receive hundreds of complaints every month, including 
complaints alleging that healthcare employers are not consistently 
following non-mandatory CDC guidance to protect employees. If guidance 
were followed more strictly, or if there were enough voluntary 
compliance with steps to prevent illness, OSHA would expect to see a 
significant reduction in COVID-19-related complaints from employees.
    The dramatic increases in the percentage of the population that 
contracted the virus toward the end of 2020 and in early 2021 indicated 
a continued risk of COVID-19 spread in workplace settings (for more 
information on the prevalence of COVID-19 see Grave Danger (Section 
IV.A of the preamble)) despite OSHA's publication of numerous specific 
and comprehensive guidance documents. OSHA has found that neither 
reliance on voluntary action by employers nor OSHA non-mandatory 
guidance is an adequate substitute for specific, mandatory workplace 
standards at the federal level. Public Citizen v. Auchter, 702 F.2d 
1150 at 1153 (voluntary action by employers ``alerted and responsive'' 
to new health data is not an adequate substitute for government 
action). The ETS is one aspect of the national response to the pandemic 
that is needed to improve compliance with infection control measures by 
establishing clear, enforceable measures that put covered employers on 
notice that they must,

rather than should, take action to protect their employees. For these 
reasons, OSHA finds that non-mandatory guidance efforts are not 
sufficient, by themselves or in conjunction with General Duty Clause 
enforcement, to protect employees covered by this ETS from being 
infected by, and suffering death or serious health consequences from, 
COVID-19.
d. A Uniform Nationwide Response to the Pandemic Is Necessary To 
Protect Workers
    OSHA is charged by Congress with protecting the health and safety 
of American workers. Yet OSHA's previous approach proved ineffective in 
meeting that charge. While some states and localities stepped in to 
fill the gaps in employee protection, these approaches do not provide 
consistent protection to workers and have, in some cases, been relaxed 
prematurely, leading to additional outbreaks (Hatef et al., April 
2021). In some states there are no workplace requirements at all. OSHA 
has determined that a Federal standard is needed to ensure sufficient 
protection for employees in all states in the settings covered by this 
ETS; clarity and consistency about the obligations employers have to 
protect their employees in these settings; and a level playing field 
among employers.
    As the pandemic has continued in the United States, there has been 
increasing recognition of the need for a more consistent national 
approach (GAO, September 2020; Budryk, November 17, 2020; Horsley, May 
1, 2020). One of the justifications for OSHA standards has always been 
to ``level the playing field'' so that employers who proactively 
protect their workforces are not placed at a competitive disadvantage 
(Am. Textile Mfrs. Inst. v. Donovan, 452 U.S. 490, 521 n.38 (1981)). 
Many employers have advised OSHA that they would welcome a nationwide 
ETS for that reason. For example, in its October 9, 2020 petition for a 
COVID-19 ETS, ORCHSE Strategies, LLC explained that it is 
``imperative'' that OSHA issue an ETS to provide employers one 
standardized set of requirements to address safety and health for their 
workers (ORCHSE, October 9, 2020). This group of prominent business 
representatives explained that an ETS would eliminate confusion and 
unnecessary burden on workplaces that are struggling to understand how 
best to protect their employees in the face of confusing and differing 
requirements across states and localities. While noting that ``OSHA 
could not pre-empt a State from keeping its own rule (assuming it is 
`at least as effective' as OSHA's standard),'' they also observed that 
``historically, the impact of federal rulemaking in similar situations 
(e.g., HazCom) has been that most, if not all, of the States ultimately 
adhere to the federal requirements . . . . That can only be 
accomplished if OSHA takes the lead'' (id.). ``Without an ETS,'' they 
continue, ``employers are left on their own to determine the preventive 
measures that need to be undertaken'' (id.).
    Given that thousands of healthcare employees each week continue to 
be infected with COVID-19, many of whom will become hospitalized or 
die, OSHA recognizes that a patchwork approach to worker safety has not 
been successful in mitigating this infectious disease outbreak, and 
that an ETS is necessary to provide clear and consistent protection to 
covered employees across the country.
e. OSHA's Other Previous Rationales for Not Promulgating an ETS No 
Longer Apply
    In addition to asserting that existing standards, guidance, and the 
General Duty Clause would provide sufficient tools to address COVID-19 
hazards to employees, OSHA had previously cited the need to respond to 
evolving scientific knowledge about the virus as part of its rationale 
for not issuing an ETS during the late spring of 2020. Knowledge of the 
nature of COVID-19 was undoubtedly less certain at the beginning of the 
pandemic when OSHA made its initial determination that an ETS was not 
necessary. There have been recent changes in CDC recommendations for 
vaccinated people outside the healthcare context. However, for 
unvaccinated workers, since the summer of 2020 there has been 
considerable stability in the guidance from the CDC and other health 
organizations regarding the basic precautions that are essential to 
protect unvaccinated people from exposure to COVID-19 while indoors. 
And the CDC still recommends these precautions to protect vaccinated 
workers in healthcare settings. For example, the CDC's COVID-19 
guidance on How to Protect Yourself & Others (CDC, March 8, 2021) 
includes the same guidance it issued in July 2020 regarding the basic 
protections of face coverings, distancing, barriers, and hand hygiene. 
Moreover, OSHA's previous concern--that an ETS would unintentionally 
enshrine requirements that are subsequently proven ineffective in 
reducing transmission--has proven to be overstated. Moreover, even 
after issuing an ETS OSHA retains the flexibility to update the ETS to 
adjust to the subsequent evolution of CDC workplace guidance. The major 
development in infection control over the last year--the development, 
authorization, and growing distribution and use of COVID-19 vaccines--
is addressed in the ETS. Going forward, further developments can be 
addressed through OSHA's authority to modify the ETS if needed, or to 
withdraw it entirely if vaccination and other efforts end the current 
emergency. Nothing in the D.C. Circuit's decision in In re Am. Fed'n of 
Labor & Cong. of Indus. Orgs., No. 20-1158, 2020 WL 3125324 (AFL-CIO, 
June 11, 2020); rehearing en banc denied (July 28, 2020) precludes 
OSHA's decision to promulgate an ETS now. To the contrary, at an early 
phase of the pandemic, when its most severe effects had not yet been 
experienced, the court decided not to second-guess OSHA's decision to 
hold off on regulation in order to see if its non-regulatory 
enforcement tools could be used to provide adequate protection against 
the virus. ``OSHA's decision not to issue an ETS is entitled to 
considerable deference,'' the court explained, noting the ``the 
unprecedented nature of the COVID-19 pandemic'' and concluding merely 
that ``OSHA reasonably determined that an ETS is not necessary at this 
time.'' (Id., with emphasis added).
    Finally, it is worth noting that OSHA's conclusion as to the 
ineffectiveness of the current approach--i.e., relying on existing 
enforcement tools and voluntary guidance--is supported by a report 
issued by the DOL Office of Inspector General, dated February 25, 2021, 
which concluded after an investigation that OSHA's prior approach to 
addressing the hazards of COVID-19 leaves employees across the country 
at increased risk of COVID-19 infection (DOL OIG, February 25, 2021). 
The DOL OIG report specifically recommended that OSHA reconsider its 
prior decision not to issue an ETS to provide the necessary protection 
to employees from the hazards of COVID-19.
f. Even in Combination, the Guidance and General Duty Clause Are Still 
Inadequate
    Early in the pandemic, OSHA took the position that existing 
standards, together with the combination of non-mandatory guidance and 
General Duty Clause citations, would be sufficient to protect employees 
so that specific mandatory requirements would not be necessary. In 
theory, where existing standards did not address an issue directly, the 
remaining regulatory gap could be filled by guidance from OSHA,

which would provide notice of COVID-19 hazards and describe feasible 
means of abating them, enabling OSHA to later issue a General Duty 
Clause citation to an employer who had failed to follow that guidance. 
OSHA's enforcement experience has now disproven that theory. As 
explained above, existing standards leave an enormous regulatory gap 
that OSHA's guidance, together with the General Duty Clause, cannot 
cover for the settings covered by this ETS.
    In practice, the combination of guidance and General Duty Clause 
authority has done little to protect employees in settings covered by 
the standard where employers were not focused on that goal. The 
limitations identified above, including the heavy litigation burden for 
General Duty Clause citations, remain. Instead of being able to rely on 
clear requirements in a standard, employers were left to wade through 
guidance not only from OSHA but also from multiple other agencies, 
states, media, and other sources without any clarity as to how the 
different guidance materials should work together or what to do when 
alternative guidance did not square with OSHA's guidance. Perhaps 
because OSHA's guidance was not mandatory, it was frequently ignored or 
followed only in part. As explained above, the General Duty Clause's 
shortcomings as an enforcement tool left OSHA, in most cases, 
ultimately unable to impose all of the layers of protection necessary 
to protect employees from COVID-19.
    In sum, based on its enforcement experience during the pandemic to 
date, OSHA concludes that continued reliance on existing standards, 
together with the combination of guidance and General Duty Clause 
obligations, in lieu of an ETS, will not protect employees covered by 
this ETS against the grave danger posed by COVID-19.
g. Recent Vaccine Developments Demonstrate the Importance of the ETS; 
They Do Not Obviate the Current Need for an ETS
    The development and availability of safe and highly effective 
vaccines is an important development in the nation's response to COVID-
19. The very low percentage of breakthrough cases (illness among 
vaccinated people) have led to recent updates to CDC guidance 
acknowledging vaccination as an effective control to prevent 
hospitalization and death from COVID-19 to such an extent that the CDC 
has concluded that most other controls are not necessary to protect 
vaccinated people outside healthcare settings. In the United States, 
all people ages 12 and older are eligible to be vaccinated, and 
vaccines are readily available in most parts of the country.
    However, despite the remarkable success of our nation's vaccine 
program and the substantial promise that vaccines hold, as explained 
below, OSHA does not believe they eliminate the need for this standard. 
OSHA embraces the value of vaccination and views the ETS as essential 
to facilitating access to this critical control for those workers who 
wish to receive it while still protecting those who cannot be, or will 
not be, vaccinated. And by excluding certain workplaces and well-
defined work areas where all employees are fully vaccinated from all 
requirements of the standard (paragraphs (a)(2)(iv) and (v)), and 
exempting fully vaccinated workers in certain settings where not all 
employees are vaccinated from several requirements of the standard 
(paragraph (a)(4)), the ETS encourages vaccination for employers and 
employees who do not want to follow those requirements.
    In addition, for vaccines to be effective, workers need first to 
actually receive them. While the supply of vaccines and their 
distribution continues to increase, as of the date of the promulgation 
of this standard, approximately a quarter of healthcare workers have 
not yet completed COVID-19 vaccination with many of those expressing 
vaccine hesitation (King et al., April 24, 2021). Although a majority 
of Americans over 65 are vaccinated, the percentage among the working-
age population is much lower (44%) (CDC, May 24, 2021a). There are 
several barriers to vaccination for the working-age population. Many 
employees who want to be vaccinated may be unable to do so unless the 
employer authorizes time off work, or may be financially unable to 
absorb a reduced paycheck for taking unpaid leave to be vaccinated or 
potentially missing a significantly larger period of time from work 
(and a larger financial hit) because of the potential side effects of 
the vaccination (SEIU Healthcare, February 8, 2021). A recent Kaiser 
Foundation survey of people who expressed reluctance to be vaccinated 
indicates that 70% of those respondents (76% and 77% among Black and 
Latinx respondents, respectively) were concerned about side effects, 
and 45% (57% Black and 54% Latinx) cited fears that they might miss 
work if the side effects made them sick (KFF, May 6, 2021). Another 
recent study, which surveyed 500 businesses, found that paid time off 
for vaccination and recovery was the highest overall motivator for 
employees to get vaccinated (51%), which was even higher than employers 
offering the vaccine on site (49%) (Azimi et al., April 9, 2021). Yet a 
different report indicates that before the pandemic, about 70% of the 
lowest-wage workers had no access to paid sick leave, meaning that any 
time off for vaccination or recovery would result in lost wages for 
those who can least afford those losses (Gould, February 28, 2020). 
Despite the American Rescue Plan (ARP) extending tax credits for some 
employers to allow this sort of sick leave, such leave is not mandated. 
Those surveys are consistent with the experience among healthcare 
workers at Yale University and Yale New Haven Hospital. When workers 
were surveyed at the time the FDA granted Emergency Use Authorization 
of the Pfizer-BioNTech vaccine, the lack of incentives or mitigation of 
risk (e.g., not using sick days or pay loss for side effects) was a key 
reason stated by people who identified themselves as unlikely to get 
the vaccine. (Roy et al., December 29, 2020). Following four months of 
vaccination efforts, researchers found that although 75% had been 
vaccinated, roughly half of low wage, hourly employees, had not yet 
been vaccinated, and based on their previous research, identified the 
provision of additional paid sick leave days as a critical barrier for 
this population of workers (Roy and Forman, April 7, 2021). Even when 
employees can arrange for time off for the first dose, some of the same 
difficulties may prevent workers from returning during the designated 
time window for the second dose of two-dose vaccines. The ETS addresses 
these obstacles with a requirement that employers must authorize paid 
leave to cover the time for vaccination and for recovery from side 
effects.
    Further, there is a need to continue building vaccine confidence in 
some parts of the population, making the ETS even more important to 
assure safe working conditions during the period before these workers 
are vaccinated. Moreover, as discussed in more depth in Grave Danger 
(Section IV.A. of the preamble), even though vaccines are now more 
readily available, they do not protect all workers. Some workers are 
unable to be vaccinated for medical or other reasons, even if they are 
willing to be. And in immunocompromised workers, vaccines can be 
considerably less effective than in immunocompetent individuals.\18\ 
And while some

employees may simply elect not to be vaccinated for personal reasons, 
OSHA has a statutory duty to ensure that employers protect those 
employees from the grave danger of COVID-19 regardless of their basis 
for refusing vaccination.
---------------------------------------------------------------------------

    \18\ There is concern that vaccines may not be effective for 
immunocompromised individuals. A study evaluating 67 individuals 
with blood cancers found that 46% of them did not generate an immune 
response despite being fully vaccinated (Agha et al., April 7, 
2021). Almost three quarters of those with chronic lymphocytic 
leukemia were non-responsive. A study on 658 transplant recipients 
found that 46% of recipients did not develop an immune response, 
including 18% of those not on an immunosuppression regimen and 33% 
of those who received their transplant more than 12 years prior 
(Boyarsky et al., May 5, 2021). A study on those with chronic 
inflammatory disease found a three-fold reduction in immune response 
generated by vaccination in comparison to immunocompetent adults, 
including a 36 fold reduction for those receiving B cell depletion 
therapies (Deepak et al., April 9, 2021). Furthermore, the 
Australian Agency for Clinical Innovation issued a summary detailing 
significant concerns about the efficacy for vaccination for 
immunocompromised persons and need for these individuals to continue 
using non-pharmaceutical interventions (ACI, April 28, 2021). While 
vaccines are a highly effective tool to minimize infections, it 
cannot be overlooked that it is likely not an effective means of 
control for all individuals.
---------------------------------------------------------------------------

    These factors, along with the uneven vaccination rates among some 
sub-populations, make the need for this ETS especially acute. For 
example, the Latinx and Black populations who have been 
disproportionately harmed by the virus also have the lowest vaccination 
rates (Ndugga et al., February 18, 2021; CDC, May 24, 2021a). This ETS 
can help facilitate vaccination among those groups, protect those who 
cannot or will not be vaccinated, and thereby mitigate the 
disproportionate impacts of the virus for workers in these groups.
    Even when the ETS helps currently unvaccinated workers overcome the 
obstacles to becoming vaccinated, they must still be protected by the 
other measures of this standard until they are fully protected by the 
vaccine. With the two-dose vaccines in particular, the time from a 
first shot to fully effective vaccination is 5 to 6 weeks.
    Furthermore, also increasing are new virus variants, the most 
prevalent of which, the B.1.1.7 variant first identified in the U.K., 
now appears responsible for almost 66% of the cases in the U.S (CDC, 
May 24, 2021b). While the currently authorized vaccines appear 
effective against all of the variants now circulating, promoting 
vaccination as quickly as possible becomes even more critical because 
the variant is not only more transmissible, it also appears to cause 
more severe disease.
    Finally, while the science continues to develop, the full extent 
and duration of the immune response remains unknown. Additional 
evidence is also needed to determine the extent to which people who are 
vaccinated could still be infected and transmit the disease to others, 
even if they themselves are protected from the worst health effects. 
Although such cases do not appear to be common, the ETS would help 
protect these employees and their co-workers in mixed groups of 
vaccinated and unvaccinated people.
    These issues, as elaborated further in the discussion of Grave 
Danger, demonstrate that the various protections required in this ETS 
are still necessary, even for workplaces in which many but not all 
members of the workforce have been vaccinated.
    This pandemic has taken a devastating toll on all of American 
society, and addressing it requires a whole-of-government response 
(White House, April 2, 2021). This ETS is part of that response. OSHA 
shares the nation's hope for the promise of recovery created by the 
vaccines. But in the meantime, it also recognizes that measures to 
mitigate the spread of COVID-19, including encouraging and facilitating 
vaccination, are still necessary in the settings covered by this 
standard. However, although OSHA finds it necessary to continue these 
mitigation measures for the immediate future, the agency will adjust as 
conditions change. As more of the workforce becomes vaccinated and the 
post-vaccination evidence base continues to grow, and the CDC updates 
its guidance, OSHA will withdraw or modify the ETS to the extent the 
workplace hazard is substantially diminished in the settings covered by 
this ETS. However, at this point in time, the available evidence 
indicates that the ETS is still necessary to protect employees in the 
settings covered by this ETS, and the potential for higher immunity 
rates later on does not obviate the need to implement the ETS now.
References
Agency for Clinical Innovation (ACI). (2021, 28 April). Evidence 
check: Immunocompromised patients and COVID-19 vaccines. https://aci.health.nsw.gov.au/__data/assets/pdf_file/0009/645750/Evidence-check-Immunocompromised-patients-COVID-19-vaccines.pdf. (ACI, 28 
April, 2021).
Agha et al., (2021, April 7). Suboptimal response to COVID-19 mRNA 
vaccines in hematologic malignancies patients. medRxiv 
2021.04.06.21254949. https://doi.org/10.1101/2021.04.06.21254949. 
(Agha et al., April 7, 2021).
American Federation of Labor and Congress of Industrial 
Organizations, USCA Case #20-1158, Document #1846700. (2020, June 
11). (AFL-CIO, June 11, 2020).
American Federation of Labor and Congress of Industrial 
Organizations. Denial of Petition for Rehearing En Banc on Behalf Of 
American Federation of Labor and Congress of Industrial 
Organizations. USCA Case #20-1158, Document #1853761. (2020, July 
28). (AFL-CIO, July 28, 2020).
Azimi, T et al., (2021, April 9).Getting to work: Employers' role in 
COVID-19 vaccination. https://www.mckinsey.com/industries/pharmaceuticals-and-medical-products/our-insights/getting-to-work-employers-role-in-covid-19-vaccination#. (Azimi, April 9, 2021).
Belanger, J and Leander, P. (2020, December 9). What Motivates COVID 
Rule Breakers? Scientific American. https://www.scientificamerican.com/article/what-motivates-covid-rule-breakers/. (Belanger and Leander, December 9, 2020).
Boyarsky, BJ et al., (2021, May 5). Antibody Response to 2-Dose 
SARS-CoV-2 mRNA Vaccine Series in Solid Organ Transplant Recipients. 
JAMA. 2021 May 5. doi: 10.1001/jama.2021.7489. PMID: 33950155. 
(Boyarsky et al., May 5, 2021).
Budryk, Z. (2020, November 17). Fauci calls for `a uniform approach' 
to coronavirus pandemic. The Hill. https://thehill.com/policy/healthcare/526378-fauci-calls-for-a-uniform-approach-to-the-coronavirus-pandemic?rl=1. (Budryk, November 17, 2020).
Centers for Disease Control and Prevention (CDC). (2020, May 28). 
United States Coronavirus (COVID-19) Death Toll Surpasses 100,000. 
https://www.cdc.gov/media/releases/2020/s0528-coronavirus-death-toll.html. (CDC, May 28, 2020).
Centers for Disease Control and Prevention (CDC). (2021, March 8). 
How to Protect Yourself & Others. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/prevention.html. (CDC, March 8, 
2021).
Centers for Disease Control and Prevention (CDC). (2021a, May 24). 
Demographic Trends of People Receiving COVID-19 Vaccinations in the 
United States. https://covid.cdc.gov/covid-data-tracker/#vaccination-demographics-trends. (CDC, May 24, 2021a).
Centers for Disease Control and Prevention (CDC). (2021b, May 24). 
Variant Proportions. https://covid.cdc.gov/covid-data-tracker/#variant-proportions. (CDC, May 24, 2021b).
Deepak, et al., (2021, April 7). Glucocorticoids and B Cell 
Depleting Agents Substantially Impair Immunogenicity of mRNA 
Vaccines to SARS-CoV-2. medRxiv 2021.04.05.21254656. https://doi.org/10.1101/2021.04.05.21254656. (Deepak et al., April 7, 2021).
Fendt, L. (2020, September 30). The JBS Coronavirus Outbreak is 
Officially Resolved, but Workers' Families Are Still Fighting For 
Compensation. CPR News. https://www.cpr.org/2020/09/30/colorado-coronavirus-jbs-outbreak-resolved-workers-families-want-compensation/. (Fendt, September 30, 2020).

Gould. E. (2020, February 28). Lack of paid sick days and large 
numbers of uninsured increase risks of spreading the coronavirus. 
https://www.epi.org/blog/lack-of-paid-sick-days-and-large-numbers-of-uninsured-increase-risks-of-spreading-the-coronavirus/. (Gould, 
February 28, 2020).
Government Accountability Office (GAO). (2020, September). COVID-19: 
Federal Efforts Could Be Strengthened by Timely and Concerted 
Actions. https://www.gao.gov/assets/710/709934.pdf. (GAO, September 
2020).
Hatef, E. et al., (2021, April). Early relaxation of community 
mitigation policies and risk of COVID-19 resurgence in the United 
States. Prev Med 145:106435. doi: 10.1016/j.ypmed.2021.106435 (Hatef 
et al., April, 2021).
Horsely, S. (2020, May 1). U.S. Workplace Safety Rules Missing in 
the Pandemic. National Public Radio. https://www.npr.org/2020/05/01/849212026/it-s-the-wild-west-u-s-workplace-safety-rules-missing-in-the-pandemic. (Horsley, May 1, 2020).
Howard, J. (2021, May 22). ``Response to request for an assessment 
by the National Institute for Occupational Safety and Health, 
Centers for Disease Control and Prevention, U.S. Department of 
Health and Human Services, of the current hazards facing healthcare 
workers from Coronavirus Disease-2019 (COVID-19).'' (Howard, May 22, 
2021).
Institute of Medicine (IOM). (2009). Respiratory Protection for 
Healthcare Workers in a Workplace Against Novel H1N1 Influenza A: A 
letter report. The National Academies Press. http://www.nap.edu/catalog/12748.html. (IOM, 2009).
Kaiser Family Foundation (KFF). (2021, May 6). KFF COVID-19 Vaccine 
Monitor: April 2021. https://www.kff.org/coronavirus-covid-19/poll-finding/kff-covid-19-vaccine-monitor-april-2021/. (KFF, May 6, 
2021).
King, WC et al., (2021, April 24). COVID-19 vaccine hesitancy 
January-March 2021 among 18-64 year old US adults by employment and 
occupation. medRxiv; https://www.medrxiv.org/content/10.1101/2021.04.20.21255821v3. (King et al., April 24, 2021).
Koshy, K, Shendell, DG, Presutti, MJ. (February 4, 2021). 
Perspectives of region II OSHA authorized safety and health trainers 
about initial COVID-19 response programs. Safety Science 138. 
https://doi.org/10.1016/j.ssci.2021.105193. (Koshy et al., February 
4, 2021).
Markman, A. (2020, April 20). Why are there still so many 
coronavirus skeptics? Fast Company. https://www.fastcompany.com/90492518/why-are-there-still-so-many-coronavirus-skeptics. (Markman, 
April 20, 2020).
Meichtry, S et al., (2020, October 26). Pandemic Fatigue is Real--
And It's Spreading; Collective exhaustion with coronavirus 
restrictions has emerged as a formidable adversary for governments. 
The Wall Street Journal. https://www.wsj.com/articles/pandemic-fatigue-is-realand-its-spreading-11603704601. (Meichtry et al., 
October 26, 2020).
Moore, KA et al., (2020, April 30). COVID-19: The CIDRAP Viewpoint. 
Part 1: The Future of the COVID-19 Pandemic: lessons Learned from 
Pandemic Influenza. University of Minnesota Center for Infectious 
Disease Research and Policy. https://www.cidrap.umn.edu/sites/default/files/public/downloads/cidrap-covid19-viewpoint-part1_0.pdf. 
(Moore et al., April 30, 2020).
Ndugga, N et al., (2021, February 18). Latest Data on COVID-19 
Vaccinations Race/Ethnicity. Kaiser Family Foundation. https://www.kff.org/coronavirus-covid-19/issue-brief/latest-data-on-covid-19-vaccinations-race-ethnicity/. (Ndugga et al., February 18, 2021).
Occupational Safety and Health Administration (OSHA). (2020, March 
9). Guidance on Preparing Workplaces for COVID-19. https://www.osha.gov/sites/default/files/publications/OSHA3990.pdf. (OSHA, 
March 9, 2020).
Occupational Safety and Health Administration (OSHA). (2020, March 
18). Letter from Loren Sweatt to Congressman Robert C. ``Bobby'' 
Scott. (OSHA, March 18, 2020).
Occupational Safety and Health Administration (OSHA). (2021, January 
29). Protecting Workers: Guidance on Mitigating and Preventing the 
Spread of COVID-19 in the Workplace. https://www.osha.gov/coronavirus/safework. (OSHA, January 29, 2021).
Occupational Safety and Health Administration (OSHA). (2021, March 
12). Enforcement Memo: Updated Interim Enforcement Response Plan for 
Coronavirus Disease 2019 (COVID-19). https://www.osha.gov/memos/2021-03-12/updated-interim-enforcement-response-plan-coronavirus-disease-2019-covid-19. (OSHA, March 12, 2021).
Occupational Safety and Health Administration (OSHA). (2021, May 
23). COVID-19 Response Summary. https://www.osha.gov/enforcement/covid-19-data. (OSHA, May 23, 2021)
ORCHSE Strategies. (2020, October 9). ``Petition to the U.S. 
Department of Labor--Occupational Safety and Health Administration 
(OSHA) for an Emergency Temporary Standard (ETS) for Infectious 
Disease.'' (ORCHSE, October 9, 2020)
Roy, B et al., (2020, December 29). Health Care Workers' Reluctance 
to Take the COVID-19 Vaccine: A Consumer-Marketing Approach to 
Identifying and Overcoming Hesitancy. NEJM Catalyst. https://catalyst.nejm.org/doi/pdf/10.1056/CAT.20.0676. (Roy et al., December 
29, 2020).
Roy, B and Forman, HP. (2021, April 7). Doctors: Essential workers 
should get two days of paid leave for COVID vaccine side effects. 
https://www.usatoday.com/in-depth/opinion/2021/04/07/essential-workers-paid-leave-covid-vaccine-side-effects-column/4816014001/. 
(Roy and Forman, April 7, 2021).
SEIU Healthcare. (2021, February 8). Research shows 81% of 
healthcare workers willing to take COVID-19 vaccines but personal 
financial pressures remain a significant barrier for uptake. https://www.newswire.ca/news-releases/research-shows-81-of-healthcare-workers-willing-to-take-covid-19-vaccines-but-personal-financial-pressures-remain-a-significant-barrier-for-uptake-888810789.html. 
(SEIU Healthcare, February 8, 2021).
Siegel, JD, Rhinehart, E, Jackson, M, Chiarello, L, and the 
Healthcare Infection Control Practices Advisory Committee. (2007). 
2007 Guideline for Isolation Precautions: Preventing Transmission of 
Infectious Agents in Healthcare Settings. Centers for Disease 
Control and Prevention. https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html. (Siegel et al., 2007).
Silva, C and Martin, M. (2020, November 14). U.S. Surgeon General 
Blames ``Pandemic Fatigue'' for Recent COVID-19 Surge. NPR. https://www.npr.org/sections/coronavirus-live-updates/2020/11/14/934986232/u-s-surgeon-general-blames-pandemic-fatigue-for-recent-covid-19-surge. (Silva and Martin, November 14, 2020).
United States Department of Labor (DOL). (2020, May 29). In Re: 
American Federation Of Labor And Congress Of Industrial 
Organizations. Department Of Labor's Response to the Emergency 
Petition for a Writ of Mandamus, No. 20-1158 (D.C. Cir., May 29, 
2020). (DOL, May 29, 2020).
United States Department of Labor (DOL), Office of the Inspector 
General (OIG). (2021, February 25). COVID-19: Increased Worksite 
Complaints and Reduced OSHA Inspections Leave U.S. Workers' Safety 
at Increased Risk. http://www.oig.dol.gov/public/reports/oa/2021/19-21-003-10-105.pdf. (DOL OIG, February 25, 2021).
World Health Organization (WHO). (2009). WHO Guidelines on Hand 
Hygiene in Health Care: A Summary--First Global Patient Safety 
Challenge Clean Care is Safer Care. (WHO, 2009).
The White House. (2021, April 2). Press Briefing by White House 
COVID-19 Response Team and Public Health Officials. https://www.whitehouse.gov/briefing-room/press-briefings/2021/04/02/press-briefing-by-white-house-covid-19-response-team-and-public-health-officials-23/. (The White House, April 2, 2021).

V. Need for Specific Provisions of the ETS

    Grave Danger (Section IV.A. of the preamble) identifies the danger 
of exposure to SARS-CoV-2 for healthcare workers and explains how the 
SARS-CoV-2 virus is transmitted. This section, on Need for Specific 
Provisions, examines the scientific underpinnings for the controls that 
OSHA has identified to stop that transmission in workplaces. In Section 
VIII, the Summary and Explanation for the various provisions of the 
ETS, OSHA

explains how those controls must be implemented in the workplace. Not 
all of the requirements of the ETS are examined in this Need for 
Specific Provisions section. Some are addressed fully in the Summary 
and Explanation sections.

A. Introduction--Effective Infection Prevention Utilizes Overlapping 
Controls

    An effective infection prevention program utilizing a suite of 
overlapping controls in a layered approach better ensures that no 
inherent weakness in any one approach results in an infection incident. 
OSHA emphasizes that each of the infection prevention practices 
required by the ETS provide some protection from COVID-19 by 
themselves, but work best when used together, layering their protective 
impact to boost overall effectiveness. A common depiction of this 
approach in use is Reason's model of accident causation dynamics, more 
commonly referred to as the ``Swiss Cheese Model of Accident 
Causation'' (Reason, April 12, 1990). Reason combined concepts of 
pathogen transmission and airplane accidents to present a model that 
illustrated that accidents are the result of the interrelatedness of 
imperfect defenses and unsafe actions that are largely unobservable 
until an adverse outcome becomes apparent. Using the Swiss cheese 
analogy, each control has certain weaknesses or ``holes.'' The 
``holes'' differ between different controls. By stacking several 
controls together with different weaknesses, the ``holes'' are blocked 
by the strengths of the other controls. In other words, if controls 
with different weaknesses are layered, then any unexpected failure of a 
single control is protected against by the strengths of other controls. 
The model provides a guiding approach to reduce incidents across many 
sectors (Reason et al., October 30, 2006) and that perspective is 
reflected in widely accepted approaches to controlling infectious 
diseases (HICPAC, January 1, 1996; Rusnak et al., July 31, 2004; CDC, 
2012; WHO, 2016).
    The CDC Healthcare Infection Control Practices Advisory Committee's 
(HICPAC) Isolation Guidelines, which apply to healthcare settings, are 
an example of established national guidelines that illustrate layered 
controls to prevent the transmission of infectious diseases (Siegel et 
al., 2007). The Isolation Guidelines recommend two tiers of 
precautions: Standard Precautions and Transmission-Based Precautions 
(e.g., airborne, droplet, contact). Standard Precautions, under the 
Isolation Guidelines, are the minimum infection prevention practices 
that apply to patient care, regardless of the suspected or confirmed 
infection status of the patient, in any setting where health care is 
practiced. They are based on the principle that there is a possible 
risk of disease transmission from any patient, patient sample, or 
interaction with infectious material. For Standard Precautions, 
guidance follows that a certain set of controls should be implemented 
to reduce infectious disease transmission regardless of the diagnosis 
of the patient, in part because there is always baseline risk that is 
not necessarily either obvious or detectable. These precautions include 
controls such as improved hand hygiene, use of personal protective 
equipment, cleaning of equipment, environmental controls, handling of 
bed linens, changing work practices, and patient placement. When used 
in concert, these approaches protect workers from potential exposure to 
infectious agents.
    The Isolation Guidelines' second tier of precautions, Transmission-
Based Precautions, takes into consideration the transmission mechanism 
of specific diseases and complements Standard Precautions to better 
protect workers from the presence of known or suspected infectious 
agents. For instance, SARS-CoV-2, the infectious agent that causes 
COVID-19, is considered to be mainly transmissible through the droplet 
route in most settings (though there is evidence for airborne 
transmission as noted throughout this preamble). Droplet transmission 
occurs by the direct spray of large droplets onto conjunctiva or mucous 
membranes (e.g., the lining of the nose or mouth) of a susceptible host 
when an infected person sneezes, talks, or coughs. Droplet precautions 
are a suite of layered controls that are designed to prevent the direct 
spray of infectious material and supplement the suite of layered 
controls used for Standard Precautions. They are designed to protect 
workers from infectious agents that can be expelled in large 
respiratory droplets from infected individuals. These added 
interventions are implemented when infection is known or suspected and 
include placing patients in single rooms or physically distant within 
the same room, increased mask usage, and limiting patient movement. 
COVID-19 is considered capable of spreading through multiple routes of 
transmission, including airborne. Thus, the CDC recommends respiratory 
protection, isolation gowns, and gloves in healthcare settings to 
protect workers in those settings.
    While a suite of layered controls is appropriate for controlling 
infectious diseases, it is important to use the hierarchy of controls 
when choosing which controls to include and the order in which to 
implement them. Briefly, the hierarchy of controls refers to the 
concept that the best way to control for hazards is to preferentially 
utilize the most effective before complementing with less effective 
controls.\19\ Ideally, the hazard is eliminated, which would likely 
mean using an option such as conducting a telehealth visit outside of a 
patient care setting with respect to COVID-19 to ensure that there is 
no shared workspace and thus no potential for employee exposure to 
COVID-19. When a telehealth visit is not possible, workers must be 
protected through the implementation of controls. Outside the realm of 
infection control, the utilization of an engineering control or a 
change in on-site work practices could alone effectively minimize a 
hazard in many cases. However, infection prevention failures often are 
not apparent until an outbreak occurs, resulting in many infected 
workers. Therefore, it is important for employers to not only adhere to 
the hierarchy of controls when identifying controls to implement, but 
also to augment layers of feasible engineering controls (e.g., adequate 
ventilation, barriers) with administrative and work practice controls 
(e.g., physical distancing, cleaning, disinfection, telework, schedule 
modification, health screening). Personal protective equipment (e.g., 
gloves, respirators, and facemasks) can provide the final layer of 
control. This approach is consistent with both OSHA and CDC guidance 
for protecting workers and the public from COVID-19.
---------------------------------------------------------------------------

    \19\ The hierarchy of controls is a longstanding occupational 
safety practice and OSHA policy. Under its hierarchy of controls 
policy reflected in a number of standards, OSHA typically only 
allows employers to rely on respirators or other PPE to the extent 
that engineering controls to eliminate the hazard are not feasible. 
See, e.g., Sec. Sec.  1910.134(a) (respiratory protection) and 
1926.103 (respiratory protection); 1910.1000(e) (air contaminants); 
1910.95(b) (occupational noise exposure) and 1926.101 (hearing 
protection).
---------------------------------------------------------------------------

    In addition to the broad recognition and implementation of layered 
controls to protect against infectious diseases, a recent study 
elucidated the effectiveness of isolated and layered controls, with 
respect to close contacts amidst several community COVID-19 outbreaks 
in Thailand (Doung-ngern et al., September 14, 2020). While individual 
controls, such as wearing a face covering or maintaining at least a 
minimum distance from others, significantly reduced cases (28% and 40%, 
respectively), the researchers concluded

that a layered approach would be expected to reduce infections by 84%.
    Several similar studies evaluated the importance of layering 
controls during the 2002/2003 SARS outbreak caused by SARS-CoV-1, which 
is a different strain of the same species of virus as the virus that 
causes COVID-19 (SARS-CoV-2) and has some similar characteristics; 
importantly, both viruses are strains of the same viral species and 
exhibit the same modes of transmission. Researchers assessed five Hong 
Kong hospitals on how the utilization of interventions affected SARS 
transmission (Seto et al., May 3, 2003). In total, the study evaluated 
244 workers on their compliance with wearing masks, gowns, and gloves 
as well as adhering to hand hygiene protocols. Among the 69 workers who 
fully complied with the layered controls, there were no infections. 
However, 13 of 185 workers who used only some of the interventions were 
infected. The researchers concluded that the combined practice of 
droplet and contact precautions together significantly reduced the risk 
of infection from exposures to SARS-infected individuals.
    Another study investigated the approaches taken to reduce SARS-CoV-
1 transmission in hospitals in Taiwan during the 2003 portion of the 
outbreak (Yen et al., February 12, 2010). Researchers surveyed forty-
eight Taiwanese hospitals that provided care for 664 SARS-CoV-1 
patients, including 119 healthcare workers, to determine which controls 
each hospital implemented. Control measures included isolation of fever 
patients in the Emergency Department (ED), installation of handwashing 
stations in the ED, routing patients from the ED to an isolation ward, 
installation of fever screen stations in the ED, and installation of 
handwashing stations throughout the hospital. Analysis showed that 
while early SARS-CoV-1 case identification at fever screening stations 
outside the hospital could reduce transmission inside the hospital by 
half, combining that intervention with other interventions could almost 
double that reduction.
    A modeling effort to simulate an epidemic of seasonal influenza at 
a hypothetical hospital in Ann Arbor, Michigan, found that different 
interventions used in a layered approach would result in a greater 
predicted reduction in nosocomial cases (i.e., healthcare-associated 
infections) (Blanco et al., June 1, 2016). The study evaluated six 
different intervention techniques thought to be effective against 
influenza, including hand hygiene, employee vaccination, patient pre-
vaccination, patient isolation, therapies (e.g., antibody treatments, 
steroids), and face coverings. The researchers found, based on the 
model, that while no individual intervention exceeded a 27% percent 
reduction in cases, utilizing all controls would prevent half of all 
cases. While this model employed influenza as the vehicle to examine 
the effectiveness of layered protections, it gives no reason to believe 
that this approach would not be equally effective for other viruses 
such as SARS-CoV-2.
    In 2016, the World Health Organization, a specialized agency of the 
United Nations that is focused on international public health (WHO, 
2016), addressed the use of layering interventions to reduce infections 
in performed systematic reviews in its ``Guidelines on Core Components 
of Infection Prevention and Control Programmes at the National and 
Acute Health Care Facility Level.'' OSHA's perspective of layered 
interventions (e.g., engineering controls, work practice controls, 
personal protective equipment, training) is consistent with what the 
WHO Guidelines define as ``multimodality.'' WHO defines multimodality 
as follows:

    A [layered] strategy comprises several elements or components 
(three or more; usually five, http://www.ihi.org/topics/bundles/Pages/default.aspx) implemented in an integrated way with the aim of 
improving an outcome and changing behavior. It includes tools, such 
as bundles and checklists, developed by multidisciplinary teams that 
take into account local conditions. The five most common components 
include: (i) System change (availability of the appropriate 
infrastructure and supplies to enable infection prevention and 
control good practices); (ii) education and training of health care 
workers and key players (for example, managers); (iii) monitoring 
infrastructures, practices, processes, outcomes and providing data 
feedback; (iv) reminders in the workplace/communications; and (v) 
culture change within the establishment or the strengthening of a 
safety climate.

    The WHO guidelines strongly recommend practicing multimodality/
layered interventions to reduce infections based on WHO's systematic 
review of implementation efforts at facility-level and national scales. 
Based on a systematic review of 44 studies on implementing infection 
control practices at the facility level, and another systematic review 
of 14 studies on the success of National rollout programs using layered 
strategies, WHO concluded that using layered strategies was effective 
in improving infection prevention and control practices and reducing 
hospital-acquired illnesses (WHO, 2016).
    Vaccination does not eliminate the need for layered controls for 
healthcare workers exposed to COVID-19 patients, which can result in 
exposures that are more frequent and potentially carrying higher viral 
loads than those faced in workplaces not engaged in COVID-19 patient 
care. The Director of the CDC's National Institute for Occupational 
Health (NIOSH) recently wrote to OSHA that layers of control are still 
needed for vaccinated healthcare workers who remain at ``particularly 
elevated risk of being infected'' while treating COVID-19 patients: 
``The available evidence shows that healthcare workers are continuing 
to become infected with SARS-CoV-2, the virus that causes COVID-19, 
including both vaccinated and unvaccinated workers . . . Regardless of 
vaccination status, healthcare workers need additional protections such 
as respirators and other personal protective equipment (PPE) during 
care of patients with suspected or confirmed COVID-19.'' (Howard, May 
22, 2021). Further, a recent CDC study found that despite the positive 
impact on the roll-out of large-scale vaccination programs on reducing 
the transmission of COVID-19, a decline in non-pharmaceutical 
interventions (NPIs; e.g., physical distancing, face covering use) may 
result in a resurgence of cases (Borchering, May 5, 2021). The authors 
concluded that vaccination coverage in addition to compliance with 
mitigation strategies are essential to minimize COVID-19 transmission 
and prevent surges in hospitalizations and deaths. Thus, to effectively 
control COVID-19 transmission to those who are not vaccinated or 
immune, an increase in vaccination coverage in addition to NPIs, such 
as physical distancing, are crucial.
    Based on the above evidence, OSHA is requiring in the ETS that 
healthcare employers must not only implement the individual infection 
prevention measures discussed in the following sections, but also layer 
their controls to protect workers from the COVID-19 hazard due to the 
additional protection provided to workers when multiple control 
measures are combined.
References
Blanco, N et al., (2016, June 1). What Transmission Precautions Best 
Control Influenza Spread in a Hospital. American Journal of 
Epidemiology 183 (11): 1045-1054. https://doi.org/10.1093/aje/kwv293. (Blanco et al., June 1, 2016).
Borchering, RK et al., (2021, May 5). Modeling of Future COVID-19 
Cases, Hospitalizations, and Deaths, by Vaccination Rates and

Nonpharmaceutical Intervention Scenarios--United States, April-
September 2021. MMWR Morb Mortal Wkly Rep. ePub: 5 May 2021. doi: 
http://dx.doi.org/10.15585/mmwr.mm7019e3. (Borchering, May 5, 2021).
Centers for Disease Control and Prevention (CDC). (2012). An 
Introduction to Applied Epidemiology and Biostatistics, Lesson 1: 
Introduction to Epidemiology, Section 10: Chain of Infection. In: 
Principles of Epidemiology in Public Health Practice, Third Edition: 
http://www.cdc.gov/ophss/csels/dsepd/SS1978/Lesson1/Section10.html. 
(CDC, 2012).
Doung-ngern, P et al., (2020, September 14). Case-control Study of 
Use of Personal Protective Measures and Risk for SARS Coronavirus 2 
Infection, Thailand. Emerg In Dis 26, 11: 2607-2616. https://doi.org/10.3201/eid2611.203003. (Doung-ngern et al., September 14, 
2020) .
Hospital Infection Control Practices Advisory Committee (HICPAC). 
(1996, January 1). Guideline for isolation precautions in hospitals. 
Infection Control and Hospital Epidemiology 17(1): 53-80. (HICPAC, 
January 1, 1996).
Howard, J. (2021, May 22). ``Response to request for an assessment 
by the National Institute for Occupational Safety and Health, 
Centers for Disease Control and Prevention, U.S. Department of 
Health and Human Services, of the current hazards facing healthcare 
workers from Coronavirus Disease-2019 (COVID-19).'' (Howard, May 22, 
2021).
Reason, J. (1990, April 12). The Contribution of Latent Human 
Failures to the Breakdown of Complex Systems. Philosophical 
Transactions of the Royal Society London B327475 B327484. https://dol.org/10.1098/rstb.1990.0090. (Reason et al., April 12, 1990).
Reason, J et al., (2006, October 30). Revisiting the Swiss Cheese 
Model of Accidents. EUROCONTROL Experimental Centre, Note No. 13/06. 
(Reason et al., October 30, 2006).
Rusnak, JM et al., (2004, July 31). Management guidelines for 
laboratory exposures to agents of bioterrorism. Journal of 
Occupational and Environmental Medicine 46(8): 791-800. doi: 
10.1097/01.jom.0000135536.13097.8a. (Rusnak et al., July 31, 2004).
Seto, WH et al., (2003, May 3). Effectiveness of precautions against 
droplets and contact in prevention of nosocomial transmission of 
severe acute respiratory syndrome (SARS). The Lancet 361(9368): 
1519-1520. https://doi.org/10.1016/s0140-6736(03)13168-6. (Seto et 
al., May 3, 2003).
Siegel, J, Rhinehart, E, Jackson M, Chiarello, L, and the Healthcare 
Infection Control Practices Advisory Committee. (2007). 2007 
Guideline for isolation precautions: preventing transmission of 
infectious agents in healthcare settings. https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf. (Siegel 
et al., 2007).
World Health Organization (WHO). (2016). Guidelines on Core 
Components of Infection Prevention and Control Programmes at the 
National and Acute Health Care Facility Level. https://www.who.int/gpsc/ipc-components-guidelines/en/. (WHO, 2016).
Yen, MY et al., (2010, February 12). Quantitative evaluation of 
infection control models in the prevention of nosocomial 
transmission of SARS virus to healthcare workers: implication to 
nosocomial viral infection control for healthcare workers. 
Scandinavian Journal of Infectious Diseases 42: 510-515. https://10.3109/00365540903582400. (Yen et al., February 12, 2010).

B. COVID-19 Plan

    An effective COVID-19 plan is modeled on the core components of 
safety and health programs, which utilize a systematic approach to 
reduce injuries and illnesses in the workplace. The occupational safety 
and health community uses various names to describe this type of 
systematic approach (e.g., safety and health programs, safety and 
health management systems, and injury and illness prevention programs) 
and uses the terms ``plans'' and ``programs'' interchangeably. An 
effective safety and health program involves proactively and 
continuously identifying and mitigating hazards, before employees are 
injured or develop disease. The approach involves trained employees and 
managers working together to identify and address issues before the 
issues become a problem. Such an approach helps employers meet their 
obligation under the OSH Act to provide employees a place of employment 
free from recognized hazards (OSHA, January 2012; OSHA, October 18, 
2016). The COVID-19 plan required by this ETS encompasses the core 
components of this type of safety and health programs. Developing and 
implementing a COVID-19 plan is an essential part of an effective 
response to the COVID-19 hazards present in the workplace because the 
process involves identifying employees who are at risk of exposure to 
the virus and determining how they can be effectively protected from 
developing COVID-19 using a multi-layered approach.
    Many companies that have received awards for their safety and 
health accomplishments have credited safety and health programs for 
their success. Because of the value, effectiveness, and feasibility of 
such programs, many countries throughout North America, Asia, and 
Europe require employers to implement programs to prevent injury and 
illness. Numerous studies and data sources provide evidence of such 
programs improving safety and health management practices and 
performance which leads to reductions in injury, illness, and 
fatalities. For example, a review of the impact of implementation of 
safety and health programs in eight states showed a reduction of injury 
and illness rates ranging from 9% to more than 60% (OSHA, January 
2012). In three of these states with mandatory injury and illness 
prevention programs, workplace fatality rates were up to 31% lower than 
the national average (OSHA, January 2012).
    OSHA has traditionally identified seven core elements of successful 
safety and health programs including (1) management leadership, (2) 
worker participation, (3) hazard identification and assessment, (4) 
hazard prevention and controls, (5) evaluation and improvement, (6) 
coordination and communication at multi-employer sites, and (7) 
education and training (OSHA, January 2012; OSHA, October 18, 2016). 
The COVID-19 plan required by this ETS was developed with these 
elements in mind. The first core element, management leadership, 
involves a demonstrated commitment to establishing a safety and health 
culture and continuously improving safety and health in the workplace. 
A commitment to health and safety is demonstrated by implementing a 
clear plan for preventing illness and injury, and communicating the 
plan to all employees (including contractors and temporary staff). 
Designating a coordinator to track progress of the plan and ensure that 
all aspects of the plan are implemented further demonstrates 
management's commitment to employee safety and health (OSHA, 2005; 
OSHA, January 2012; OSHA, October 18, 2016).
    The second, and one of the most important components of a safety 
and health program, is the participation of trained and knowledgeable 
employees, including those employed by other employers (e.g., 
contractors, temporary staff). Employees provide unique perspective and 
expertise because they are often the most knowledgeable people about 
the hazards associated with their jobs and how those hazards can be 
controlled. Employees who are trained to recognize hazards and 
appropriate controls to address those hazards and know that they can 
speak freely to employers, can provide valuable input on hazards that 
need to be addressed, which can lead to a reduction in hazards or 
exposure to hazards. They can also provide input on improvements that 
are needed to protections that have already been implemented. An 
emphasis on employee participation is consistent with the OSH Act, OSHA 
standards, and

OSHA enforcement policies and procedures, which recognize the rights 
and roles of workers and their representatives in matters of workplace 
safety and health (OSHA, 2005; OSHA, January 2012; OSHA, October 18, 
2016).
    The third core element of a safety and health program approach is 
hazard identification and assessment. To be most effective, hazard 
assessments must be conducted as a team approach with management, 
coordinators, and employees involved in the hazard assessment process 
(e.g., identifying potential hazards) and the development and 
implementation of the COVID-19 plan. An assessment to identify safety 
and health hazards can include surveying the facility to observe 
employee work habits and evaluating employee input from surveys or 
meeting minutes. Specifically, the risk of exposure to biological 
hazards, such as the COVID-19 virus, can be assessed by determining if 
workers could be exposed (e.g., through close contact with patients, 
co-workers, or members of the public; contact with contaminated 
surfaces, objects, or waste) and if controls are present to mitigate 
those risks (OSHA, 2005; OSHA, October 18, 2016). While a standard can 
specify controls applicable to particular hazards, the hazard 
assessment can help identify where controls are needed in specific 
areas of a particular worksite.
    The fourth core element of an effective workplace safety and health 
program approach is hazard prevention and control, which involves teams 
of managers, coordinators, and employees assessing if a hazard can be 
eliminated (e.g., by working at home to eliminate potential virus 
exposure in the workplace). When hazards cannot be eliminated, the 
hazard prevention process considers which hazards can be controlled by 
implementing work practices (e.g., regular cleaning, disinfecting, 
physical distancing) or controls (e.g., physical barriers, improvements 
to the ventilation system). Additionally, the process of hazard 
prevention and control determines if PPE is required as part of a 
multi-layered strategy to protect workers from infectious biological 
agents (OSHA, 2005; OSHA, October 18, 2016). The controls may function 
more effectively when implemented in the most targeted manner following 
a hazard assessment and team-based evaluation.
    The fifth core element of an effective safety and health program 
approach is evaluation and improvement. Safety and health programs 
require periodic evaluation to ensure they are implemented as intended 
and continue to achieve the goal of preventing injury and illness. This 
re-evaluation can reduce hazards, or result in improvements in controls 
to help reduce hazards. Managers have the prime responsibility for 
ensuring the effectiveness of the program but managers should work as a 
team with coordinators and employees to continually monitor the 
worksite to identify what is and is not working and make adjustments to 
improve worker safety and health measures (OSHA, January 2012; OSHA, 
October 18, 2016).
    The sixth core element of an effective safety and health program 
approach is communication and coordination between host employers, 
contractors, and staffing agencies. Because the employees of one 
employer may expose employees of a different employer to a hazard, this 
communication is essential to protecting all employees. An effective 
program ensures that before employees go to a host worksite, both the 
host employer and staffing agencies communicate about hazards on the 
worksite, procedures for controlling hazards, and how to resolve any 
conflicts that could affect employee safety and health (e.g., who will 
provide PPE). The exchange of information about each employer's plans 
can help reduce exposures by identifying areas where one employer may 
need to provide additional protections (barriers, timing of workshifts, 
etc.) to its employees. Additionally, exchanging contact information 
between employers can facilitate worker protection in case they need to 
report hazards or illnesses that may occur (OSHA, October 18, 2016). In 
order to reduce COVID-19 transmission in the workplace, it will be 
particularly important for employers to have clear plans about how they 
can quickly alert other employers if a worker at a multi-employer site 
subsequently tests positive for COVID-19 and was in close contact with 
workers of other employers.
    The seventh core element of an effective safety and health program 
is education and training. Education and training ensures that 
employees, supervisors, and managers are able to recognize and control 
hazards, allowing them to work more safely and contribute to the 
development and implementation of the safety and health program (OSHA, 
2005; OSHA, January 2012; OSHA, October 18, 2016). Later in this Need 
for Specific Provisions section there is a detailed explanation about 
the need for training as a separate control to minimize COVID-19 
transmission.
    The effectiveness of a safety and health program approach in 
preventing injury and illnesses is recognized by a number of 
authoritative bodies. In its Total Worker Health program, the National 
Institute for Occupational Safety and Health (NIOSH) lists a number of 
core elements that are consistent with OSHA's safety and health program 
approaches, including demonstrating leadership commitment to safety and 
health, eliminating or reducing safety and health hazards, and 
promoting and supporting employee involvement (NIOSH, December 2016).
    The International Organization for Standardization (ISO) developed 
ISO 45001, a consensus standard to help organizations implement a 
safety and health management system (ISO, 2018). ISO notes that key 
potential benefits of the system include reduced workplace incidents, 
establishment of a health and safety culture by encouraging active 
involvement of employees in ensuring their health and safety, 
reinforcement of leadership commitment to health and safety, and 
improved ability to comply with regulatory requirements.
    The American National Standards Institute (ANSI) and American 
Society of Safety Professionals (ASSP) also developed a health and 
safety management systems standard for the purpose of reducing hazards 
and risk in a systematic manner, based on a team approach that includes 
management commitment and employee involvement, with an emphasis on 
continual improvement (ANSI/ASSP, 2019). ANSI/ASSP note the widespread 
acceptance that safety and health management systems can improve 
occupational safety and health performance. (Id.) They further 
highlight OSHA reports of improved safety and health performance by 
companies who implement programs that rely on management system 
principles (e.g., the Voluntary Protection Program), and that major 
professional safety and health organizations support management systems 
as effective in improving safety and health. As further proof that 
safety and health management systems are valuable, they note that many 
large and small organizations within the U.S. and internationally are 
implementing these systems.
    Based on the best available evidence, OSHA concludes that a COVID-
19 plan that is modeled on the safety and health program principles 
discussed above, implemented by a COVID-19 coordinator, influenced by 
employee input, and continuously evaluated, is an effective tool to 
ensure comprehensive identification and mitigation of COVID-19 hazards. 
As a result, OSHA concludes that a COVID-19 plan will reduce the 
incidence of COVID-19 in

the workplace by helping to ensure that all effective measures are 
implemented as part of a multi-layered strategy to minimize employee 
exposure to COVID-19.
References
American National Standards Institute (ANSI)/American Society of 
Safety Professionals (ASSP). (2019). ANSI/ASSP Z10.0-2019. 
Occupational Health and Safety Management Systems. (ANSI/ASSP, 
2019).
International Organization for Standardization (ISO). (2018). 
Occupational health and safety. ISO 45001. (ISO, 2018).
National Institute for Occupational Safety and Health (NIOSH). 
(2016, December). Fundamentals of total worker health approaches: 
essential elements for advancing worker safety, health, and well-
being. Publication no. 2017-112. https://www.cdc.gov/niosh/docs/2017-112/pdfs/2017_112.pdf. (NIOSH, December 2016).
Occupational Safety and Health Administration (OSHA). (2005). Small 
Business Handbook. Small Business Safety and Health Management 
Series. OSHA 2209 02R 2005. https://www.osha.gov/sites/default/files/publications/small-business.pdf. (OSHA, 2005).
Occupational Safety and Health Administration (OSHA). (2012, 
January). Injury and Illness Prevention Programs. White Paper. 
https://www.osha.gov/dsg/InjuryIllnessPreventionProgramsWhitePaper.html. (OSHA, January 
2012).
Occupational Safety and Health Administration (OSHA). (2016, October 
18). Recommended Practices for Safety and Health Programs. OSHA 
3885. https://www.osha.gov/sites/default/files/publications/OSHA3885.pdf. (OSHA, October 18, 2016).

C. Patient Screening and Management

    Limited contact with potentially infectious persons is a 
cornerstone of COVID-19 pandemic management. For example, screening and 
triage of everyone entering a healthcare setting is an essential means 
of identifying those individuals who have symptoms that could indicate 
infection with the SARS-CoV-2 virus (CDC, February 23, 2021). Persons 
with such symptoms can then be triaged appropriately to minimize 
exposure risk to employees. CDC guidance provides a number of 
approaches for screening and triage, including screening at entry, 
separate triage areas for patients desiring evaluation for COVID-19 
concerns, and electronic pre-screening prior to arrival (CDC, February 
23, 2021). Once identified, potentially infected individuals can then 
be isolated for evaluation, testing, and treatment. Triage increases 
the likelihood of implementation of the appropriate level of personal 
protective equipment for employees and other protections required for 
exposure to potentially infectious patients. Patient segregation in 
healthcare settings also reduces nosocomial (healthcare-acquired) 
infections for employees. Inpatients continue to require regular re-
evaluation for COVID-19 symptoms.\20\
---------------------------------------------------------------------------

    \20\ Limiting and monitoring points of entry to the setting will 
also help limit contact with potentially infectious persons. For 
further discussion, see the Need for Specific Provisions for 
Physical Distancing.
---------------------------------------------------------------------------

    Symptoms-based screening is a standard component of infection 
control. This approach was recommended during the 2003 SARS epidemic 
(caused by SARS-CoV-1, a different strain of SARS) and is routinely 
recommended for airborne infections such as M. tuberculosis and 
measles, and as a general practice in infection control programs 
(Siegel et al., 2007). Because SARS-CoV-2 can be transmitted by 
individuals who are infected but do not have symptoms (asymptomatic and 
presymptomatic transmission), symptom-based screening will not identify 
all infectious individuals (Viswanathan et al., September 15, 2020). 
However, persons with symptoms early in their SARS-CoV-2 infection are 
among the most infectious (Cevik et al., November 19, 2020). Therefore, 
symptom-based screening will identify some of the highest-risk 
individuals for SARS-CoV-2 transmission and thereby reduce the risk to 
workers.
References
Centers for Disease Control and Prevention (CDC). (2021, February 
23). Interim infection prevention and control recommendations for 
healthcare personnel during the Coronavirus Disease 2019 (COVID-19) 
pandemic. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html. (CDC, February 23, 2021).
Cevik, M. et al., (2020, November). SARS-CoV-2, SARS-CoV, and MERS-
CoV viral load dynamics, duration of viral shedding, and 
infectiousness: A systematic review and meta-analysis. Lancet 
Microbe 2021; 2: e13-22. https://doi.org/10.1016/S2666-5247(20)30172-5. (Cevik et al., November 19, 2020).
Siegel, J., Rhinehart, E., Jackson, M., Jackson, M., Chiarello, L. 
(2007). Guideline for isolation precautions: Preventing transmission 
of infectious agents in healthcare settings. https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf. (Siegel 
et al., 2007).
Viswanathan, M. et al., (2020, September 15). Universal screening 
for SARS-CoV-2 infection: A rapid review. Cochrane Database of 
Systematic Reviews, Issue 9. Art. No.: CD013718. DOI: 10.1002/
14651858.CD013718. (Viswanathan et al., September 15, 2020).

D. Standard and Transmission-Based Precautions

    Standard and Transmission-Based Precautions are well-accepted as 
important to controlling disease transmission (HICPAC, December 27, 
2018; CDC, January 7, 2016). It should be noted that during times of 
significant transmission, such as during this pandemic, additional 
protections are needed to supplement the basic level of recommended 
precautions and practices in these guidelines. For instance, wearing at 
least a facemask regardless of interaction with known or suspected 
infectious patients is needed during the pandemic (CDC, February 23, 
2021).
    Standard Precautions refers to infection prevention practices, 
implemented in healthcare settings, where the presence of an infectious 
agent is assumed (i.e., without the suspicion or confirmation of 
exposure). The use of Standard Precautions thus relies on the 
assumption that all patients, patient samples, potentially contaminated 
materials (e.g., patient laundry, medical waste), and human remains in 
healthcare settings are potentially infected or colonized with an 
infectious agent(s). For example, Standard Precautions would include 
appropriate hand hygiene and use of personal protective equipment as 
well as practices to ensure respiratory hygiene, sharps safety, safe 
injection practices, and sterilization and disinfection of equipment 
and surfaces (CDC, February 23, 2021).
    Transmission-Based Precautions add an additional layer of 
protection to Standard Precautions. Transmission-Based Precautions 
refers to those good infection prevention practices, used in tandem 
with Standard Precautions that are based on the way an infectious 
agent(s) may be transmitted. These precautions are needed, for example, 
when treating a patient where it is suspected or confirmed that the 
patient may be infected or colonized with agents that are infectious 
through specific routes of exposure (Siegel et al., 2007). For example, 
handwashing and safe handling of sharps (needles, etc.) are routine 
Standard Precautions. An infectious agent capable of airborne 
transmission through aerosols would require patient care in an airborne 
infection isolation room (AIIR), if available, under Transmission-Based 
Precautions.
    Even before a patient is treated, certain Transmission-Based 
Precautions

can be critical to protecting healthcare workers. For example, one 
typical precaution is that patients and visitors who enter a waiting 
room before being seen or triaged must wear facemasks, or face 
coverings, as a source control device to prevent them from spreading 
airborne droplets near the employees. These source control devices may 
also be critical to reducing the likelihood that COVID-19 is spread as 
the patients are transported from the admission area to a treatment 
area.
    The critical need for implementing Standard and Transmission-Based 
Precautions in healthcare settings is evident in the Healthcare 
Infection Control Practices Advisory Committee's (HICPAC's) 2017 Core 
Infection Prevention and Control Practices for Safe Healthcare Delivery 
in All Settings.\21\ The core practices included in that document 
include Standard and Transmission-Based Precautions, which, HICPAC 
recommended, need to be implemented in all settings where healthcare is 
delivered.
---------------------------------------------------------------------------

    \21\ HICPAC is a federal advisory committee that provides 
guidance to the CDC and the Secretary of the Department of Health 
and Human Services (HHS) regarding the practice of infection 
control. In March 2013, CDC charged HICPAC with a review of existing 
CDC guidelines to identify all recommendations that warrant 
inclusion as core practices. In response, a HICPAC workgroup was 
formed that contained representatives from the following stakeholder 
organizations: America's Essential Hospitals, the Association for 
Professionals in Infection Control and Epidemiology (APIC), the 
Council of State and Territorial Epidemiologists (CSTE), the Public 
Health Agency of Canada (PHAC), the Society for Healthcare 
Epidemiology of America (SHEA), and the Society of Hospital Medicine 
(SHM) (HICPAC, March 15, 2017). This process resulted in HICPAC's 
Core Infection Prevention and Control Practices for Safe Healthcare 
Delivery in All Settings.
---------------------------------------------------------------------------

    That Standard and Transmission-Based Precautions are a long-
standing and essential element of infection control in healthcare 
industries is also evidenced by the CDC's 2007 Guideline for Isolation 
Precautions: Preventing Transmission of Infectious Agents in Healthcare 
Settings, which incorporate Standard and Transmission-Based Precautions 
into their recommendations. This 2007 Guideline updated 1996 
guidelines, which introduced the concept of Standard Precautions and 
also noted the existence of infection control recommendations dating 
back to 1970 (Siegel et al., 2007).
    Both Standard and Transmission-Based Precautions are recommended by 
the CDC for healthcare personnel during the COVID-19 pandemic (CDC, 
February 23, 2021). The CDC considers healthcare personnel (HCP) to 
include all paid and unpaid persons serving in healthcare settings who 
have the potential for direct or indirect exposure to patients or 
infectious materials, including body substances (e.g., blood, tissue, 
and specific body fluids); contaminated medical supplies, devices, and 
equipment; contaminated environmental surfaces; or contaminated air. 
HCP include, but are not limited to, emergency medical service 
personnel, nurses, nursing assistants, home healthcare personnel, 
physicians, technicians, therapists, phlebotomists, pharmacists, 
students and trainees, contractual staff not employed by the healthcare 
facility, and persons not directly involved in patient care, but who 
could be exposed to infectious agents that can be transmitted in the 
healthcare setting (e.g., clerical, dietary, environmental services, 
laundry, security, engineering and facilities management, 
administrative, billing, and volunteer personnel).
    The CDC also has recommendations for protection of workers in 
industries associated with healthcare. According to the CDC's Interim 
Infection Prevention and Control Recommendations for Healthcare 
Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic 
(incorporated by reference, Sec.  1910.509), on-site management of 
laundry, food service utensils, and medical waste should also be 
performed in accordance with routine procedures (CDC, February 23, 
2021).
    The work of the College of American Pathologists (CAP) illustrates 
the importance of taking core precautionary measures in healthcare 
industries during the pandemic. CAP has provided recommendations for 
staff protection during the COVID-19 pandemic. For example, CAP has 
provided COVID-19-specific autopsy recommendations which include 
biosafety considerations such as performing autopsies on COVID-19-
positive cases in an airborne infection isolation room (College of 
American Pathologists, February 2, 2021).\22\
---------------------------------------------------------------------------

    \22\ CAP is known for its peer-based Laboratory Accreditation 
Program. The Centers for Medicare & Medicaid Services (CMS) allows a 
CAP inspection in lieu of a CMS inspection. CAP inspections have a 
similar status with a number of other leading healthcare and 
biomedical laboratory authorities including the Joint Commission, 
United Network for Organ Sharing, the National Marrow Donor Program, 
the Foundation for the Accreditation of Cellular Therapies, and many 
state agencies (College of American Pathologists, February 1, 
2021b). CAP has worked with the CMS to implement virtual laboratory 
inspections allowing labs to remain in compliance with Clinical 
Laboratory Improvement Amendments regulations (College of American 
Pathologists, February 1, 2021a).
---------------------------------------------------------------------------

    The Standard and Transmission-Based Precautions required by the ETS 
only extend to exposure to SARS-CoV-2 and COVID-19 protection. The 
agency does not intend the ETS to apply to other workplace hazards.
References
Centers for Disease Control and Prevention (CDC). (2016, January 7). 
Transmission-based precautions. https://www.cdc.gov/infectioncontrol/basics/transmission-based-precautions.html. (CDC, 
January 7, 2016).
Centers for Disease Control and Prevention (CDC). (2021, February 
23). Interim infection prevention and control recommendations for 
healthcare personnel during the Coronavirus Disease 2019 (COVID-19) 
pandemic. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html. (CDC, February 23, 2021).
College of American Pathologists. (2021, February 2). Amended COVID-
19 autopsy guideline statement from the CAP Autopsy Committee. 
https://documents.cap.org/documents/COVID-Autopsy-Statement.pdf. 
(College of American Pathologists, February 2, 2021).
Healthcare Infection Control Practices Advisory Committee (HICPAC). 
(2018, December 27). Core infection prevention and control practices 
for safe healthcare delivery in all settings. https://www.cdc.gov/hicpac/recommendations/core-practices.html. (HICPAC, December 27, 
2018).
Siegel, J., Rhinehart, E., Jackson, M., Jackson, M., Chiarello, L. 
(2007). Guideline for isolation precautions: Preventing transmission 
of infectious agents in healthcare settings. https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf. (Siegel 
et al., 2007).

E. Personal Protective Equipment (PPE)

    As previously discussed in Grave Danger (Section IV.A. of the 
preamble), COVID-19 infections occur mainly through exposure to 
respiratory droplets (referred to as droplet transmission) when a 
person is in close contact with someone who has COVID-19. COVID-19 can 
sometimes also be spread by airborne transmission (CDC, May 13, 2021). 
As the CDC explains, when people with COVID-19 cough, sneeze, sing, 
talk, or breathe, they produce respiratory droplets, which can travel a 
limited distance--thereby potentially infecting people within close 
physical proximity--before falling out of the air due to gravity. 
Facemasks, face coverings, and face shields are all devices used for 
their role in reducing the risk of droplet, and potentially airborne, 
transmission of COVID-19 primarily at the source. Additional discussion 
on the efficacy of each device, and the need for facemasks and face 
shields specifically, is explained below. (Respirator use is also 
included in the ETS and more information on the

need for respirators to prevent the spread of COVID-19 is discussed in 
the Need for Specific Provisions for Respirators, further below.)
    Well-fitting facemasks, not face coverings, are the baseline 
requirement in healthcare settings because of their fluid resistant 
qualities (discussed in detail below). However, the role of facemasks 
and face coverings are otherwise similar in source control and personal 
protection for the wearer. OSHA's position on the importance of face 
coverings and facemasks is supported by a substantial body of evidence. 
Consistent and correct use of face coverings and facemasks is widely 
recognized and scientifically supported as an important evidence-based 
strategy for COVID-19 control. Accordingly, with specific exceptions 
relevant to outdoor areas and vaccinated persons, the CDC recommends 
everyone two years of age and older wear a face covering in public 
settings and when around people outside of their household (CDC, April 
19, 2021). And, on January 21, 2021, President Biden issued Executive 
Order 13998, which recognizes the use of face coverings or facemasks as 
a necessary, science-based public health measure to prevent the spread 
of COVID-19, and therefore directed regulatory action to require that 
they be worn in compliance with CDC guidance while traveling on public 
transportation (e.g., buses, trains, subway) and while at airports 
(Executive Order 13998, 86 FR 7205, 7205 (Jan. 21, 2021); CDC, February 
2, 2021). Similarly, the World Health Organization (WHO) has recognized 
face coverings as a key measure in suppressing COVID-19 transmission, 
and thus, saving lives. The WHO observes that face coverings (and 
facemasks) serve two purposes, to both protect healthy people from 
acquiring COVID-19 and to prevent sick people from further spreading it 
(WHO, December 1, 2020).
I. Need for Facemasks
    Facemasks are simple bi-directional barriers that tend to keep 
droplets, and to a lesser extent airborne particulates, on the side of 
the filter from which they originate. The term ``facemask,'' as used in 
this ETS, is defined as a surgical, medical procedure, dental, or 
isolation mask that is FDA-cleared, FDA-authorized, or offered or 
distributed as described in an FDA enforcement policy. These are most 
commonly referred to as ``surgical masks'' or ``medical procedure 
masks.'' As previously mentioned, facemasks reduce the risk of droplet 
transmission through their dual function as both source control and 
personal protection (OSHA, January 28, 2021; Siegel et al., 2007). In 
healthcare settings, facemasks have long been recognized as an 
important method of source control for preventing the spread of 
infectious agents transmitted via respiratory droplets (e.g., in the 
operating room to prevent provider saliva and respiratory secretions 
from contaminating the surgical field and infecting patients). However, 
facemasks do not filter out very small airborne particles and do not 
provide complete protection even from larger particles because the mask 
seal is not tight (FDA, December 7, 2020).
    Facemasks are designed and regulated through various FDA processes 
to protect the person wearing them. Not all devices that resemble 
facemasks are FDA-cleared or authorized. To receive FDA clearance, 
manufacturers are required to submit an FDA premarket notification 
(also known as a 510(k) notification) for new products. Data in the 
510(k) submission must show that the facemask is substantially 
equivalent to a facemask already on the market in terms of safety and 
effectiveness. Facemasks are tested for fluid resistance, filtration 
efficiency (particulate filtration efficiency and bacterial filtration 
efficiency), differential pressure, flammability and biocompatibility 
(FDA, July 14, 2004).\23\
---------------------------------------------------------------------------

    \23\ Medical devices are subject to premarket review through 
risk-based classification under the Federal Food, Drug, and Cosmetic 
Act. Premarket approval (PMA) applies to the highest-risk, Class III 
devices, and 510(k) notification applies to most Class II and some 
Class I devices. Under the 510(k) notification pathway, FDA 
determines whether the device is substantially equivalent to a 
lawfully marketed predicate device. Medical device manufacturers are 
required to submit a 510(k) notification if they intend to introduce 
a device into commercial distribution for the first time or 
reintroduce a device that will be significantly changed or modified 
to the extent that its safety or effectiveness could be affected. 
Such change or modification could relate to the design, material, 
chemical composition, energy source, manufacturing process, or 
intended use. For more information, see https://www.fda.gov/medical-devices/device-advice-comprehensive-regulatory-assistance/how-study-and-market-your-device and https://www.fda.gov/medical-devices/device-approvals-denials-and-clearances/510k-clearances.
---------------------------------------------------------------------------

    Research developed during the current SARS-CoV-2 pandemic provides 
evidence of the protection afforded by facemasks. First, a universal 
surgical masking requirement for all healthcare workers and patients 
was implemented in Spring 2020 in the Mass General Brigham healthcare 
system, which is the largest in Massachusetts (Wang et al., July 14, 
2020). Based on daily infection rates among healthcare workers, the 
authors found that universal masking was associated with a 
significantly lower rate of SARS-CoV-2 positivity. Although the authors 
noted that other interventions, such as restricting visitors, were also 
put in place, they concluded that their results supported universal 
masking as part of a multi-pronged infection reduction strategy in 
healthcare settings.
    Second, a systematic review and meta-analysis evaluated research on 
healthcare workers exposed to SARS-CoV-2, as well as the SARS and 
Middle East respiratory syndrome (MERS) viruses (Chu et al., June 27, 
2020). Six studies compared the odds of infection in those who wore 
surgical or similar facemasks compared to those who did not wear any 
facemask; four of the six studies were on healthcare workers and all 
six were from the 2003 SARS epidemic. Participants who wore surgical or 
similar facemasks had only a third of the infection risk of those who 
did not wear any facemask.
    Third, a review of respiratory protection for healthcare workers 
during pandemics noted that surgical mask material has been shown to 
protect against more than 95% of viral aerosols under laboratory 
conditions (Garcia-Godoy et al., May 5, 2020). The authors also 
reviewed research showing that surgical masks reduced aerosolized 
influenza exposure by an average of six-fold, depending on mask 
design.\24\
---------------------------------------------------------------------------

    \24\ For a discussion of the efficacy of respirators over 
facemasks for protection against aerosolized particles, please see 
the respirator discussion in the Need for Specific Provisions 
section, below.
---------------------------------------------------------------------------

    Finally, in one epidemiological study, a specialized team of 
contact tracers at Duke University Health System in North Carolina 
categorized recorded COVID-19 cases among their healthcare workers 
(Seidelman et al., June 25, 2020). Of the cases that were categorized 
as healthcare-acquired (meaning acquired as a result of either an 
unmasked exposure for greater than 10 minutes at less than 6 feet to 
another healthcare worker who was symptomatic and tested positive for 
the virus, or an exposure to a COVID-19-positive patient while not 
wearing all CDC-recommended PPE or while there was a breach in PPE), 
70% were linked to an unmasked exposure to another healthcare worker.
    Although cloth face coverings have gained widespread use outside of 
healthcare settings during this pandemic, OSHA has determined that 
cloth face coverings do not offer sufficient protection for covered 
healthcare workers for multiple reasons. First, cloth face coverings, 
as defined by the CDC, encompass such a wide variety of coverings that 
there is no assurance

of any consistent protection to the wearer, and even source protection 
can vary significantly depending on the construction and fit of the 
face covering. Second, a number of studies suggest that, properly worn 
over the nose and mouth, facemasks provide better protection than face 
coverings, which is an important consideration in healthcare settings 
where there are regular, known exposures to COVID-19-positive persons. 
For example, one randomized trial of cloth face coverings compared 
rates of clinical respiratory illness, influenza-like illness, and 
laboratory-confirmed respiratory virus infections in 1,607 healthcare 
workers in 14 hospitals in Vietnam (MacIntyre et al., March 26, 2015). 
Infection risks were statistically higher in the cloth face covering 
group compared to the facemask group: The risk of influenza-like 
illness was 6.6 times higher, and the risk of laboratory-confirmed 
respiratory virus infection was 1.7 times higher, in those who wore 
cloth face coverings compared to those who wore facemasks. Another 
study which reviewed respiratory protection for healthcare workers 
during pandemics showed greater protection from surgical masks compared 
to face coverings (Garcia-Godoy et al., May 5, 2020). Finally, Ueki et 
al., (June 25, 2020) evaluated the effectiveness of cotton face 
coverings, facemasks, and N95s (a commonly used respirator) in 
preventing transmission of SARS-CoV-2 using a laboratory experimental 
setting with manikins. The researchers found that all offerings 
provided some measure of protection as source control, limiting 
droplets expelled from both infected and uninfected wearers, but that 
facemasks and N95s provided better protection than cotton face 
coverings. Specifically, the researchers found that when spaced roughly 
20 inches apart, if both an infected and uninfected individual were 
wearing a cotton face covering, the uninfected person reduced 
inhalation of infectious virus by 67%. But if both individuals were 
wearing facemasks, exposure was reduced by 76% and when an infected 
individual was wearing an N95, exposure was reduced by 96%.
    Third, cloth face coverings do not function as a barrier to protect 
employees from hazards such as splashes or large droplets of blood or 
bodily fluids, which is a common hazard in healthcare settings. And 
finally, OSHA has previously established that medical facemasks are 
essential PPE for many workers in healthcare, as enforced under both 
the PPE standard (29 CFR 1910.132) and more specifically, the 
Bloodborne Pathogens standard (29 CFR 1910.1030).
    Given the health outcomes related to COVID-19 and the exposure 
characteristics found in healthcare settings (e.g., splashes or large 
droplets of blood or bodily fluids), OSHA has determined that cloth 
face coverings are not appropriate for workers in these settings. 
Research clearly indicates that facemasks provide essential protection 
for workers in covered healthcare settings.
II. Need for Face Shields
    The term ``face shield,'' as used in this ETS, is a device 
typically made of clear plastic, that covers the wearer's eyes, nose, 
and mouth, wraps around the sides of the wearer's face, and extends 
below the wearer's chin. Face shields have long been recognized as 
effective in preventing splashes, splatters, and sprays of bodily 
fluids and have a role in preventing the primary route of droplet 
transmission, although not aerosolized transmission. As explained 
above, OSHA has determined based on the best available evidence that 
facemask usage is a necessary protective measure to prevent the spread 
of COVID-19 for any covered employee. However, the use of face shields, 
a less protective barrier, is permitted to either supplement facemasks 
where there is a particular risk of droplet exposure, or as an 
alternative option in certain limited circumstances where facemask 
usage is not feasible.
    Face shields are proven to provide some protection to the wearer 
from exposure to droplets, and OSHA has long considered face shields to 
be PPE under the general PPE standard (29 CFR 1910.132) and the Eye and 
Face Protection standard (29 CFR 1910.133) for protection of the face 
and eyes from splashes and sprays. The potential protective value of 
face shields against droplet transmission is supported by a 2014 study, 
in which NIOSH investigated the effectiveness of face shields in 
preventing the transmission of viral respiratory diseases. The purpose 
of the study was to quantify exposure of cough aerosol droplets and 
examine the efficacy of face shields in reducing this exposure. 
Although face shields were not found to be effective against smaller 
particles, which can remain airborne for extended periods and can 
easily flow around a face shield to be inhaled, the face shields were 
effective in blocking larger aerosol particles (median size of 8.5 
[micro]M). Face shields worn over a respirator also reduced surface 
contamination of the respirator by 97%. The study's final conclusion 
was that face shields can be a useful complement to respiratory 
protections; however, they cannot be used as a substitute for 
respiratory protection, when needed (Lindsley et al., June 27, 2014). A 
recent update of the Lindsley study (Lindsley et al., January 7, 2021) 
found that face shields blocked only 2% of aerosol produced by 
coughing. These findings suggest that face shields might be a relevant 
form of protection in healthcare settings to protect employees from 
droplet exposure when they could have close contact with individuals 
who are potentially infected with COVID-19.
    Face shields have proven less effective as a method of source 
control or a method of personal protection than facemasks. For example, 
in considering face shields' value as source control, Verma et al., 
(June 30, 2020) observed the effect of a face shield on respiratory 
droplets produced by simulating coughs or sneezes with a manikin. The 
face shield initially blocked the forward motion of the droplet stream, 
but droplets were then able to flow around the shield and into the 
surrounding area. The study authors concluded that face shields alone 
may not be as effective in blocking droplets.
    In another study, Stephenson et al., (February 12, 2021) evaluated 
the effectiveness of face coverings, facemasks, and face shields in 
reducing droplet transmission. Breathing was simulated in two manikin 
heads (a transmitter and receiver) that were placed four feet apart. 
Artificial saliva containing a marker simulating viral genetic material 
was used to generate droplets from the transmitter head. The 
researchers found that face coverings, facemasks, and face shields all 
reduced the amount of surrogate genetic material measured in the 
environment and the amount that reached the receiver manikin head at 
four feet. While face shields reduced surrogate genetic material by 
98.6% in the environment and 95.2% at the receiver, genetic material 
was still deposited downward in the immediate area of the transmitter, 
suggesting that use of face shields without a facemask could result in 
a contamination of shared surfaces. This limits the effectiveness of 
face shields alone as a method of source control for shared workspaces. 
Additionally, face shields used as personal protective devices showed 
that the face shields protected the wearer from large cough aerosols 
directed at the face, but were much less effective against smaller 
aerosols which were able to flow around the edges of the shield and be 
inhaled (Lindsley et al., June 27, 2014).
    Based on this evidence, OSHA has determined that face shields are 
not

generally appropriate as a substitute for a facemask because they are 
less effective at reducing the risk of droplet and potential airborne 
transmission. However, face shields do offer some protection from 
droplet transmission and are, accordingly, required by the ETS to be 
used in any circumstance where, for example, an individual may not be 
able to wear a facemask due to a medical condition or due to other 
hazards (e.g., heat stress, arc flash fire hazards). In such limited 
(and often temporary) situations, a face shield may be the most 
effective measure to add a layer of protection to reduce workers' 
overall COVID-19 transmission risk, particularly when combined with 
other protective measures.
    Additionally, OSHA recognizes that face shields can provide some 
additional protection when used in addition to a facemask by protecting 
the wearer's eyes and preventing their facemask from being contaminated 
with respiratory droplets from other persons. This additional 
protection may be particularly useful for employees who cannot avoid 
close contact with others or are unable to work behind barriers. 
Accordingly, the ETS allows employers to require face shields in 
addition to facemasks where employment circumstances might warrant the 
additional protection.
    OSHA has always considered recognized consensus standards, with 
design and construction specifications, when determining the PPE 
requirements of the agency's standards, as required by the OSH Act (29 
U.S.C. 655(b)(8)) and the National Technology Transfer and Advancement 
Act (15 U.S.C. 272 note).
    The agency has already incorporated by reference the ANSI/ISEA 
Z87.1, Occupational and Educational Personal Eye and Face Protection 
Devices consensus standard for face shields in its Eye and Face 
Protection standard (29 CFR 1910.133). In this ETS the agency will 
incorporate by reference more recent editions of the ANSI/ISEA standard 
than are currently provided for in the existing standard. Additionally, 
for the limited purpose of complying with the ETS, the agency will also 
allow any face shield that meets the criteria outlined in the 
definition of ``face shield'' found in the definition sections of the 
ETS. That is: (1) Certified to the ANSI/ISEA Z87.1-2010, 2015, or 2020 
standard; or (2) covers the wearer's eyes, nose, and mouth to protect 
from splashes, sprays, and spatter of body fluids, wraps around the 
sides of the wearer's face (i.e., temple-to-temple), and extends below 
the wearer's chin. Any face shield that is worn for the purpose of 
complying with any OSHA standard other than Subpart U must still meet 
the requirements of 29 CFR 1910.133.
III. Need for Other Types of PPE
    Gloves and gowns (overgarments) are the two most common types of 
PPE used in healthcare settings. A major principle of Standard 
Precautions is that all blood and body fluids, whether from a patient, 
patient sample, or infectious material, may contain transmissible 
infectious agents (Siegel et al., 2007). Therefore, gloves and gowns 
(overgarments) are required for certain examinations and all 
procedures. These include everything from venipuncture to removing 
medical waste to intubation. Similarly, gowns or similar protective 
clothing are necessary for any activities in which splashes or clothing 
contamination is possible. This applies as part of Standard Precautions 
as well as for care of patients on Contact Precautions where 
unintentional contact with contaminated environmental surfaces must be 
avoided (Siegel et al., 2007).
    Eye protection in the form of goggles or face shields (as discussed 
above) can be used with facemasks to protect mucous membranes (eyes, 
nose, and mouth) in situations where, for example, sprays of blood or 
body fluids are possible. CDC recommends that healthcare workers wear 
eye protection during patient care encounters to ensure eyes are 
protected from infectious bodily fluids (CDC, February 23, 2021).
IV. Conclusion
    In closing, the best available experimental and epidemiological 
data support consistent use of facemasks in healthcare work settings to 
reduce the spread of COVID-19 through droplet transmission. Adopting 
facemask policies is necessary, as part of a multi-layered strategy 
combined with other non-pharmaceutical interventions such as physical 
distancing, hand hygiene, and adequate ventilation, to protect 
employees from COVID-19. Based on the proven effectiveness of facemask 
use and the effectiveness of face shields in preventing contamination 
of facemasks and protecting the eyes when there is a particular risk of 
droplet exposure, OSHA's COVID-19 ETS includes necessary provisions for 
required use of facemasks and face shields (e.g., either as a 
complementary device or in such circumstances where it is not 
appropriate or possible to wear a facemask). The ETS also requires 
additional PPE, such as gloves, gowns, and eye protection, in certain 
limited circumstances where there is likely exposure to persons with 
COVID-19.
References
Centers for Disease Control and Prevention (CDC). (2021, February 
2). Order under Section 361 of the Public Health Service Act (42 
U.S.C. 264) and 42 Code of Federal Regulations 70.2, 71.31(b), 
71.32(b). Federal Register notice: wearing of face masks while on 
conveyances and at transportation hubs. https://www.cdc.gov/quarantine/masks/mask-travel-guidance.html. (CDC, February 2, 2021).
Centers for Disease Control and Prevention (CDC). (2021, February 
23). Interim infection prevention and control recommendations for 
healthcare personnel during the Coronavirus Disease 2019 (COVID-19) 
pandemic. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html. (CDC, February 23, 2021).
Centers for Disease Control and Prevention (CDC). (2021, April 19). 
Guidance for Wearing Masks. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/cloth-face-cover-guidance.html. (CDC, 
April 19, 2021).
Centers for Disease Control and Prevention (CDC). (2021, May 13). 
How COVID-19 spreads. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/how-covid-spreads.html. (CDC, May 13, 2021).
Chu, DK et al., (2020, June 27). Physical Distancing, Face Masks, 
and Eye Protection to Prevent Person-to-Person Transmission of SARS-
CoV-2 and COVID-19: a systematic review and meta-analysis. The 
Lancet 395: 1973-1987. https://doi.org/10.1016/. (Chu et al., June 
27, 2020).
Food and Drug Administration (FDA). (2004, July 14). Guidance for 
industry and FDA staff. Surgical masks--premarket notification 
[510(k)] submissions. https://www.fda.gov/regulatory-information/search-fda-guidance-documents/surgical-masks-premarket-notification-510k-submissions. (FDA, July 14, 2004).
Food and Drug Administration (FDA). (2020, December 7). N95 
respirators, surgical masks, and face masks. https://www.fda.gov/medical-devices/personal-protective-equipment-infection-control/n95-respirators-surgical-masks-and-face-masks#s2. (FDA, December 7, 
2020).
Garcia-Godoy, L. et al., (2020, May 5). Facial protection for 
healthcare workers during pandemics: A scoping review. BMJ global 
health, 5(5), e002553. https://doi.org/10.1136/bmjgh-2020-002553. 
(Garcia-Godoy et al., May 5, 2020).
Lindsley, W. et al., (2014, June 27). Efficacy of face shields 
against cough aerosol droplets from a cough simulator. Journal of 
Occupational and Environmental Hygiene, 11(8), 509-518. doi: 
10.1080/15459624.2013.877591. (Lindsley et al., June 27, 2014).
Lindsley, W. et al., (2021, January 7). Efficacy of face masks, neck 
gaiters and face shields for reducing the expulsion of simulated 
cough-generated aerosols. Aerosol Science and Technology, DOI:

10.1080/02786826.2020.1862409. (Lindsley et al., January 7, 2021).
MacIntyre, C. et al., (2015, March 26). A cluster randomised trial 
of cloth masks compared with medical masks in healthcare workers. 
BMJ Open 2015; 5: e006577. doi: 10.1136/bmjopen-2014-006577. 
(MacIntyre et al., March 26, 2015).
Occupational Safety and Health Administration (OSHA). (2021, January 
28). Frequently asked questions COVID-19. https://www.osha.gov/coronavirus/faqs. (OSHA, January 28, 2021).
Seidelman, J. et al., (2020, June 25). Universal masking is an 
effective strategy to flatten the severe acute respiratory 
coronavirus virus 2 (SARS-CoV-2) healthcare worker epidemiologic 
curve. Infection Control & Hospital Epidemiology, 41(12), 1466-1467. 
doi: 10.1017/ice.2020.313. (Seidelman et al., June 25, 2020).
Siegel, J, Rhinehart, E, Jackson, M, Chiarello, L, and the 
Healthcare Infection Control Practices Advisory Committee. (2007). 
2007 Guideline for isolation precautions: preventing transmission of 
infectious agents in healthcare settings. https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf. (Siegel 
et al., 2007).
Stephenson, T. et al., (2021, February 12). Evaluation of facial 
protection against close-contact droplet transmission. MedRxiv. doi: 
10.1101/2021.02.09.21251443. (Stephenson et al., February 12, 2021).
Ueki, H et al., (2020, June 25). Effectiveness of face masks in 
preventing airborne transmission of SARS-CoV-2. mSphere 5: e00637-
20. https://doi.org/10.1128/mSphere.00637-20. (Ueki et al., June 25, 
2020).
Verma, S. et al., (2020, June 30). Visualizing the effectiveness of 
face masks in obstructing respiratory jets. Physics of Fluids, 
32(6), 061708. doi: https://doi.org/10.1063/5.0016018. (Verma et 
al., June 30, 2020).
Wang, X. et al., (2020, July 14). Association between universal 
masking in a health care system and SARS-CoV-2 positivity among 
health care workers. Journal of the American Medical Association, 
324(7), 703-704. doi: 10.1001/jama.2020.12897. (Wang et al., July 
14, 2020).
World Health Organization (WHO). (2020, December 1). Mask use in the 
context of COVID-19. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public/when-and-how-to-use-masks. (WHO, 
December 1, 2020).

F. Respirators

I. Respirator Use in Healthcare
    As noted in Grave Danger (Section IV.A. of the preamble), it is 
well-accepted that COVID-19 might spread through airborne transmission 
during aerosol-generating procedures (AGPs) such as intubation. 
Moreover, outside of AGP scenarios, CDC has noted growing evidence that 
airborne droplets and particles can remain suspended in air, travel 
distances beyond 6 feet, and be breathed in by others (CDC, May 13, 
2021). Grave Danger (Section IV.A. of the preamble) notes studies 
showing that infectious viral particles have been collected at 
distances as far as 4.8 meters away from a COVID-19 patient (Lednicky 
et al., September 11, 2020), and airborne COVID-19 infection has been 
identified in a Massachusetts hospital (Klompas et al., February 9, 
2021). Accordingly, the CDC recommends the use of airborne Transmission 
Precautions, including the use of respirators, for any healthcare 
workers caring for patients with suspected or confirmed COVID-19 (CDC, 
March 12, 2020). This airborne transmission risk is in addition to the 
risks associated with contact and droplet transmission. Respirators 
have long been recognized as an effective and mandatory means of 
controlling airborne transmissible diseases and the use of this 
personal protective equipment is regulated under OSHA's Respiratory 
Protection standard (29 CFR 1910.134).
    The CDC has issued core guidelines for when ``healthcare 
personnel'' should use respiratory protection against COVID-19 
infection (see Interim Infection Prevention and Control Recommendations 
for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) 
Pandemic (CDC, February 23, 2021)). These recommendations have been 
based on the most currently available information about COVID-19, such 
as how the virus spreads, and are applicable to all healthcare settings 
in the U.S. In the guidance, the CDC defines ``healthcare settings'' as 
places where healthcare is delivered, including but not limited to: 
acute care facilities, long-term acute care facilities, inpatient 
rehabilitation facilities, nursing homes, assisted living facilities, 
home healthcare, vehicles where healthcare is delivered (e.g., mobile 
clinics), and outpatient facilities (e.g., dialysis centers, physician 
offices). In addition, the CDC provides examples of ``healthcare 
personnel,'' which include emergency medical service personnel, nurses, 
nursing assistants, home healthcare personnel, physicians, technicians, 
therapists, phlebotomists, pharmacists, students and trainees, 
contractual staff not employed by the healthcare facility, and persons 
not directly involved in patient care, but who could be exposed to 
infectious agents that can be transmitted in the healthcare setting 
(e.g., clerical, dietary, environmental services, laundry, security, 
engineering and facilities management, administrative, billing, and 
volunteer personnel).
    The CDC describes who is at greatest risk for COVID-19 infection in 
a set of FAQs designed for healthcare workers (CDC, March 4, 2021). In 
the FAQs, the CDC notes that those currently at greatest risk of COVID-
19 infection are persons who have had prolonged, unprotected close 
contact (i.e., within 6 feet for a combined total of 15 minutes or 
longer in a 24 hour period) with a patient with confirmed COVID-19, 
regardless of whether the patient has symptoms. Moreover, according to 
the CDC, persons frequently in congregate healthcare settings (e.g., 
nursing homes, assisted living facilities) are at increased risk of 
acquiring infection because of the increased likelihood of close 
contact. In the FAQs, the CDC also reports that current data suggest 
that close-range aerosol transmission by droplet and inhalation, and 
contact followed by self-delivery to the eyes, nose, or mouth are 
likely routes of transmission for COVID-19, and that long-range aerosol 
transmission, has not been a feature of the virus. The CDC further 
explains that potential routes of close-range transmission include 
splashes and sprays of infectious material onto mucous membranes and 
inhalation of infectious virions (i.e., the active, infectious form of 
a virus) exhaled by an infected person, but that the relative 
contribution of each of these is not known for COVID-19.
    As the CDC states in the FAQs (CDC, March 4, 2021), although 
facemasks are routinely used for the care of patients with common viral 
respiratory infections, N95 filtering facepiece respirators or 
equivalent (e.g., elastomeric half-mask respirators) or higher-level 
(e.g., full facepiece respirators or PAPRs) respirators are routinely 
recommended to protect healthcare workers from emerging pathogens like 
the virus that causes COVID-19, which have the potential for 
transmission via small particles. The CDC further advises that while 
facemasks will provide barrier protection against droplet sprays 
contacting mucous membranes of the nose and mouth, they are not 
designed to protect wearers from inhaling small particles. Because of 
this, the CDC recommends the use of respirators for close-contact care 
of patients with suspected or confirmed COVID-19. The CDC recommends 
that N95 filtering facepiece respirators (FFRs) and higher-level 
respirators, such as other disposable FFRs, powered air-purifying 
respirators (PAPRs), and elastomeric respirators, should be used when 
both barrier and respiratory protection is

needed for healthcare workers because respirators provide better fit 
and filtration characteristics.
    The CDC recommendations in Interim Infection Prevention and Control 
Recommendations for Healthcare Personnel During the Coronavirus Disease 
2019 (COVID-19) Pandemic are divided into two separate categories. 
These include: (1) Recommended infection prevention and control 
practices when caring for a patient with suspected or confirmed COVID-
19; and (2) recommended routine infection prevention and control 
practices during the COVID-19 pandemic (CDC, February 23, 2021).
    A topic of interest related to the selection and use of respirators 
is their dual role as both personal protective equipment for the wearer 
and also source control to reduce the potential for transmission of 
potentially infectious exhaled air to others. While many filtering 
facepiece respirators do not have an exhalation valve, other filtering 
facepiece respirators do. The other ``higher-level'' respirators 
referenced above, and in CDC guidance (e.g., half or full facepiece 
elastomeric respirators and PAPRs), do have exhalation valves. An 
exhalation valve is a portal in the respirator to allow unfiltered air 
to leave the respirator in order to reduce breathing resistance for the 
wearer and reduce moisture and heat buildup inside the respirator. 
While the exhalation valve does allow some particles to escape through 
the valve, it is important to compare the performance of a respirator 
with an exhalation valve to other acceptable forms of source control in 
order to determine if there are actually reduced levels of 
effectiveness. NIOSH studied this issue and released a technical report 
entitled ``Filtering Facepiece Respirators with an Exhalation Valve: 
Measurements of Filtration Efficiency to Evaluate Their Potential for 
Source Control'' (NIOSH, December 2020). In the report, NIOSH concluded 
that respirators with exhalation valves were equally effective as 
facemasks:

this study found that unmitigated FFRs with an exhalation valve that 
were tested in an outward position (with particles traveling in the 
direction of exhalation) have a wide range of penetration, emitting 
between <1% and 55%. Further testing could measure greater particle 
penetration. Even without mitigation, FFRs with exhalation valves 
can reduce 0.35-[micro]m MMAD particle emissions more consistently 
than surgical masks, procedure masks, cloth face coverings, or 
fabric from cotton t-shirts; . . . FFRs with an exhalation valve 
provide respiratory protection to the wearer, and this study 
demonstrates that they can also reduce 0.35-[micro]m MMAD particle 
emissions to levels similar to or better than those provided by 
surgical masks and unregulated barrier face coverings.

    The results that NIOSH observed can be explained in two ways. 
First, the majority of the leakage takes place around the seal by the 
nose and mouth, and respirators are designed to provide tight seals 
around the face so that there is only minimal leakage. Facemasks, on 
the other hand, do not typically seal tightly to the face and thus 
significant quantities of unfiltered air with small particles will also 
escape through the gaps on the side and at the nose, as well as 
potentially through the fabric of less protective filter materials. 
Second, the level of filtration in facemasks is highly variable, so a 
wide range of filter efficiencies have been acceptable under CDC 
guidance. The CDC does not recommend that respirators with exhaust 
valves be used as source controls, but the CDC's last updated 
recommendation on this subject was published in August of 2020, four 
months before the NIOSH study, and cited lack of data as the basis for 
the warning against relying on such respirators (CDC, April 9, 2021b). 
Therefore, the NIOSH study with its conclusion that respirators with 
exhaust valves are not less adequate as source controls than other 
acceptable source controls, appears to represent the best available 
evidence. OSHA therefore concludes that at this time there is no basis 
for OSHA to prohibit any NIOSH-approved filtering facepiece respirator 
from serving as both personal protective equipment and as source 
control. The NIOSH report also details methods of covering the 
filtering facepiece respirator's exhalation valve in various manners to 
further improve the effectiveness as source control, which OSHA 
considers a recommended practice, but not strictly necessary. There are 
also other methods that can be used to cover or filter the exhalation 
valve of elastomeric respirators (e.g., place a medical mask over the 
respirator).
II. The CDC's Recommended Infection Prevention and Control Practices 
When Caring for a Patient With Suspected or Confirmed COVID-19
    The CDC recommends that healthcare personnel (including workers 
that perform healthcare services and those that perform healthcare 
support services) who enter the room or area of a patient with 
suspected or confirmed COVID-19 adhere to Standard Precautions plus 
gown, gloves, and eye protection, and also use a NIOSH-approved N95 
filtering facepiece or equivalent or higher-level respirator. The CDC 
notes in a set of FAQs that its recommendation to use NIOSH-approved 
N95 disposable filtering facepiece or higher-level respirators when 
providing care for patients with suspected or known COVID-19 is based 
on the current understanding of the COVID-19 virus and related 
respiratory viruses (CDC, March 10, 2021).
    As noted above, the CDC recommendations listed in Interim Infection 
Prevention and Control Recommendations for Healthcare Personnel During 
the Coronavirus Disease 2019 (COVID-19) Pandemic are applicable to all 
U.S. settings where healthcare is delivered. To this end, the 
recommendations on respirator use are repeated in a variety of 
additional CDC guidelines for specific categories of healthcare 
settings (e.g., nursing homes, dental settings, assisted living 
facilities, home health care settings). For example, in its guidance 
for nursing homes, the CDC recommends that residents with known or 
suspected COVID-19 be cared for while using all recommended PPE, 
including an N95 or higher-level respirator (CDC, March 29, 2021). In 
addition, in its guidance for dental settings, the CDC recommends that 
dental healthcare personnel who enter the room of a patient with 
suspected or confirmed COVID-19 use a NIOSH-approved N95 or equivalent 
or higher-level respirator, as well as other PPE (CDC, December 4, 
2020). Additionally, in its guidance for assisted living facilities, 
the CDC recommends an N95 or higher-level respirator for personnel for 
situations where close contact with any (symptomatic or asymptomatic) 
resident cannot be avoided, if COVID-19 is suspected or confirmed in a 
resident of the assisted living facility (i.e., resident reports fever 
or symptoms consistent with COVID-19) (CDC, May 29, 2020). Also, in its 
guidance for home healthcare settings, the CDC recommends that when 
home health agency personnel are involved in the care of people with 
confirmed or suspected COVID-19 at their homes, the personnel adhere to 
relevant infection prevention and control practices as described in the 
core healthcare guidance Interim Infection Prevention and Control 
Recommendations for Healthcare Personnel During the Coronavirus Disease 
2019 (COVID-19) Pandemic (i.e., that they use N95 or higher-level 
respirators) (CDC, October 16, 2020).
    In addition to its infection prevention and control guidelines for 
healthcare personnel in healthcare settings, the CDC has issued 
infection prevention and control guidelines for conducting postmortem 
procedures on decedents/

human remains during the COVID-19 pandemic in Collection and Submission 
of Postmortem Specimens from Deceased Persons with Confirmed or 
Suspected COVID-19 (CDC, December 2, 2020). In this guidance, the CDC 
recommends respirators while conducting autopsies on decedents in all 
cases due to the likelihood of aerosol generation during the 
performance of autopsies (CDC, December 2, 2020). The WHO has also 
issued guidelines for COVID-19 infection control for aerosol-generating 
procedures during autopsies. For example, WHO recommends respirators 
for procedures such as the use of power saws (WHO, September 4, 2020).
    As supported by the above evidence and guidance from authoritative 
bodies, OSHA has concluded that healthcare employees have a heightened 
risk of COVID-19 infection when working with patients with known or 
suspected COVID-19. Accordingly, in any healthcare setting where 
employees are exposed to patients with known or suspected COVID-19, 
whether or not AGPs are performed, employers are required to provide 
N95s or higher-level respirators and follow all requirements under 29 
CFR 1910.134, including medical evaluations and fit testing.
III. Applicability of the Respiratory Protection Standard to COVID-19
    OSHA's Respiratory Protection standard (29 CFR 1910.134) has 
general requirements for respiratory protection for workers exposed to 
respiratory hazards, including the COVID-19 virus. In the context of 
the pandemic, the agency has applied the Respiratory Protection 
standard to situations in healthcare settings where workers are exposed 
to suspected or confirmed sources of COVID-19. OSHA's Respiratory 
Protection standard has been in effect since 1998 and the purpose of 
those controls have been established for decades (63 FR 1152, January 
8, 1998). The standard contains requirements for the administration of 
a respiratory protection program, with worksite-specific procedures, 
respirator selection, employee training, fit testing, medical 
evaluation, respirator use, respirator cleaning, maintenance, and 
repair, among other requirements. It is important to note that the 
standard applies to ``biological hazards'' (63 FR 1180, January 8, 
1998). Accordingly, the agency will continue to apply the Respiratory 
Protection standard to work tasks and situations in healthcare as 
covered by 29 CFR 1910.502.
IV. Respirator Provisions Tailored to the COVID-19 Pandemic Will 
Clarify Employer Responsibilities
    Notwithstanding the applicability of the Respiratory Protection 
standard, as OSHA will explain in this discussion, it is imperative 
that the ETS contain additional provisions related to the employer's 
discretion to select respirators beyond what is required by 29 CFR 
1910.134. These additional requirements are necessary in order to 
appropriately protect workers in healthcare industries. In the Need for 
the ETS (Section IV.B. of the preamble), OSHA has addressed why 
existing standards in general are inadequate to address the COVID-19 
hazard. In this discussion the agency focuses more specifically on how 
clarifications regarding respirator need and use will help address 
COVID-19 hazards.
    Many employers are confused as to when respiratory protection is 
required for protection against COVID-19, leaving many unprotected 
healthcare workers at high risk of becoming infected with COVID-19. 
This confusion has been exacerbated by two factors. First, many 
employers that need to provide respirators to protect their workers 
from COVID-19 have never needed to provide respirators to their workers 
in the past (e.g., many employers in the home health care or nursing 
home sector), or have not had to routinely provide respirators to 
certain workers in their facilities to protect them against infectious 
disease hazards (e.g., the housekeeping or facilities maintenance staff 
in some medical facilities). Second, there have been respirator and fit 
testing supply shortages and a widespread misinterpretation by 
employers of OSHA's temporary enforcement memoranda on respiratory 
protection. One issue of great concern to the agency is a 
misunderstanding by employers about crisis capacity strategies, which 
were initially suggested by the CDC as a means to optimize supplies of 
disposable N95 FFRs in healthcare settings when the alternative would 
be no respiratory protection at all. Many workers report that their 
employers have employed crisis capacity strategies as the de facto 
daily practice, even when additional respirators were available for 
use. To address these issues, the ETS contains clear mandates on when 
respiratory protection is required for protection against COVID-19 and 
contains a note encouraging employers to use elastomeric respirators or 
PAPRs instead of filtering facepiece respirators to prevent shortages 
and supply chain disruption.
    To address initial N95 FFR shortages, the CDC began to create and 
issue a series of strategies to optimize supplies of disposable N95 
FFRs in healthcare settings when there is limited supply (CDC, April 9, 
2021a). The strategies are based on the three general strata that have 
been used to describe surge capacity to prioritize measures to conserve 
N95 FFR supplies along the continuum of care (Hick et al., June 1, 
2009). Contingency measures (temporary measures during expected N95 
shortages), and then crisis capacity measures (emergency strategies 
during known shortages that are not commensurate with U.S. standards of 
care), augment conventional capacity measures and are meant to be 
considered and implemented sequentially. However, as the supply of 
respirators for healthcare personnel has increased, the CDC and FDA 
have encouraged employers to transition away from the most extreme 
measures of respirator conservation, crisis and contingency capacity 
strategies, to conventional use (FDA, April 9, 2021; CDC, April 9, 
2021a). The use of crisis capacity strategies is likely to increase the 
risk of COVID-19 exposure when compared to conventional and contingency 
capacity strategies.
    The CDC's conventional capacity strategies for optimizing the 
supply of N95 FFRs, which the CDC recommends be incorporated into 
everyday practices, include a variety of measures, such as training on 
use and indications for the use of respirators, just-in-time fit 
testing, limiting respirators during training, qualitative fit testing, 
and the use of alternatives to FFRs. CDC's conventional capacity 
strategy recommendation is to use NIOSH-approved alternatives to N95 
FFRs where feasible. These include other classes of disposable FFRs, 
reusable elastomeric half-mask and full facepiece air-purifying 
respirators, and reusable powered air-purifying respirators (PAPRs). 
All of these alternatives provide equivalent or higher-level protection 
than N95 FFRs when properly worn. To assist employers in this effort, 
NIOSH maintains a searchable, online Certified Equipment List 
identifying all NIOSH-approved respirators (NIOSH, n.d., retrieved on 
January 11, 2021). Since they are reusable, elastomeric respirators and 
PAPRs have the added advantage of being able to be disinfected, 
cleaned, and reused according to manufacturers' instructions. As such, 
they can be used by workers after the COVID-19 pandemic and during 
future pandemics that may again create N95 FFR

shortages. Consistent with this, the ETS provides in a note that, where 
possible, employers are encouraged to select elastomeric respirators or 
PAPRs instead of filtering facepiece respirators to prevent shortages 
and supply chain disruption.
    Also consistent with this, the ETS provides in the same note that, 
when there is a limited supply of filtering facepiece respirators (and 
only when there is a limited supply of filtering facepiece 
respirators), employers may follow the CDC's Strategies for Optimizing 
the Supply of N95 Respirators (April 9, 2021a). This may include the 
use of respirators beyond the manufacturer-designated shelf life for 
healthcare delivery; use of respirators approved under standards used 
in other countries that are similar to NIOSH-approved N95 respirators; 
limited re-use of N95 FFRs; and prioritizing the use of N95 respirators 
and facemasks by activity type. However, again, the FDA and CDC are 
recommending healthcare personnel and facilities transition away from 
crisis capacity conservation strategies, such as decontaminating or 
bioburden reducing disposable respirators for reuse, due to the 
increased domestic supply of new respirators. The FDA and CDC believe 
there is an increased supply of respirators to transition away from 
these strategies (FDA, April 9, 2021; CDC, April 9, 2021a).
    OSHA notes finally that its enforcement of the Respiratory 
Protection standard has been complicated by the respirator and fit-
testing supply shortages incurred during the pandemic. In response to 
these shortages, the agency issued numerous temporary enforcement 
guidance memoranda allowing its Compliance Safety and Health Officers 
(CSHOs) to exercise enforcement discretion when considering issuing 
citations under the Respiratory Protection standard and/or the 
equivalent respiratory protection provisions of other health standards 
during the pandemic (OSHA, n.d., Retrieved December 22, 2020). OSHA's 
temporary enforcement memoranda are aligned with CDC's Strategies for 
Optimizing the Supply of N95 Respirators, which recommend a variety of 
conventional, contingency, and crisis capacity control strategies, as 
mentioned above (CDC, April 9, 2021a). Unfortunately, these memoranda 
have been widely misinterpreted by employers, resulting in additional 
confusion about OSHA's respiratory protection requirements during the 
pandemic. OSHA bases this conclusion on staff expertise and experience, 
as well as on reporting in news media articles (Safety + Health, April 
9, 2020; Bailey and Martin, March 19, 2020). (See also Need for the ETS 
(Section IV.B. of the preamble).) For example, employers have 
misinterpreted the temporary enforcement guidance memoranda as offering 
blanket waivers or exemptions for complying with certain provisions of 
the Respiratory Protection standard (e.g., annual fit-testing 
requirements). In addition, many employers did not understand that 
these memoranda allow for enforcement discretion by CSHOs only in 
circumstances where an employer can demonstrate that it made 
unsuccessful but objectively reasonable efforts to obtain and conserve 
supplies of FFRs and fit-testing supplies. While the memoranda were 
intended as guidelines for CSHOs, employer misinterpretation of these 
memoranda has resulted in fewer protections for workers, particularly 
in healthcare industries.
    OSHA is therefore clarifying that respirators are required for the 
protection of workers exposed to suspected or confirmed sources of 
COVID-19 in healthcare settings, and in all of those cases the 
respirators must be used in accordance with the Respiratory Protection 
standard (29 CFR 1910.134). OSHA also encourages employers, where 
possible, to select elastomeric respirators or PAPRs instead of 
filtering facepiece respirators to prevent shortages and supply chain 
disruption. Because the crisis capacity strategy is less protective, 
the employer should only use crisis capacity strategies for a limited 
period of time and take immediate steps to purchase and use elastomeric 
respirators or PAPRs in order to prevent future shortages and further 
expose their workers to the grave danger of COVID-19.
V. Conclusion
    The best available evidence demonstrates that respirator use is an 
important means of reducing the likelihood of COVID-19 infection of the 
wearer when used in accordance with Sec.  1910.134. Respirators are 
necessary controls that provide some protection to healthcare workers 
and healthcare support service workers when exposed to persons with 
known or suspected COVID-19.
    Based on the above analysis, the agency concludes that it is 
necessary to add into the ETS respiratory protection requirements 
tailored specifically to the COVID-19 pandemic. These requirements will 
assist employers in identifying when respiratory protection is required 
for healthcare workers and will help address and strengthen worker 
protection during the pandemic. To this end, the ETS takes a 
prioritization approach to the conservation of respirators by requiring 
the use of respirators only where airborne transmission is the most 
likely (when employees are exposed to persons with suspected or 
confirmed COVID-19, or in accordance with Standard and Transmission-
Based Precautions in healthcare settings).
    The increased certainty associated with the respirator requirements 
in the healthcare section and added flexibility of allowing employers 
to follow 29 CFR 1910.504 in some limited circumstances will lead to 
more compliance, and more compliance will lead to improved protection 
of workers. In addition, a note in the ETS will better inform employers 
that they can consider selecting from other NIOSH-approved respirator 
options (i.e., elastomeric respirators and PAPRs) as alternatives to 
N95 FFRs for protection against COVID-19, as well as other respiratory 
infections (e.g., tuberculosis, varicella, etc.) both during the 
pandemic and beyond. Knowledge of alternative respiratory protection 
options for healthcare employers to consider will help them choose 
appropriate alternative respirators and help mitigate respirator supply 
shortages.
References
Bailey, M. and Martin, J. (2020, March 19). OSHA allows healthcare 
employers to suspend N95 annual fit-testing during Coronavirus 
``Outbreak.'' The National Law Review. https://www.natlawreview.com/article/osha-allows-healthcare-employers-to-suspend-n95-annual-fit-testing-during. (Bailey and Martin, March 19, 2020).
Centers for Disease Control and Prevention (CDC). (2020, March 12). 
What healthcare personnel should know about caring for patients with 
confirmed or possible COVID-19. https://www.cdc.gov/coronavirus/2019-ncov/hcp/caring-for-patients-H.pdf. (CDC, March 12, 2020).
Centers for Disease Control and Prevention (CDC). (2020, May 29). 
Considerations for preventing spread of COVID-19 in assisted living 
facilities. https://www.cdc.gov/coronavirus/2019-ncov/hcp/assisted-living.html. (CDC, May 29, 2020).
Centers for Disease Control and Prevention (CDC). (2020, October 
16). Interim guidance for implementing home care of people not 
requiring hospitalization for COVID-19. https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-home-care.html. (CDC, October 16, 
2020).
Centers for Disease Control and Prevention (CDC). (2020, December 
2). Collection and submission of postmortem specimens from deceased 
persons with confirmed or suspected COVID-19.

https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-postmortem-specimens.html. (CDC, December 2, 2020).
Centers for Disease Control and Prevention (CDC). (2020, December 
4). Guidance for dental settings. https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html. (CDC, December 4, 2020).
Centers for Disease Control and Prevention (CDC). (2021, February 
23). Interim infection prevention and control recommendations for 
healthcare personnel during the coronavirus disease 2019 (COVID-19) 
pandemic. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html. (CDC, February 23, 2021).
Centers for Disease Control and Prevention (CDC). (2021, March 4). 
Clinical questions about COVID-19: Questions and answers. https://www.cdc.gov/coronavirus/2019-ncov/hcp/faq.html. (CDC, March 4, 
2021).
Centers for Disease Control and Prevention (CDC). (2021, March 10). 
Frequently asked questions about Coronavirus (COVID-19) for 
laboratories. https://www.cdc.gov/coronavirus/2019-ncov/lab/faqs.html#Laboratory-Biosafety. (CDC, March 10, 2021).
Centers for Disease Control and Prevention (CDC). (2021, March 29). 
Interim Infection Prevention and Control Recommendations to Prevent 
SARS-CoV-2 Spread in Nursing Homes. https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html. (CDC, March 29, 2021).
Centers for Disease Control and Prevention (CDC). (2021a, April 9). 
Strategies for optimizing the supply of N95 respirators. https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirators-strategy/index.html. (CDC, April 9, 2021a).
Centers for Disease Control and Prevention (CDC). (2021b, April 9). 
Personal Protective Equipment: Questions and Answers. https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirator-use-faq.html. (CDC, 
April 9, 2021b).
Centers for Disease Control and Prevention (CDC). (2021, May 13). 
How COVID-19 spreads. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/how-covid-spreads.html. (CDC, May 13, 2021).
Food and Drug Administration (FDA). (2021, April 9). FDA Recommends 
Transition from Use of Decontaminated Disposable Respirators--Letter 
to Health Care Personnel and Facilities. https://www.fda.gov/medical-devices/letters-health-care-providers/fda-recommends-transition-use-decontaminated-disposable-respirators-letter-health-care-personnel-and. (FDA, April 9, 2021).
Hick, J. et al., (2009, June 1). Refining surge capacity: 
Conventional, contingency, and crisis capacity. Disaster Medicine 
and Public Health Preparedness, 3(2 Suppl), S59-S67. https://doi.org/10.1097/DMP.0b013e31819f1ae2. (Hick et al., June 1, 2009).
Klompas, M. et al., (2021). A SARS-CoV-2 cluster in an acute care 
hospital. Annals of Internal Medicine. [Epub ahead of print 9 
February 2021] https://doi.org/10.7326/M20-7567. (Klompas et al., 
February 9, 2021).
Lednicky, J. et al., (2020, September 11). Viable SARS-CoV-2 in the 
air of a hospital room with COVID-19 patients. International Journal 
of Infectious Diseases, 100, 476-482. doi: 10.1016/
j.ijid.2020.09.025. (Lednicky et al., September 11, 2020).
National Institute for Occupational Safety and Health (NIOSH) (2020, 
December). Filtering facepiece respirators with an exhalation valve: 
Measurements of filtration efficiency to evaluate their potential 
for source control. By Portnoff, L., Schall, J., Brannen, J., Suhon, 
N., Strickland, K., Meyers, J. DHHS (NIOSH) Publication No. 2021-
107. https://www.cdc.gov/niosh/docs/2021-107/pdfs/2021-107.pdf?id=10.26616/NIOSHPUB2021107. Retrieved January 10, 2021. 
(NIOSH, December, 2020).
National Institute for Occupational Safety and Health (NIOSH). 
(n.d.) Certified equipment lists. Retrieved January 11, 2021 from 
https://www.cdc.gov/niosh/npptl/topics/respirators/cel/default.html. 
(NIOSH, n.d., Retrieved January 11, 2021).
Occupational Safety and Health Administration (OSHA). (n.d.). COVID-
19--regulations--enforcement memoranda. Retrieved December 22, 2020 
from https://www.osha.gov/coronavirus/standards#temp_enforcement_guidance. (OSHA, n.d., Retrieved December 
22, 2020).
Safety + Health. (2020, April 9). OSHA allowing all employers to 
suspend annual respirator fit testing. https://www.safetyandhealthmagazine.com/articles/19685-osha-allowing-all-employers-to-suspend-annual-respirator-fit-testing. (Safety + 
Health, April 9, 2020).
World Health Organization (WHO). (2020, September 4). Infection 
prevention and control for the safe management of a dead body in the 
context of COVID-19. https://www.who.int/publications/i/item/infection-prevention-and-control-for-the-safe-management-of-a-dead-body-in-the-context-of-covid-19-interim-guidance. (WHO, September 4, 
2020).

G. Mini Respiratory Protection Program

I. Introduction
    OSHA emphasizes that when respirators are required under the ETS to 
protect employees against exposure to suspected or confirmed sources of 
COVID-19, they must be used in accordance with the Respiratory 
Protection standard (29 CFR 1910.134). Moreover, nothing in the ETS 
changes an employer's obligation to identify hazards or provide a 
respirator that must be used in accordance with the Respiratory 
Protection standard for any other workplace hazard that might require 
respiratory protection (e.g., silica, asbestos, airborne infectious 
agents such as Mycobacterium tuberculosis).
    OSHA's Respiratory Protection standard requires employers to 
develop and implement a comprehensive written respiratory protection 
program, required worksite-specific procedures and elements that 
include, but are not limited to, respirator selection and use, medical 
evaluation, fit testing, respirator maintenance and care, and training. 
Establishing such a program can take time to establish and require a 
level of expertise that some employers do not have, particularly if 
they are a covered healthcare employer that did not typically have 
respiratory hazards before COVID-19 (e.g., many employers in the home 
health care or nursing home sector). In such cases, these regulatory 
requirements may have unintentionally prevented employers from 
providing their employees with a higher level of respiratory protection 
than afforded by a facemask in circumstances where it may have been 
beneficial to do so.
    The ``mini respiratory protection program'' section of the ETS (29 
CFR 1910.504) is designed to strengthen employee protections with a 
small set of provisions for the safe use of respirators designed to be 
easier and faster to implement than the more comprehensive respiratory 
protection program. The ETS is addressing an emergency health crisis, 
so it is critical for employers to be able to get more employee 
protection in place quickly. OSHA expects that this approach will 
facilitate additional employee choice for the additional protection 
provided by respirators while reducing disincentives that may have 
discouraged employers from allowing or voluntarily providing 
respirators. A mini respirator program is therefore an important 
control to protect employees from the hazard posed by COVID-19.
    The mini respiratory protection program section is primarily 
intended to be used for addressing circumstances where employees are 
not exposed to suspected or confirmed sources of COVID-19, but where 
respirator use could offer enhanced protection to employees. Examples 
include when a respirator could offer enhanced protection in 
circumstances where a less protective (in terms of filtering and fit) 
facemask is required under the ETS. (See 29 CFR 1910.502(f)(4).) The 
decision to use a respirator in place of a facemask could be due to the 
higher filter efficiency and better sealing characteristics of 
respirators when compared to facemasks and/or in consideration of an 
employer's determination during their hazard assessment of constraints 
on their

ability to implement other ETS provisions (e.g., physical distancing 
and barriers).
    If an employee uses a respirator in place of a facemask, then the 
employer must ensure that the respirator is used in accordance with the 
mini respiratory protection program section of the ETS or in accordance 
with the Respiratory Protection standard. For example, if an employee 
that is required to wear a facemask instead chooses to wear a 
respirator when performing an aerosol-generating procedure (AGP) on a 
patient who is not suspected or confirmed with COVID-19, the ETS only 
requires the employer to ensure that the respirator is used in 
accordance with the mini respiratory protection program section, rather 
than in accordance with the Respiratory Protection standard, because 
there is no exposure to a suspected or confirmed source of COVID-19 
(see 29 CFR 1901.502(f)(4)(ii)). In contrast, employees performing AGPs 
on patients with suspected or confirmed COVID-19 must be provided with 
respirators that are used in accordance with the Respiratory Protection 
standard (see 29 CFR 1901.502(f)(3)(i)). Additionally, employers will 
still be obligated to provide a respirator that is used in accordance 
with the Respiratory Protection standard for any AGPs performed on 
patients suspected or confirmed with an airborne disease, such as 
tuberculosis or measles.
II. Experience From the Respiratory Protection Standard (29 CFR 
1910.134)
    In determining the need for a mini respiratory protection program 
section, the agency considered its experience with the existing 
Respiratory Protection standard. While the majority of the Respiratory 
Protection standard pertains to the use of respirators that are 
required for the protection of employees against airborne hazards, 
there is one provision allowing, but not requiring, employers to permit 
employees to wear respirators in situations where respirators are not 
required for protection against airborne hazards. (See 29 CFR 
1910.134(c)(2).) In establishing the requirements of this provision of 
the Respiratory Protection standard, OSHA also establishes some general 
concepts to guide respirator use. These concepts include: (1) That the 
respirator use will not in itself create a hazard; (2) that the 
employer provides the respirator user with information about the safe 
use and limitations of respirators; and (3) that the respirator is 
cleaned, stored, and maintained so that its use does not present a 
health hazard to the user. (29 CFR 1910.134(c)(2)(i) and (ii)).
    OSHA has historically imposed a different set of requirements on 
employers for when respirators are required to protect employees from 
airborne hazards as compared to when they are not required for 
protection against airborne hazards but are instead used voluntarily by 
employees. More specifically, paragraph (c)(1) of the Respiratory 
Protection standard requires employers to develop and implement a 
comprehensive written respiratory protection program with required 
worksite-specific procedures and elements whenever respirator use is 
required by the standard. As noted earlier, these elements include, but 
are not limited to, respirator selection and use, medical evaluation, 
fit testing, respirator maintenance and care, and training. In 
contrast, paragraph (c)(2) of the Respiratory Protection standard 
requires employers to implement only a subset of these elements for the 
voluntary use of respirators, greatly reducing the obligations of 
employers who allow their employees to use respirators when such use is 
not required for employee protection. In the 1998 rulemaking, OSHA 
determined that paragraph (c)(2) is necessary because the use of 
respirators may itself present a health hazard to employees who are not 
medically able to wear them, who do not have adequate information to 
use and care for respirators properly, and who do not understand the 
limitations of respirators. Paragraph (c)(2) is intended to allow 
employers flexibility to permit employees to use respirators in 
situations where the employees wish to do so, without imposing the 
burden of implementing an entire respirator program. At the same time, 
it will help ensure that such use does not create an additional hazard 
and that employees are provided with enough information to use and care 
for their respirators properly (63 FR 1190, January 8, 1998).
    The vast majority of voluntary respirator use situations under the 
Respiratory Protection standard have historically involved the use of 
FFRs, worn merely for an employee's comfort (63 FR 1190, January 8, 
1998). Examples include employees who have seasonal allergies 
requesting a FFR for comfort when working outdoors and employees 
requesting a FFR for comfort while sweeping a dusty floor (63 FR 1190, 
January 8, 1998). In contrast, respirator use situations under this 
section of the ETS will involve employers who provide a respirator or 
employees who want to wear a respirator, out of an abundance of 
caution, as enhanced protection against COVID-19. They may also opt to 
wear respirators other than FFRs (e.g., elastomeric respirators, 
PAPRs), particularly given the supply shortages of N95 FFRs experienced 
during the COVID-19 pandemic. Thus, the circumstances of respirator use 
in the ETS are not merely to accommodate individual conditions or 
comfort, but rather in recognition of some increased risk due to 
asymptomatic and pre-symptomatic transmission of COVID-19 that is not 
expected to rise to the level where respirators are required for 
exposure to suspected or confirmed sources of COVID-19.
    OSHA emphasizes that while the new set of requirements for 
respirator use under the ETS differ in some aspects from those 
specified under the Respiratory Protection standard, their intent 
remains the same; that is, employers who provide respirators at the 
request of their employees or who allow their employees to bring their 
own respirators into the workplace must ensure that the respirator used 
does not present a hazard to the health of the employee.
    In the 1998 rulemaking, OSHA concluded in the rare case where an 
employee is voluntarily using other than a filtering facepiece (dust 
mask) respirator (paragraph (c)(2)(ii)), the employer must implement 
some of the elements of a respiratory protection program, e.g., the 
medical evaluation component of the program and, if the respirator is 
to be reworn, the cleaning, maintenance, and storage components. An 
exception to this paragraph makes clear that, where voluntary 
respirator use involves only filtering facepieces (dust masks), the 
employer is not required to implement a written program. While medical 
evaluation is required when employees are voluntarily wearing 
respirators other than FFRs under the Respiratory Protection standard, 
there are no requirements under the ETS to provide medical evaluations 
for employees wearing such respirators. The agency concludes that it 
would be too onerous and costly for employers to provide medical 
evaluations to employees wearing elastomeric respirators or PAPRs in 
place of FFRs used in accordance with crisis capacity strategies during 
the short period of the ETS. However, OSHA's experience with its 
Respiratory Protection standard suggests that respiratory protection 
can still be effective even when subject to particular safety 
provisions, but not subject to the full range of requirements. In place 
of medical evaluations, the agency has included a training requirement 
on how to recognize medical signs and symptoms that may

limit or prevent the effective use of employer-provided respirators and 
what to do if the employee experiences signs and symptoms (29 CFR 
1910.504(d)(1)(v)), as well as a requirement for the discontinuation of 
employer-provided respirator use (see 29 CFR 1910.504(d)(4)). This 
requirement mandates that employees who wear employer-provided 
respirators must discontinue respirator use when the employer or 
supervisor reports medical signs or symptoms that are related to their 
ability to use a respirator. In addition, any employee who previously 
had a medical evaluation and was determined to not be medically fit to 
wear a respirator should not be provided with an employer-provided 
respirator under the ETS.
    The ETS does not require employers to include any of the use 
requirements specified under the ETS into a written respiratory 
protection program. OSHA concludes that it would be too onerous for 
employers to incorporate these requirements into a written respiratory 
protection program during the short period of the ETS, particularly for 
those employers who have no need to have a written respiratory 
protection program in place for required respirator use. OSHA 
reemphasizes that the intent of the requirements in the mini 
respiratory protection program are to ensure that employees are 
provided with information to safely wear respirators, without imposing 
the burden of additional requirements for a written respiratory 
protection program on employers.
    OSHA notes that unlike the voluntary use requirements specified 
under the Respiratory Protection standard, there are different 
requirements for the use of employee-provided respirators as compared 
to those for employer-provided respirators under the mini respiratory 
protection program section. This is because the agency is requiring 
employers to permit the use of employee-provided respirators. OSHA 
concludes that it is necessary to permit employees to wear their own 
respirators in healthcare settings given the risk for asymptomatic and 
pre-symptomatic transmission and the nature of much of the work that 
precludes such control measures as physical distancing and barriers. 
However, the agency concludes that it would be too onerous to mandate 
as many requirements for such use as are mandated when employers are 
given the option of whether or not to provide employees with 
respirators for use.
III. Requirements for Employee-Provided Respirators
    In the 1998 rulemaking, OSHA determined that complete training is 
not required for employees using respirators voluntarily; instead, the 
final rule required employers to provide the information contained in 
Appendix D to the Respiratory Protection standard, entitled 
``Information for Employees Using Respirators When Not Required Under 
the Standard,'' to ensure that employees are informed of proper 
respirator use and the limitations of respirators (63 FR 1190-1192, 
January 8, 1998). Under the ETS, there is only one requirement for the 
use of employee-provided respirators. This requirement is for the 
employer to provide these employees with a specific notice, as 
specified under paragraph (c) of the mini respiratory protection 
program section. This notice is almost identical to the notice 
contained in Appendix D to the Respiratory Protection standard, with 
some minor changes intended only to tailor the information to the 
situational needs of the COVID-19 pandemic.
IV. Requirements for Employer-Provided Respirators
    As noted above, under the ETS, the requirements for the use of 
employer-provided respirators are more expansive under the mini 
respiratory protection program section than the requirements for 
employee-provided respirators. However, OSHA notes that employers are 
not obligated by the ETS to provide employees with respirators for use 
under the mini respiratory protection program section, so these 
requirements are only mandated when an employer voluntarily provides 
employees with respirators for use under the mini program. The 
requirements include provisions pertaining to training, user seal 
checks, reuse of respirators, and discontinuing use of respirators. 
When employers choose to provide respirators to employees, the same 
rationale applies as it did in the 1998 rulemaking requiring employers 
to undertake these minimal obligations when they allow voluntary 
respirator use is consistent with the fact that employers control the 
working conditions of employees and are therefore responsible for 
developing procedures designed to protect the health and safety of the 
employees. Employers routinely develop and enforce rules and 
requirements for employees to follow based on considerations of safety. 
For example, although an employer allows employees discretion in the 
types of clothing that may be worn on site, the employer would prohibit 
the wearing of loose clothing in areas where clothing could get caught 
in machinery, or prohibit the use of sleeveless shirts where there is a 
potential for skin contact with hazardous materials. Similarly, if an 
employer determines that improper or inappropriate respirator use 
presents a hazard to the wearer, OSHA finds that the employer must 
exert control over such respirator use and take steps to see that 
respirators are safely used under an appropriate program (63 FR 1190-
1191, January 8, 1998).
    The training requirements for the use of employer-provided 
respirators expand on the basic respirator awareness notice required 
for the use of employee-provided respirators. They require the employer 
to provide training on: (a) How to inspect, put on and remove, and use 
a respirator; (b) the limitations and capabilities of the respirator, 
particularly when the respirator has not been fit tested; (c) 
procedures and schedules for storing, maintaining, and inspecting 
respirators; (d) how to perform a user seal check as described in 
paragraph (e) of this section; and (e) how to recognize medical signs 
and symptoms that may limit or prevent the effective use of respirators 
and what to do if the employee experiences signs and symptoms. These 
training requirements for respirator use are similar to the training 
requirements mandated under the Respiratory Protection standard for 
required respirator use. (See 29 CFR 1910.134(k)). OSHA concludes that 
more extensive training provisions are required for the use of 
employer-supplied respirators under the ETS because such use is likely 
to be based on other factors related to the risk of COVID-19, including 
the ability to implement other control measure (e.g., physical 
distancing and barriers).
    The user seal check requirements mandate employers to ensure that 
employees conduct user seal checks and to ensure the employees correct 
any problems discovered during the user seal check. This is similar to 
the user seal check provision for required respirator use under the 
Respiratory Protection standard. (See 1910.134(g)(1)(iii)). OSHA 
concludes that ensuring that user seal checks are conducted is 
necessary because employees who wear respirators are not required to be 
fit tested under the ETS. OSHA notes that, in the 1998 rulemaking, OSHA 
concluded that user seal checks are important in assuring that 
respirators are functioning properly, and that although user seal 
checks are not as objective a measure of facepiece leakage as a fit 
test, they do

provide a quick and easy means of determining that a respirator is 
seated properly (63 FR 1239-40, January 8, 1998). Given that employees 
who choose to wear employer-provided respirators will likely be doing 
so out of an abundance of caution to protect against potential airborne 
transmission of SARS-CoV-2 and will not be fit tested, OSHA concludes 
that it is necessary for employers to train employees how to conduct a 
user seal check and to ensure that they are performed properly in order 
to improve the effectiveness of the respirator.
    In the 1998 rulemaking, OSHA determined that ``if the respirators 
being used voluntarily are reused, it is necessary to ensure that they 
are maintained in proper condition to ensure that the employee is not 
exposed to any contaminants that may be present in the facepiece, and 
to prevent skin irritation and dermatitis associated with the use of a 
respirator that has not been cleaned or disinfected'' (63 FR 1190, 
January 8, 1998). To this end, and given the potential for supply 
shortages of FFRs necessitating their reuse under certain circumstances 
during the COVID-19 pandemic, OSHA concludes that it is necessary to 
add specific requirements for the reuse of respirators used 
voluntarily. These requirements incorporate some CDC recommendations 
for the reuse of FFRs used in accordance with crisis capacity 
strategies (CDC, April 9, 2021).
References
Centers for Disease Control and Prevention (CDC). (2021, April 9). 
Strategies for Optimizing the Supply of N95 Respirators. https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirators-strategy/index.html. (CDC, April 9, 2021).

H. Aerosol-Generating Procedures on Persons With Suspected or Confirmed 
COVID-19

    As explained in more detail in Grave Danger (Section IV.A. of the 
preamble), aerosol-generating procedures (AGP) are well-known to be 
high-risk activities for exposure to respiratory infections. Workers in 
a wide range of settings, such as emergency responders, healthcare 
providers, and medical examiners performing autopsies, are at risk 
during AGPs. For the purposes of the ETS, only the following procedures 
are considered AGPs: Open suctioning of airways, sputum induction, 
cardiopulmonary resuscitation, endotracheal intubation and extubation, 
non-invasive ventilation (e.g., BiPAP, CPAP), bronchoscopy, manual 
ventilation, medical/surgical/postmortem procedures using oscillating 
bone saws, and dental procedures involving ultrasonic scalers, high-
speed dental handpieces, air/water syringes, air polishing, and air 
abrasion. For further information on why these procedures are 
considered AGPs under the ETS, please see the discussion of aerosol-
generating procedures in Section VIII, Summary and Explanation.
    The CDC provides extensive guidance for performance of AGPs (CDC, 
February 23, 2021). First, exposure should be limited where possible. 
The CDC recommends that the use of procedures or techniques that might 
produce infectious aerosols should be minimized when feasible, as 
should the number of people in the room.
    CAP has also recognized the risks involved in conducting AGPs by 
recommending limiting the use of aerosol-generating tools, such as 
oscillating bone saws, during autopsies on COVID-19-positive cases 
(College of American Pathologists, February 2, 2021). Post-mortem 
procedures using oscillating bone saws have specifically been noted as 
a COVID-19-related exposure concern (Nolte et al., December 14, 2020). 
The following controls are therefore recommended for autopsies 
involving the use of oscillating bone saws: Isolation rooms, limiting 
the number of people in the room who are exposed, negative pressure 
ventilation, adequate air exchange, double door access, and use of 
respirators.
    As noted in Grave Danger (Section IV.A. of the preamble), it is 
well-accepted that COVID-19 may spread through infectious aerosols 
during AGPs. Therefore, where these procedures must be performed, there 
are two important controls for these situations: Ventilation (for 
example, in the form of air infection isolation rooms (AIIR), if 
available) and respiratory protection. Both of these controls are 
required for AGPs in the ETS. For more information on why there is a 
need to include in this ETS a requirement for respirators during 
aerosol-generating procedures, please see Need for Specific Provisions 
(Section V of this preamble) on Respirators.
    It is well-established that insufficient ventilation increases the 
risk of airborne disease transmission; indeed, this is the foundation 
for the World Health Organization recommendations on ventilation in 
healthcare settings (Atkinson et al., 2009). When air is stagnant or 
poorly ventilated, aerosols may increase in concentration and increase 
exposure. Both a lack of ventilation and inadequate ventilation are 
associated with increased infection rates of airborne diseases. 
Increasing ventilation rates has been shown to decrease transmission 
risk of airborne disease. Ventilation is able to direct airflow away 
from uninfected individuals, which reduces risk of transmission.
    The American Society of Heating, Refrigerating and Air-Conditioning 
Engineers (ASHRAE) is the authoritative organization for ventilation 
standards in the U.S. The U.S. Army Corps of Engineers (USACE) has been 
tasked by the U.S. Federal Emergency Management Agency with the design 
and construction of alternative care sites during surges in the COVID-
19 pandemic. USACE requested that ASHRAE provide engineering guidance 
for ventilation within alternative care sites. The resulting joint 
ASHRAE/USACE document makes recommendations for removal of aerosols 
generated by patients during AGPs and other patient care activities in 
alternative care sites (ASHRAE and USACE. November 20, 2020). 
Additionally, ASHRAE provides specific guidance on source control and 
AIIRs related to aerosol-generating procedures during the COVID-19 
pandemic (ASHRAE, January 30, 2021).
    Airborne infection isolation rooms (AIIR) are specifically designed 
to control the spread of aerosols and prevent airborne transmission of 
disease (Sehulster and Chinn, June 6, 2003). An AIIR has negative 
pressure in comparison to accessible areas outside the room, which 
causes air to flow into (rather than out of) the room from the room's 
access points when they are open (e.g., an open door). When the access 
points (e.g., the door) are closed and ventilation is adequate, 
contaminated air cannot escape at all into the rest of the facility. 
Air exhaust can be delivered directly outdoors or passed through a 
special high-efficiency (HEPA) filter. In this way, AIIRs minimize 
potentially contaminated air flow outward into the rest of the 
facility.
    Because of the risk of airborne transmission, the CDC recommends 
the use of AIIRs when AGPs are performed on patients with suspected or 
confirmed COVID-19. However, increased protection for workers 
performing AGPs is not a new recommendation solely for the COVID-19 
pandemic. The CDC and WHO both routinely recommend higher levels of 
personal protective equipment for workers performing these procedures 
on patients with other respiratory infections (CDC, October 30, 2018). 
The CDC recommendations for AGPs performed on influenza patients 
specify use of AIIRs when feasible. The

recommendations also specify that the use of portable HEPA filtration 
units to further reduce the concentration of contaminants in the air 
should be considered. Similarly, the World Health Organization 
recommends more protective respirators for AGPs (WHO, April, 2008). 
Finally, the National Institute for Occupational Safety and Health 
(NIOSH) has developed a ventilated headboard that can be used to reduce 
employee exposure to patient-generated aerosols containing respiratory 
pathogens (NIOSH, May 26, 2020).
References
American Society of Heating, Refrigerating and Air-Conditioning 
Engineers (ASHRAE). (2021, January 30). Guide to the COVID-19 Pages. 
https://www.ashrae.org/technical-resources/healthcare. (ASHRAE, 
January 30, 2021).
American Society of Heating, Refrigerating and Air-Conditioning 
Engineers (ASHRAE) and United States Army Corps of Engineers 
(USACE). (2020, November 20). Alternate Care Site HVAC Guidebook. 
https://www.ashrae.org/about/news/2020/new-alternative-care-site-guidebook-available-to-help-respond-to-the-rising-need-for-hospital-beds-due-to-covid-19. (ASHRAE and USACE, November 20, 2020).
Atkinson, J et al., (2009). Natural Ventilation for Infection 
Control in Health-Care Setting World Health Organization Guidelines. 
https://www.who.int/water_sanitation_health/publications/natural_ventilation/en/. (Atkinson et al., 2009).
Centers for Disease Control and Prevention (CDC). (2018, October 
30). Prevention strategies for seasonal influenza in healthcare 
settings. https://www.cdc.gov/flu/professionals/infectioncontrol/healthcaresettings.htm. (CDC, October 30, 2018).
Centers for Disease Control and Prevention (CDC). (2021, February 
23). Interim infection prevention and control recommendations for 
healthcare personnel during the Coronavirus Disease 2019 (COVID-19) 
pandemic. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html. (CDC, February 23, 2021).
College of American Pathologists. (2021, February 2). Amended COVID-
19 autopsy guideline statement from the CAP Autopsy Committee. 
https://documents.cap.org/documents/COVID-Autopsy-Statement.pdf. 
(College of American Pathologists, February 2, 2021).
National Institute for Occupational Safety and Health (NIOSH). 
(2020, May 26). Worker protective controls--engineering controls to 
reduce airborne, droplet and contact exposures during epidemic/
pandemic response. https://www.cdc.gov/niosh/topics/healthcare/engcontrolsolutions/ventilated-headboard.html. (NIOSH, May 26, 
2020).
Nolte, K. et al., (2020, December 14). Design and construction of a 
biosafety level-3 autopsy laboratory. Arch Path Lab Med. doi: 
10.5858/arpa.2020-0644-SA. (Nolte et al., December 14, 2020).
Sehulster, L. and Chinn, R. (2003, June 6). Guidelines for 
Environmental Infection Control in Health-Care Facilities. MMWR 
52(RR10); 1-42. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5210a1.htm. (Sehulster and Chinn, June 6, 2003).
World Health Organization (WHO). (2008, April). Epidemic- and 
pandemic-prone acute respiratory diseases--Infection prevention and 
control in health care. https://www.who.int/csr/resources/publications/aidememoireepidemicpandemid/en/. (WHO, April, 2008).

I. Physical Distancing

    The best available current scientific evidence demonstrates that 
COVID-19 spreads mainly through transmission between people who are 
physically near each other. The basic concept is that the majority of 
respiratory droplets expelled from an infected person through talking, 
coughing, breathing, or sneezing can travel a limited distance before 
falling to the surface below due to gravity. Therefore, the farther a 
person is away from the source of the respiratory droplets, the fewer 
infectious viral particles are likely to reach that person's eyes, 
nose, or mouth. The fewer infectious viral particles that reach that 
person, the lower the risk of transmission. Additional explanation of 
transmission is discussed in Grave Danger (Section IV.A. of the 
preamble). OSHA recognizes that this is a simplification of the complex 
issue of how droplets and aerosols moving through space applies to the 
transmission of SARS-CoV-2. Nonetheless, the broad scientific 
principles described in this preamble enable OSHA to describe to 
affected employers and employees why the protective measures required 
by this ETS are necessary to protect employees from exposure to the 
virus.
    The research described below demonstrates that a significant factor 
in determining whether a healthy employee will become infected with 
COVID-19 is how close that employee is to other people (e.g., co-
workers, patients, visitors, delivery people). Infected individuals can 
transmit the virus to others whether or not the infected person is 
experiencing symptoms, and symptoms may not be immediately noticeable, 
so it is important to keep all employees distanced from other people 
whether or not those other people exhibit symptoms. Symptomatic, 
asymptomatic, and pre-symptomatic transmission is discussed further in 
Grave Danger (Section IV.A. of the preamble). The role that physical 
distancing plays in this ETS is thus to ensure that employees are 
separated from other people as much as possible so as to reduce the 
risk that virus-containing droplets reach employees.
    Consistent with CDC guidance, OSHA defines physical distancing as 
maintaining a sufficient distance between two people--generally 
considered to be at least six feet of separation--such that the risk of 
viral transmission through inhalation of virus-containing particles 
from an infected individual is significantly reduced. OSHA is aware of 
emerging scientific literature that suggests even greater distances may 
be beneficial. OSHA is also aware of some literature from other 
countries that suggests less than six feet may be appropriate in some 
circumstances; however, based on the evidence summarized below, OSHA 
believes that anything less than six feet is not sufficient to address 
the level of risk established in the studies the agency has reviewed. 
While it is likely that a distance of greater than six feet will result 
in some lowered risk and OSHA recommends six feet as a minimum 
distance, OSHA is not aware of sufficient evidence to justify mandating 
a distance farther than the six feet recommended by the CDC. Physical 
distancing is a critical component of infectious disease prevention 
guidelines and is a key protective measure of the current COVID-19-
specific prevention recommendations from the CDC, WHO, and other public 
health entities, as discussed in greater detail below (CDC and OSHA, 
March 9, 2020; WHO, June 26, 2020; CalOSHA, 2020; ECDC, March 23, 2020; 
PHAC, May 25, 2020).
    The importance of physical distancing is evident from CDC's 
guidance for determining who qualifies as close contacts of an 
individual who is COVID-19 positive. People who have been in close 
contact with a COVID-19-positive individual are most likely to become 
infected. To become infected with COVID-19, a healthy individual 
typically needs to inhale a certain amount of viral particles (i.e., an 
infectious dose). The closer that healthy individual is to an infected 
person emitting infectious viral particles, the greater their exposure 
may be. In practice, a person generally needs to be both close enough 
to an infectious person and near them long enough to inhale an 
infectious dose. The CDC acknowledges the potential for inhalation at 
distances greater than six feet from an infectious source, but notes

that this is less likely than at a closer distance (CDC, May 7, 2021). 
This continues to support OSHA's recommendation for a minimum distance 
of six feet. It is also important to note that multiple short exposures 
over the course of a day can add up to a long enough period of time to 
receive an infectious dose of COVID-19. Therefore, CDC's definition of 
close contact is dependent on both proximity to one or more infected 
people and the time period over which that proximity occurred. The CDC 
defines close contact as ``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'' (CDC, March 11, 2021). The CDC uses this close 
contact designation to help determine contact tracing to minimize 
transmission spread and to help communicate the risk of transmission to 
the public.
    The CDC close contact definition describes the likely context for 
transmission events under most circumstances. However, it should be 
noted that infections can occur from exposures of less than 15 minutes. 
For example, one infection event was documented that resulted from only 
roughly five minutes of exposure (Kwon et al., November 23, 2020). 
Thus, distancing may reduce COVID-19 exposure during even short periods 
of exposure.
    The notion that physical distancing can protect a healthy 
individual from respiratory droplets is well established for droplet-
transmissible diseases and has been a topic of study for well over a 
hundred years (Flugge, 1897; Jennison, 1942; Duguid, November 1, 1945; 
Wells, November 1, 1955). Carl Flugge (1897) is credited with 
originating the concept of droplet transmission. In his study using 
settling plates to collect large droplets that were emitted from an 
individual, he found that droplets fell to the plates within two meters 
(approximately 6.6 feet). Combining this knowledge with the known 
presence of infectious materials in respiratory droplets, Flugge 
suggested that remaining two meters from infected individuals would be 
protective. This understanding of droplet transmission was further 
expanded a few decades later, when William F. Wells noted that in 
Flugge's study, Flugge was unable to observe a proportion of small 
droplets that would evaporate before settling on the plates and that 
these evaporated droplets traveled differently, suggesting that some 
measure of transmission may happen beyond the large droplet 
transmission that Flugge observed (Wells, November 1, 1934). 
Subsequently, in the 1940s and 1950s, high-speed photography improved 
to the point where it could capture, upon emission, most of the 
respiratory droplets--large and small--that formed; this line of study 
validated much of the groundwork that Flugge and Wells laid (Jennison, 
1942; Duguid, November 1, 1945; Hamburger and Robertson, May 1, 1948; 
Wells, November 1, 1955). These studies illustrated that large droplets 
can be a major driver of disease transmission, but also that there 
might be exceptions to the effectiveness of physical distancing when it 
comes to virus-laden small droplets.
    Even though COVID-19 is a recent disease, evidence of the 
effectiveness of physical distancing in reducing exposures to SARS-CoV-
2 has been illustrated through a variety of scientific approaches, 
including an experimental study by Ueki et al., (October 21, 2020), a 
modeling study by Li et al., (November 3, 2020), and real world 
observational studies by Chu et al., (June 27, 2020) and Doung-ngern et 
al., (September 14, 2020). In a controlled laboratory experiment 
performed by Ueki et al., (October 21, 2020), researchers developed a 
scenario where 6 mL of SARS-CoV-2 viral serum was nebulized from a 
mannequin's mouth to form a mist that simulated a cough. Another 
mannequin, which was outfitted with an artificial ventilator set to an 
average adult ventilation rate, collected a proportion of the mist at 
distances of 0.25 meters (approximately 0.8 feet), 0.5 meters 
(approximately 1.6 feet), and 1 meter (approximately 3.3 feet). Using 
the 0.25-meter distance as a baseline, increasing the distance between 
the mannequins reduced viral particle exposure (measured as the number 
of viral RNA copies) by 62% at 0.5 meters and 77% at 1 meter. The study 
clearly illustrates the increased protection from viral exposure that 
results from increasing distance between individuals.
    Modeling studies also provide evidence supporting the effectiveness 
of physical distancing in preventing exposure to SARS-CoV-2. In Li et 
al., (November 3, 2020), researchers modeled exposures resulting from 
respiratory droplets dispersed from a simulated typical cough using 
simulated saliva with a SARS-CoV-2 viral concentration measured from 
infected individuals. The simulated cough emitted 30,558 viral copies 
at distances of one meter (approximately 3.3 feet) and two meters 
(approximately 6.6 feet) between the infectious person and the person 
exposed. At one meter, more than 65% of the droplet volume (about 
20,000 viral copies) reached the recipient. However, almost all of the 
exposure was deposited below the head, with only 9 viral copies 
estimated to land on the area that would normally be covered by a face 
covering. When the distance was increased to two meters, 63 viral 
copies landed on the recipient, with only 0.6 copies expected to hit 
the face covering area. This study illustrates not only the benefit of 
distance for reducing inhalation exposure, but also for reducing 
contamination of clothing, which can contribute to overall exposure if 
a person touches their contaminated clothing and then touches their 
eyes, nose, or mouth.
    Outside of experimental and modeling scenarios, observations in 
real world situations also substantiate the finding that increasing 
physical distance protects people from developing infections. A 
systematic review of 172 studies on SARS-CoV-2 (up to early May 2020), 
SARS-CoV-1 (a viral strain related to SARS-CoV-2), and Middle Eastern 
Respiratory Syndrome (MERS) (a disease caused by a virus that is 
similar to SARS-CoV-2 and spreads through droplet transmission) found 
38 studies, containing 18,518 individuals, to use in a meta-analysis 
that evaluated the effectiveness of physical distancing (Chu et al., 
June 27, 2020). The researchers compared the infection rates for 
individuals who were within one meter (approximately 3.3 feet) of 
infected people versus the infection rates for those who were greater 
than one meter away. For individuals who were within one meter, the 
chance of viral infection was 12.8%. When distance was greater than one 
meter, the chance of viral infection decreased to 2.6%. Furthermore, 
researchers projected that with each additional meter of distance the 
risk would be reduced by an additional 2.02 times.
    The importance of physical distancing even when people are not 
exhibiting symptoms was further demonstrated by a COVID-19 study from 
Thailand. Researchers reviewed physical distancing information 
collected from 1,006 individuals who had an exposure to infected 
individuals (Doung-ngern et al., September 14, 2020). At the time of 
the exposure, many of the infected individuals were not yet 
experiencing symptoms, and none of the exposed individuals included in 
the study were experiencing symptoms. The researchers contacted the 
individuals 21 days after their exposures to determine if any secondary 
infections had occurred. Out of 1,006 participants, 197 tested positive 
and 809 either tested

negative or were considered low risk contacts, did not exhibit symptoms 
and, therefore, were not tested. The researchers then compared the 
incidence of secondary infections to data on how close the exposed 
individuals were to the infected individuals. Exposed individuals were 
placed into three groups: Those who had direct physical contact with 
the infected individual, those who were within one meter (approximately 
3.3 feet) but without physical contact, and those who remained more 
than one meter away. The study revealed that the group with direct 
physical contact and the group within one meter but without physical 
contact were equally likely to become infected with SARS-CoV-2. 
However, the group that remained more than one meter away had an 85% 
lower infection risk than the other two groups.
    As noted earlier, there is additional nuance to droplet fate beyond 
just the general effects of gravity on large droplets. Studies 
evaluating the dispersion of aerosols (i.e., particles that are smaller 
than typical droplets) and atypical droplets in the air have created a 
more thorough understanding of disease transmission and the limitations 
on the effectiveness of physical distancing (Jones et al., August 25, 
2020). The distance that droplets may be able to travel depends on 
their size, expelled velocity, airflow, and other environmental 
considerations (Xie et al., May 29, 2007; Dbouk and Drikakis, May 1, 
2020; Li et al., April 22, 2020). Bahl et al., (April 16, 2020) 
reviewed ten studies on the horizontal spread of droplets, finding that 
seven of the studies observed maximum distances traveled by droplets 
that greatly exceeded two meters (approximately 6.6 feet); one of which 
suggested the possibility of travel up to eight meters (approximately 
26.2 feet). Several case studies have identified incidents where 
transmission of SARS-CoV-2 occurred over distances of 15.1 feet (Li et 
al., April 22, 2020), 21.3 feet (Kwon et al., November 23, 2020) and 
26.2 feet (Gunther et al., October 27, 2020). These studies suggest 
that while maintaining a physical distance of two meters reduces 
transmission significantly, there is still some risk of transmission 
beyond two meters. Thus, these studies illustrate that physical 
distancing is an important control, but also why physical distancing 
alone is insufficient, and a multi-layered strategy that includes 
additional control measures is necessary to protect employees from 
contracting COVID-19.
    As demonstrated by the studies above, it is widely accepted that 
physical distancing reduces transmission of infectious diseases 
generally, and COVID-19 specifically. While the specific distance 
needed to ensure maximum reduction of COVID-19 transmission can be 
debated, six feet has long been used in the U.S. as the minimum 
acceptable distance in most situations to prevent transmission of 
droplet-transmissible infectious diseases, and the CDC has recommended 
that distance to combat COVID-19 since the start of the pandemic (CDC 
and OSHA, March 9, 2020).
    Physical distancing strategies can be applied on an individual 
level (e.g., avoiding coming within six feet of another individual), a 
group level (e.g., canceling group activities where individuals would 
be in close contact), and an operational level (e.g., promoting 
telework, reconfiguring the infrastructure or reducing facility 
occupancy levels to allow sufficient space for physical distancing). As 
described in further detail in Summary and Explanation (Section VIII of 
the preamble), CDC and OSHA have identified various approaches to 
maintaining physical distance between employees, such as: Reducing the 
number of employees on-site at one time; reducing facility occupancy 
levels (both for employees and non-employees); staggering arrival, 
break, and departure times to maintain distancing during specific times 
at work when adherence is difficult; and holding on-site training or 
meeting activities in larger spaces to allow for sufficient distance 
between attendees (CDC and OSHA, March 9, 2020).
    Physical distancing practices and recommendations are also well-
accepted internationally as an effective measure to reduce the spread 
of COVID-19. The World Health Organization (WHO) recommends physical 
distance of at least one meter (approximately 3.3 feet) in all 
workplace settings, with a preference for two meters (approximately 6.6 
feet) (WHO, June 26, 2020). WHO also recommends providing sufficient 
work space of at least 10 square meters for each employee where it is 
feasible based on work tasks. Some foreign governments have implemented 
physical distancing requirements and recommendations varying in 
distances of: One meter (e.g., Hong Kong, Singapore, United Kingdom, 
Norway), 1.5 meters (e.g., Germany, Spain), and 2 meters (e.g., Japan, 
South Korea, Canada) (Han et al., November 7, 2020; PHAC, May 25, 
2020). While the required or recommended amount of distance varies 
between jurisdictions, it is clear that physical distancing is 
considered to be a critical tool in preventing the spread of COVID-19 
around the world and that, even where six feet of distance cannot be 
maintained, maintaining as much distance as possible can help minimize 
the possibility of disease transmission (Chu et al., June 27, 2020; 
Doung-ngern et al., September 14, 2020; Li et al., November 3, 2020; 
Ueki et al., 2020).
    Based on the best available evidence, the agency concludes that 
physical distancing of at least six feet is an effective and necessary 
tool to protect employees from COVID-19 by reducing incidence of COVID-
19 illness. This conclusion applies to physical distancing on its own 
and also when complemented by other measures as part of a multi-layered 
strategy to minimize employee exposure to COVID-19.
References
Bahl, P. et al., (2020, April 16). Airborne or Droplet Precautions 
for Health Workers Treating Coronavirus Disease 2019. The Journal of 
Infectious Diseases jiaa189. https://doi.org/10.1093/infdis/jiaa189. 
(Bahl et al., April 16, 2020).
California Division of Occupational Safety and Health (CalOSHA). 
(2020). COVID-19 Prevention Emergency Standard. OSHSB-98(2/98). 
(CalOSHA, 2020).
Centers for Disease Control and Prevention (CDC) and Occupational 
Safety and Health Administration (OSHA). (2020, March 9). Guidance 
on Preparing Workplaces for COVID-19. https://www.osha.gov/sites/default/files/publications/OSHA3990.pdf. (CDC and OSHA, March 9, 
2020).
Centers for Disease Control and Prevention (CDC). (2021, March 11). 
Appendices (Close Contact). https://www.cdc.gov/coronavirus/2019-ncov/php/contact-tracing/contact-tracing-plan/appendix.html#contact. 
(CDC, March 11, 2021).
Centers for Disease Control and Prevention (CDC). (2021, May 7). 
Scientific Brief: SARS-CoV-2 Transmission. https://www.cdc.gov/coronavirus/2019-ncov/more/scientific-brief-sars-cov-2.html. (CDC, 
May 7, 2021).
Chu, DK et al., (2020, June 27). Physical Distancing, Face Masks, 
and Eye Protection to Prevent Person-to-Person Transmission of SARS-
CoV-2 and COVID-19: a systematic review and meta-analysis. The 
Lancet 395: 1973-1987. https://doi.org/10.1016/. (Chu et al., June 
27, 2020).
Dbouk, T. and Drikakis, D. (2020). On Coughing and Airborne Droplet 
Transmission to Humans. Physics of Fluids 32, 053310. https://doi.org/10.1063/5.0011960. (Dbouk and Drikakis, May 1, 2020).
Doung-ngern, P. et al., (2020, September 14). Case-control Study of 
Use of Personal Protective Measures and Risk for SARS Coronavirus 2 
Infection, Thailand. Emerging Infectious Diseases 26, 11: 2607-2616. 
https://doi.org/10.3201/

eid2611.203003. (Doung-ngern et al., September 14, 2020).
Duguid, JP. (1945). The Numbers and the Sites of Origin of the 
Droplets Expelled During Expiratory Activities. Edinburgh Medical 
Journal 52, 11: 385-401. (Duguid, November 1, 1945).
European Centre for Disease Prevention and Control (ECDC). (2020, 
March 23). Considerations related to social distancing measures in 
response to COVID-19--second update. https://www.ecdc.europa.eu/en/publications-data/considerations-relating-social-distancing-measures-response-covid-19-second. (ECDC, March 23, 2020).
Flugge, C. (1897). Uber Luftinfection. Zeitschrift fur Hygiene und 
Infektionskrankheiten 25: 179-224. (Flugge, 1897).
Gunther, T. et al., (2020, October 27). SARS-CoV-2 Outbreak 
Investigation in a German Meat Processing Plant. EMBO Molecular 
Medicine. https://doi.org/10.15252/emmm.202013296. (Gunther et al., 
October 27, 2020).
Hamburger, M. and Robertson, OH. (1948, May 1). Expulsion of Group A 
Hemolytic Streptococci in Droplets and Droplet Nuclei by Sneezing, 
Coughing, and Talking. American Journal of Medicine 4(5): 690-701. 
(Hamburger and Robertson, May 1, 1948).
Han, E. et al., (2020, November 7). Lessons Learned from Easing 
COVID-19 Restrictions: An Analysis of Countries and Regions in Asia 
Pacific and Europe. The Lancet 396: 1525-1534. https://doi.org/10.1016/. (Han et al., November 7, 2020).
Jennison, MW. (1942). Atomising of Mouth and Nose Secretions into 
the Air as Revealed by High-Speed Photography. Aerobiology 17: 106-
128. (Jennison, 1942).
Jones, NR et al., (2020, August 25). Two Metres or One: What is the 
Evidence for Physical Distancing in COVID-19? BMJ 370: m3223. http://dx.doi.org/10.1136/bmj.m3223. (Jones et al., August 25, 2020).
Kwon, KS et al., (2020, November 23). Evidence of Long-Distance 
Droplet Transmission of SARS-CoV-2 by Direct Air Flow in a 
Restaurant in Korea. J Korean Med Sci 35(46): e415. https://jkms.org/DOIx.php?id=10.3346/jkms.2020.35.e415. (Kwon et al., 
November 23, 2020).
Li, H. et al., (2020, November 3). Dispersion of Evaporating Cough 
Droplets in Tropical Outdoor Environment. Physics of Fluids 32, 
113301. https://doi.org/10.1063/5.0026360. (Li et al., November 3, 
2020).
Li, Y. et al., (2020, April 22). Aerosol Transmission of SARS-CoV-2: 
Evidence for Probable Aerosol Transmission of SARS-CoV-2 in a Poorly 
Ventilated Restaurant. PREPRINT https://doi.org/10.1101/2020.04.16.20067728. (Li, April 22, 2020).
Public Health Agency of Canada (PHAC). (2020, May 25). Physical 
Distancing: How to Slow the Spread of COVID-19. ID 04-13-01. https://www.canada.ca/content/dam/phac-aspc/documents/services/publications/diseases-conditions/coronavirus/social-distancing/physical-distancing-eng.pdf. (PHAC, May 25, 2020).
Ueki, H. et al., (2020, October 21). Effectiveness of Face Masks in 
Preventing Airborne Transmission of SARS-CoV-2. mSphere 5: e00637-
20. https://doi.org/10.1128/mSphere.00637-20. (Ueki et al., October 
21, 2020).
Wells, WF. (1934, November 1). On Airborne Infection: Study II. 
Droplets and Droplet Nuclei. American Journal of Epidemiology 20(3): 
611-618. (Wells, November 1, 1934).
Wells, WF. (1955, November 1). Airborne Contagion and Air Hygiene: 
An Ecological Study of Droplet Infections. Journal of the American 
Medical Association 159: 90. (Wells, November 1, 1955).
World Health Organization (WHO). (2020, June 26). Coronavirus 
disease (COVID-19): Health and Safety in the Workplace. https://www.who.int/news-room/q-a-detail/coronavirus-disease-covid-19-health-and-safety-in-the-workplace. (WHO, June 26, 2020).
Xie, X. et al., (2007, May 29). How far droplets can move in indoor 
environments--revisiting the Wells evaporation-falling curve. Indoor 
Air 17: 211-225. doi: 10.1111/j.1600-0668.2006.00469.x. (Xie et al., 
May 29, 2007).

J. Physical Barriers

    When people with COVID-19 cough, sneeze, sing, talk, yell, or 
breathe, they produce respiratory droplets. Epidemiological research 
has found that most COVID-19 transmission occurs via respiratory 
droplets that are spread from an infected individual during close 
(within 6 feet) person-to-person interactions (CDC, May 7, 2021; CDC, 
May 13, 2021a; WHO, July 9, 2020). The amount of respiratory droplets 
and particles released when a person breathes is significant, and the 
amount increases when someone talks or yells (Asadi et al., February 
20, 2019; Alsved et al., September 17, 2020; Abkarian et al., October 
13, 2020).
    Barriers can be used to minimize occupational exposure to SARS-CoV-
2. Barriers work by preventing droplets from traveling from the source 
(i.e., an infected person) to an employee, thus reducing droplet 
transmission. When barriers are used properly, they will intercept 
respiratory droplets that may contain SARS-CoV-2. Barriers are 
particularly critical when physical distancing of six feet is required 
but not feasible (AIHA, September 9, 2020; Fischman and Baker, June 4, 
2020; CDC, April 7, 2021; CDC, March 8, 2021; WHO, May 10, 2020; 
University of Washington, October 29, 2020).
    When engineering controls, such as physical barriers, are 
appropriately installed and located, they can reduce exposure to 
infectious agents, such as SARS-CoV-2, without relying on changes in 
employee behavior (OSHA, 2009). Therefore, engineering controls are 
often the most effective type of control and can also be a cost-
effective layer of protection (AIHA, September 9, 2020). Physical 
barriers are not a stand-alone measure and are only one part of a 
multi-layered approach for infection control. To protect employees from 
exposure to SARS-CoV-2, engineering controls need to be combined with 
work practice controls, administrative controls, and PPE to ensure 
adequate protection (CDC, April 7, 2021; CDC, March 8, 2021).
    Physical barriers, such as plastic or acrylic partitions, are well-
established and accepted as an infection control approach to containing 
droplet transmissible diseases. Recommendations for the use of physical 
barriers are commonly made in connection with pandemic events, such as 
the 2010 pandemic influenza (see, for example, OSHA, 2009) or avian 
influenza pandemics (see, for example, CDC, January 23, 2014). However, 
physical barriers are recognized as effective engineering controls for 
preventing the transmission of infectious agents and, therefore, have 
been commonly used in other workplace settings even under non-pandemic 
conditions. For instance, sneeze guards are included in the FDA's 2017 
Food Code, which all 50 states use for their food safety regulations 
(FDA, 2017). These barriers, typically placed in front of and above 
food items, intercept contaminants, such as respiratory droplets, that 
may be expelled from a person's mouth or nose (Todd et al., August 1, 
2010).
    Impermeable barriers intercept respiratory droplets and prevent 
them from reaching another individual (Fischman and Baker, June 4, 
2020; Ibrahim et al., June 1, 2020; Dehghani et al., December 22, 2020; 
University of Washington, October 29, 2020). Thus, physical barriers 
can be a practical solution for decreasing the transmission of 
infectious viral particles for a wide range of work activities and 
locations. Only barriers that keep respiratory droplets out of an 
employee's breathing zone will reduce overall exposure to SARS-CoV-2. 
The breathing zone is the area immediately around an individual's mouth 
and nose from which a person draws air when they breathe and extends 9 
inches beyond a person's nose and mouth (OSHA, February 11, 2014). 
Additional considerations for the design and implementation of physical 
barriers to

properly block face-to-face pathways of breathing zones, including 
acceptable materials and installation, is discussed in the Summary and 
Explanation (Section VIII of the preamble).
    While COVID-19-related research on barriers is fairly limited due 
to the recent emergence and ongoing nature of the pandemic, there is 
some evidence of the effectiveness of physical barriers in healthcare 
settings during the COVID-19 pandemic. Using a surrogate for SARS-CoV-
2, Mousavi et al., (August 13, 2020) designed an experimental study in 
which general patient rooms in a healthcare facility were converted 
into isolation rooms constructed out of plastic barriers with zipper 
doors. The authors found that the use of the barrier alone could stop 
the particles that contacted the barrier and prevent 80% of the 
surrogate SARS-CoV-2 particles from spreading to adjacent spaces. In 
contrast, without the barrier, particles were easily dispersed to other 
areas of the facility. The barrier was actually more effective at 
containing particles than a solid door, as the barrier did not create 
changes in airflow patterns like a door does when it opens and closes.
    A simulation study using a double set of plastic drapes as a 
barrier around a patient's head and neck during patient intubation 
found that the drapes were effective at minimizing contamination to the 
healthcare provider and patient (Ibrahim et al., June 1, 2020). 
Similarly, a simulation study performed in a dental healthcare setting 
evaluated the use of clear, flexible barriers that were fitted over the 
patient chair and covered the patient's head, neck, and chest; the 
barriers had small openings for the employee's hands. The barriers were 
found to reduce the number of dyed water droplets landing on the 
provider and in the surrounding work environment during the dental 
procedure (Teichert-Filho et al., August 18, 2020). A simulation study 
of peroral endoscopy procedures performed through the mouth found that 
the use of an acrylic box around a patient's head during the procedure 
may reduce the number of droplets transmitted to the providers 
performing the procedure (Gomi et al., October 21, 2020).
    A separate group of researchers developed a simulation study in an 
open work station environment to evaluate how physical barriers may 
impact disease transmission. They found that physical barriers were 
able to reduce the transmission of simulated 1um aerosolized particles 
from a source individual to others who were over 6 feet away by 92% 
(Abuhegazy et al., October 20, 2020). OSHA notes that it would be 
expected that large droplets, as opposed to aerosolized particles, 
would be reduced to a greater extent because they do not remain 
airborne for extended periods of time unlike aerosolized particles, as 
noted in the Physical Distancing section of the Need for Specific 
Provisions analysis.
    Researchers found that a COVID-19 outbreak among hospital food 
service employees was effectively contained with the prompt 
implementation of physical barriers in the workplace where physical 
distancing was not implemented (Hale and Dayot, August 13, 2020). This 
included installing partitions at cashier stations between employees 
and non-employees, as well as in food preparation areas between 
workstations (Hale and Dayot, August 13, 2020). While this evidence of 
the effectiveness of barriers was not drawn from healthcare settings, 
the same concept would be equally applicable to preventing transmission 
between people at similarly fixed locations in healthcare facilities, 
such as barriers separating a receptionist from a patient in intake or 
barriers separating workers sitting side by side at desks in a 
hospital's administrative office.
    It is not clear, however, that barriers are necessary to separate 
fully vaccinated employees from employees who are not fully vaccinated 
and are not suspected or confirmed to have COVID-19. As discussed in 
the Grave Danger section and in the explanation for the scope exception 
in Sec.  1910.501(a)(4), the CDC has acknowledged a ``growing body'' of 
evidence that vaccination can reduce the potential that a vaccinated 
person will transmit the SARS-CoV-2 virus to non-vaccinated co-workers 
(CDC, April 12, 2021; CDC, May 13, 2021b).
    Based on the best available evidence, the agency concludes that 
physical barriers are an effective and necessary means of, and play a 
vital role in, reducing transmission of SARS-CoV-2 when complemented by 
other measures as part of a multi-layered strategy to minimize the 
risks of employee exposure to SARS-CoV-2 by employees who are not fully 
vaccinated or from non-employees.
References
Abkarian, M. et al., (2020, October 13). Speech can produce jet-like 
transport relevant to asymptomatic spreading of virus. PNAS 117: 41, 
25237-25245. https://www.pnas.org/cgi/doi/10.1073/pnas.2012156117. 
(Abkarian et al., October 13, 2020).
Abuhegazy, A. et al., (2020, October). Numerical investigation of 
aerosol transport in a classroom with relevant to COVID-19. Physics 
of Fluids 32, 103311. https://doi.org/10.1063/5.0029118. (Abuhegazy 
et al., October 20, 2020).
Alsved, M. et al.,(2020, September 17). Exhaled respiratory 
particles during singing and talking. Aerosol Science and Technology 
54: 1245-1248. https://doi.org/10.1080/02786826.2020.1812502. 
(Alsved et al., September 17, 2020).
American Industrial Hygiene Association (AIHA). (2020, September 9). 
Reducing the Risk of COVID-19 Using Engineering Controls: Guidance 
Document. https://aiha-assets.sfo2.digitaloceanspaces.com/AIHA/resources/Guidance-Documents/Reducing-the-Risk-of-COVID-19-using-Engineering-Controls-Guidance-Document.pdf. (AIHA, September 9, 
2020).
Asadi, S et al., (2019, February 20). Aerosol emission and 
superemission during human speech increase with voice loudness. 
Scientific Reports 9: 2348. https://doi.org/10.1038/s41598-019-38808-z. (Asadi et al., February 20, 2019).
Centers for Disease Control and Prevention (CDC). (2014, January 
23). Interim Guidance for Infection Control Within Healthcare 
Settings When Caring for Confirmed Cases, Probable Cases, and Cases 
Under Investigation for Infection with Novel Influenza A Viruses 
Associated with Severe Disease. https://www.cdc.gov/flu/avianflu/novel-flu-infection-control.htm. Accessed January 28, 2021. (CDC, 
January 23, 2014).
Centers for Disease Control and Prevention (CDC). (2021, April 12). 
Benefits of getting a COVID-19 vaccine. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/vaccine-benefits.html. (CDC, April 
12, 2021).
Centers for Disease Control and Prevention (CDC). (2021, May 7). 
Scientific Brief: SARS-CoV-2 Transmission. https://www.cdc.gov/coronavirus/2019-ncov/more/scientific-brief-sars-cov-2.html. (CDC, 
May 7, 2021).
Centers for Disease Control and Prevention (CDC). (2021a, May 13). 
How COVID-19 Spreads. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/how-covid-spreads.html. (CDC, May 13, 2021a).
Centers for Disease Control and Prevention (CDC). (2021b, May 13). 
Interim Public Health Recommendations for Fully Vaccinated People. 
https://www.cdc.gov/coronavirus/2019-ncov/vaccines/fully-vaccinated-guidance.html. (CDC, May 13, 2021b).
Centers for Disease Control and Prevention (CDC). (2021, March 8). 
Guidance for Businesses and Employers Responding to Coronavirus 
Disease 2019 (COVID-19). https://www.cdc.gov/coronavirus/2019-ncov/community/guidance-business-response.html. (CDC, March 8, 2021).
Centers for Disease Control and Prevention (CDC). (2021, April 7). 
COVID-19 Employer Information for Office Buildings. https://www.cdc.gov/coronavirus/2019-ncov/community/office-buildings.html. 
(CDC, April 7, 2021).
Dehghani, F. et al., (2020, December 22). The hierarchy of 
preventive measures to

protect workers against the COVID-19 pandemic: A review. Work 67: 
771-777. DOI: 10.3233/WOR-203330. (Dehghani et al., December 22, 
2020).
Fischman, ML and Baker, B. (2020, June 4). COVID-19 Resource Center. 
American College of Occupational and Environmental Medicine [ACOEM]. 
https://acoem.org/COVID-19-Resource-Center/COVID-19-Q-A-Forum/Could-you-provide-guidance-on-the-use-of-plexiglass-barriers-for-workplaces-for-sneeze-guard%E2%80%9D-dropl. (Fischman and Baker, 
June 4, 2020).
Food and Drug Administration (FDA). (2017). Food Code: 2017 
Recommendations of the United States Public Health Service, Food and 
Drug Administration. (FDA, 2017).
Gomi, K. et al., (2020, October 21). Peroral endoscopy during the 
COVID-19 pandemic: Efficacy of the acrylic box (Endo-Splash 
Protective (ESP) box) for preventing droplet transmission. Journal 
of Gastroenterology and Hepatology 4: 1224-1228. doi: 10.1002/
jgh3.12438. (Gomi et al., October 21, 2020).
Hale, M. and Dayot, A. (2020). Outbreak Investigation of COVID-19 in 
Hospital Food Service Workers. American Journal of Infection 
Control. S0196-6553(20)30777-X. https://doi.org/10.1016/j.ajic.2020.08.011. (Hale and Dayot, August 13, 2020).
Ibrahim, M. et al., (2020, June 1). Comparison of the effectiveness 
of different barrier enclosure techniques in protection of 
healthcare workers during tracheal intubation and extubation. 
Anesthesia and Analgesia Practice 14: 3. DOI: 10.1213/
XAA.0000000000001252. (Ibrahim et al., June 1, 2020).
Mousavi, ES et al., (2020, August 13). Performance analysis of 
portable HEPA filters and temporary plastic anterooms on the spread 
of surrogate coronavirus. Building and Environment 183: 107186. 
https://doi.org/10.1016/j.buildenv.2020.107186. (Mousavi et al., 
August 13, 2020).
Occupational Safety and Health Administration (OSHA). (2009). 
Guidance on Preparing Workplaces for an Influenza Pandemic. https://www.osha.gov/Publications/influenza_pandemic.html. (OSHA, 2009).
Occupational Safety and Health Administration (OSHA). (2014, 
February 11). OSHA Technical Manual, Section II: Chapter 1--Personal 
Sampling for Air Contaminants. https://www.osha.gov/dts/osta/otm/otm_ii/otm_ii_1.html. (OSHA, February 11, 2014).
Teichert-Filho, R. et al., (2020, August 18). Protective device to 
reduce aerosol dispersion in dental clinics during the COVID-19 
pandemic. International Endodontic Journal. doi: 10.1111/iej.13373. 
(Teichert-Filho et al., August 18, 2020).
Todd, ECD et al., (2010, August 1). Outbreaks where food workers 
have been implicated in the spread of foodborne disease. Part 7. 
Barriers to reduce contamination of food by workers. J. of Food 
Protection 73(8): 1552-1565. https://doi.org/10.4315/0362-028X-73.8.1552. (Todd et al., August 1, 2010).
University of Washington. (2020, October 29). University of 
Washington Guidance for Plexiglass Barriers in Support of COVID-19 
Prevention Efforts. University of Washington Environmental Health & 
Safety. https://www.ehs.washington.edu/system/files/resources/COVID-19-plexiglass-barriers-workplace.pdf. (University of Washington, 
October 29, 2020).
World Health Organization (WHO). (2020, May 10). Considerations for 
public health and social measures in the workplace context of COVID-
19: Annex to Considerations in adjusting public health and social 
measures in the context of COVID-19, May 2020. https://www.who.int/publications-detail-redirect/considerations-for-public-health-and-social-measures-in-the-workplace-in-the-context-of-covid-19. (WHO, 
May 10, 2020).
World Health Organization (WHO). (2020, July 9). Transmission of 
SARS-CoV-2: Implications for infection prevention precautions. 
https://www.who.int/news-room/commentaries/detail/transmission-of-sars-cov-2-implications-for-infection-prevention-precautions. (WHO, 
July 9, 2020).

K. Hygiene and Cleaning

    COVID-19 can also be spread through contact transmission, which 
occurs when a person touches another person who has COVID-19 (e.g., 
during a handshake) or a surface or item contaminated with the virus 
(e.g., workstations, shared equipment or products) and then touches 
their own eyes, nose, or mouth (CDC, May 13, 2021; CDC, April 5, 
2021d). Contact transmission via inanimate objects is also known as 
fomite transmission. While contact transmission is less common than 
droplet transmission, and the risk of infection from touching a surface 
is low, contracting COVID-19 via contact transmission remains a concern 
in the workplace. Contact transmission is discussed in greater detail 
in Grave Danger (Section IV.A. of the preamble).
    To protect against COVID-19 transmission, the CDC has recommended 
cleaning and situational disinfecting of high-touch surfaces, as well 
as frequent handwashing, as key prevention methods (CDC, April 5, 
2021a, and CDC, May 17, 2020, respectively). Cleaning means the removal 
of dirt and impurities, including germs, from surfaces using soap and 
water or other cleaning agents (i.e., not Environmental Protection 
Agency (EPA)-registered disinfectants). Cleaning alone reduces germs on 
surfaces by removing contaminants and may also weaken or damage some of 
the virus particles, which decreases risk of infection from surfaces. 
Disinfection means using an EPA-registered List N disinfectant in 
accordance with manufacturers' instructions to kill germs on surfaces 
or objects. Disinfection further lowers the risk of spreading infection 
and the CDC recommends disinfection in indoor community settings where 
there has been a suspected or confirmed COVID-19 case in the previous 
24 hours (CDC, April 5, 2021d).
I. Cleaning and Hand Hygiene Are Most Effective in Combination
    Based on the best available evidence, OSHA has determined that 
proper hand hygiene, cleaning, and situational disinfection of high-
touch surfaces and surfaces touched by someone with COVID-19 are 
critical provisions of the ETS, both on their own and also when 
complemented by other measures as part of a multi-layered strategy to 
minimize employee exposure to this grave COVID-19 danger. Practicing 
proper hand hygiene combined with routine cleaning of contact surfaces, 
minimizes the risk of contracting COVID-19 through contact with 
contaminated surfaces, followed by touching the mouth, nose, or eyes 
(Honein et al., December 11, 2020). Cleaning surfaces removes harmful 
contaminants from surfaces, reducing the risk of COVID-19 transmission 
following hand contact with those surfaces. Disinfection of surfaces 
and equipment in indoor community settings should be done if a 
suspected or confirmed COVID-19 case was utilizing those areas within 
the past 24 hours (CDC, April 5, 2021d). Cleaning, disinfection, and 
hand hygiene are foundational components of Standard and Transmission-
Based Precautions for infection control and prevention (Siegel et al., 
2007).
II. Cleaning and Disinfection
    Respiratory secretions or droplets expelled by infected individuals 
can contaminate surfaces and objects (WHO, July 9, 2020). Evidence 
suggests that the virus that causes COVID-19 may remain viable on 
surfaces for hours to days (Riddell et al., October 7, 2020; van 
Doremalen et al., April 16, 2020; CDC, April 5, 2021b), depending on 
the ambient environment and the type of surface (WHO, July 9, 2020). 
Although fomites and contaminated surfaces are not a common 
transmission mode of COVID-19, demonstration of surface contamination 
and experiences with surface contamination linked to subsequent 
infection transmission with other coronaviruses, have informed the 
development of cleaning and situational

disinfection recommendations to mitigate the potential of fomite 
transmission of COVID-19 (WHO, May 14, 2020; CDC, April 5, 2021d). 
Cleaning of visibly dirty surfaces is a best practice measure for 
prevention of COVID-19 and other viral respiratory illnesses in all 
settings, including healthcare. Disinfection of these surfaces may be 
appropriate if it is reasonable to assume that individuals with COVID-
19 may have been present. Cleaning and disinfection reduces the risk of 
spreading infection by removing and killing germs on surfaces people 
frequently touch, and in areas that were occupied or visited by a 
person confirmed to have COVID-19 (CDC, April 5, 2021a; WHO, May 14, 
2020; CDC, April 5, 2021c; CDC, April 5, 2021d).
    Scientific evidence and guidelines from the CDC and WHO support 
cleaning and situational disinfection of surfaces as an effective 
practice to prevent the transmission of infectious viruses. Human 
coronaviruses, including MERS coronavirus or endemic human 
coronaviruses (HCoV), can be efficiently inactivated by surface 
disinfection procedures (Kampf et al., February 6, 2020). A study of 
124 Beijing households with one or more laboratory-confirmed COVID-19 
positive family members demonstrated the efficacy of disinfection in 
preventing the transmission of COVID-19. The study found that disease 
transmission to family members was 77% less with use of chlorine- or 
ethanol-based disinfectants every day compared to use of disinfectants 
once in two or more days, irrespective of other protective measures 
taken such as mask wearing and physical distancing (Wang et al., May 
11, 2020).
    The World Health Organization recommends thoroughly cleaning 
environmental surfaces with water and detergent and applying commonly 
used hospital-level disinfectants, such as sodium hypochlorite (i.e., 
the active ingredient in chlorine bleach), for effective cleaning and 
disinfection (WHO, May 14, 2020). Surface disinfection with 0.1% sodium 
hypochlorite or 62-71% ethanol significantly reduces coronavirus 
infectivity on surfaces within 1 minute of exposure time (Kampf et al., 
February 6, 2020). The Environmental Protection Agency (EPA) has 
compiled List N, a list of disinfectant products that can be used 
against the virus that causes COVID-19, including ready-to-use sprays, 
concentrates, and wipes (EPA, April 9, 2021). EPA includes products on 
List N if they have demonstrated efficacy against the COVID-19 virus, 
or a germ that is harder to kill than SARS-CoV-2 virus, or another 
human coronavirus that is similar to the SARS-CoV-2 virus (EPA, 
February 17, 2021).
III. Hand Hygiene
    In all settings, including settings where regular cleaning may be 
difficult, frequent hand washing and avoiding touching of the face 
should be considered the primary prevention approach to mitigate COVID-
19 transmission associated with surface contamination (WHO, May 14, 
2020). Hand hygiene is generally recognized as an effective 
intervention at preventing respiratory illnesses and infectious disease 
transmission (Rabie and Curtis, March 7, 2006; Haque, July 12, 2020; 
Rundle et al., July 22, 2020). The CDC and the WHO have determined that 
frequent handwashing, plus sanitization, are essential control measures 
for COVID-19 prevention within the workplace, and HICPAC identifies 
hand hygiene as an essential element of Standard Precautions (CDC, May 
17, 2020; WHO, July 9, 2020; WHO, May 14, 2020; Siegel et al., 2007).
    To prevent virus transmission, the CDC recommends that healthcare 
workers engage in frequent handwashing with soap and water for at least 
20 seconds, or use an alcohol-based hand sanitizer with at least 60% 
alcohol (CDC, May 17, 2020). Alcohol-based hand sanitizers are the most 
effective products for reducing the number of germs on the hands of 
healthcare providers and are the preferred method for cleaning hands in 
most clinical situations, while handwashing is necessary whenever hands 
are visibly soiled (CDC, January 8, 2021). Handwashing with soap and 
water mechanically removes pathogens (Burton et al., January 6, 2011), 
and laboratory data demonstrates that hand sanitizers that contain at 
least 60% alcohol are effective at killing the virus that causes COVID-
19 (Kratzel et al., July 2020; Siddharta et al., March 15, 2017).
    Experience with work settings shows that flexible hand hygiene 
approaches are effective to address unique scenarios in various work 
environments. For example, handwashing is usually emphasized over hand 
sanitizing, but CDC recommends the use of alcohol-based hand sanitizers 
as the primary method for hand hygiene in most healthcare situations 
(CDC, October 14, 2020). In healthcare settings, alcohol-based hand 
sanitizers with 60-95% alcohol effectively reduce the number of 
pathogens that may be present on the hands of healthcare providers, 
particularly after interacting with patients (CDC, May 17, 2020). In 
most clinical settings, unless hands are visibly soiled, an alcohol-
based hand rub is preferred over soap and water due to evidence of 
better compliance compared to soap and water. However, CDC does 
recommend healthcare workers wash their hands for at least 20 seconds 
with soap and water when hands are visibly dirty, before eating, and 
after using the restroom (CDC, May 17, 2020). Alcohol-based hand 
sanitizers are also important as an alternative to soap and water for 
workers who do not have ready access to handwashing facilities (e.g., 
emergency responders).
References
Burton, M. et al., (2011, January 6). The effect of handwashing with 
water or soap on bacterial contamination of hands. International 
Journal of Environmental Research and Public Health, 8(1), 97-104. 
https://doi.org/10.3390/ijerph8010097. (Burton et al., January 6, 
2011).
Centers for Disease Control and Prevention (CDC). (2020, May 17). 
Hand hygiene recommendations: Guidance for healthcare providers 
about hand hygiene and COVID-19. https://www.cdc.gov/coronavirus/2019-ncov/hcp/hand-hygiene.html. (CDC, May 17, 2020).
Centers for Disease Control and Prevention (CDC). (2020, October 
14). Frequent questions about hand hygiene. https://www.cdc.gov/handwashing/faqs.html. (CDC, October 14, 2020).
Centers for Disease Control and Prevention (CDC). (2021, January 8). 
Hand Hygiene in Healthcare Settings. https://www.cdc.gov/handhygiene/providers/index.html. (CDC, January 8, 2021).
Centers for Disease Control and Prevention (CDC) and Environmental 
Protection Agency (EPA). (2021a, April 5). Reopening guidance for 
cleaning and disinfecting public spaces, workplaces, businesses, 
schools, and homes. https://www.cdc.gov/coronavirus/2019-ncov/community/reopen-guidance.html. (CDC, April 5, 2021a).
Centers for Disease Control and Prevention (CDC). (2021b, April 5). 
Cleaning and disinfection for households: Interim recommendations 
for U.S. households with suspected or confirmed COVID-19. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/cleaning-disinfection.html. (CDC, April 5, 2021b).
Centers for Disease Control and Prevention (CDC). (2021c, April 5). 
Cleaning and disinfecting your facility. https://www.cdc.gov/coronavirus/2019-ncov/community/disinfecting-building-facility.html. 
(CDC, April 5, 2021c).
Centers for Disease Control and Prevention (CDC). (2021d, April 5). 
Science Brief: SARS-CoV-2 and Surface (Fomite) Transmission for 
Indoor Community Environments. https://www.cdc.gov/coronavirus/2019-ncov/more/science-and-research/surface-transmission.html. (CDC, 
April 5, 2021d).

Centers for Disease Control and Prevention (CDC). (2021, May 13). 
How COVID-19 spreads. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/how-covid-spreads.html. (CDC, May 13, 2021).
Environmental Protection Agency (EPA). (2021, February 17). How does 
EPA know that the products on List N work on SARS-CoV-2? https://www.epa.gov/coronavirus/how-does-epa-know-products-list-n-work-sars-cov-2. (EPA, February 17, 2021).
Environmental Protection Agency (EPA). (2021, April 9). List N tool: 
COVID-19 disinfectants. https://cfpub.epa.gov/giwiz/disinfectants/index.cfm. (EPA, April 9, 2021).
Haque, M. (2020). Handwashing in averting infectious diseases: 
Relevance to COVID-19. Journal of Population Therapeutics and 
Clinical Pharmacology, 27(S Pt 1), e37-e52. https://doi.org/10.15586/jptcp.v27SP1.711. (Haque, July 12, 2020).
Honein, MA et al., (2020, December 11). Summary of Guidance for 
Public Health Strategies to Address High Levels of Community 
Transmission of SARS-CoV-2 and Related Deaths, December 2020. MMWR 
Morb Mortal Wkly Rep 2020; 69: 1860-1867. DOI: http://dx.doi.org/10.15585/mmwr.mm6949e2. (Honein et al., December 11, 2020).
Kampf, G. et al., (2020). Persistence of coronaviruses on inanimate 
surfaces and their inactivation with biocidal agents. The Journal of 
Hospital Infection, 104(3), 246-251. https://doi.org/10.1016/j.jhin.2020.01.022. (Kampf et al., February 6, 2020).
Kratzel, A. et al., (2020, July). Inactivation of SARS-CoV-2 by 
WHO--recommended hand rub formulations and alcohols. Emerging 
Infectious Diseases, 26(7), 1592-1595. https://doi.org/10.3201/eid2607.200915. (Kratzel et al., July 2020).
Rabie, T. and Curtis, V. (2006). Handwashing and risk of respiratory 
infections: A quantitative systematic review. Tropical Medicine & 
International Health, 11(3), 258-267. https://doi.org/10.1111/j.1365-3156.2006.01568.x. (Rabie and Curtis, March 7, 2006).
Riddell, S. et al., (2020, October 7). The effect of temperature on 
persistence of SARS-CoV-2 on common surfaces. Virology journal, 
17(1), 145. https://doi.org/10.1186/s12985-020-01418-7. (Riddell et 
al., October 7, 2020).
Rundle, C. et al., (2020, July 22). Hand hygiene during COVID-19: 
Recommendations from the American Contact Dermatitis Society. 
Journal of the American Academy of Dermatology, 83(6), 1730-1737. 
https://doi.org/10.1016/j.jaad.2020.07.057. (Rundle et al., July 22, 
2020).
Siddharta, A. et al., (2017, March 15). Virucidal activity of World 
Health Organization--recommended formulations against enveloped 
viruses, including Zika, Ebola, and Emerging Coronaviruses. The 
Journal of Infectious Diseases, 215(6), 902-906. https://doi.org/10.1093/infdis/jix046. (Siddharta et al., March 15, 2017).
Siegel, J., Rhinehart, E., Jackson, M., Chiarello, L., and the 
Healthcare Infection Control Practices Advisory Committee. (2007). 
2007 Guideline for isolation precautions: Preventing transmission of 
infectious agents in healthcare settings. https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf. (Siegel 
et al., 2007).
 van Doremalen, N. et al., (2020, April 16). Aerosol and surface 
stability of SARS-CoV-2 as compared with SARS-CoV-1. The New England 
Journal of Medicine, 382(16), 1564-1567. https://doi.org/10.1056/NEJMc2004973. (van Doremalen et al., April 16, 2020).
Wang, Y., Tian, H., Zhang, L., Zhang, M., Guo, D., Wu, W. (2020). 
Reduction of secondary transmission of SAR-CoV-2 in households by 
face mask use, disinfection and social distancing: A cohort study in 
Beijing, China. BMJ Global Health, 5, e002794. doi: 10.1136/bmjgh-
2020-002794. (Wang et al., May 11, 2020).
World Health Organization (WHO). (2020, May 14). Coronavirus disease 
2019 (COVID-19): Situation report, 115. https://apps.who.int/iris/handle/10665/332090. (WHO, May 14, 2020).
World Health Organization (WHO). (2020, July 9). Transmission of 
SARS-CoV-2: Implications for infection prevention precautions. 
https://www.who.int/news-room/commentaries/detail/transmission-of-sars-cov-2-implications-for-infection-prevention-precautions. (WHO, 
July 9, 2020).

L. Ventilation

    Improving existing ventilation and ensuring optimal performance of 
ventilation is an effective way to reduce viral transmission in 
occupational populations. Work sites with existing heating, 
ventilation, and air conditioning (HVAC) systems can utilize 
improvements to, and maintenance of, high performance ventilation as 
part of a layered response for infectious disease control. The 
effectiveness of ventilation in controlling disease transmission is 
based on scientific research and the recommendations of well-respected 
occupational safety and health organizations, including government 
agencies.
    As explained in Grave Danger (Section IV.A. of the preamble), there 
is evidence of airborne COVID-19 transmission within enclosed spaces 
with inadequate ventilation. As a result, there is considerable support 
for ensuring adequate ventilation through maintenance and improvements. 
Federal agencies, international organizations, industry associations, 
and scientific researchers agree that ensuring adequate ventilation is 
important in reducing potential airborne transmission of COVID-19 
(ASHRAE, April 14, 2020; Schoen, May 2020; WHO, May 10, 2020; AIHA, 
September 9, 2020; CDC, May 7, 2021; CDC, April 7, 2021; CDC, March 23, 
2021; Tang et al., August 7, 2020; Morawska et al., May 27, 2020).
    In one scientific brief, the CDC provides a basic overview of how 
ventilation can reduce the transmission of COVID-19 in indoor spaces. 
Once respiratory droplets are exhaled, the CDC explains, they move 
outward from the source and their concentration decreases through 
fallout from the air (largest droplets first, smaller later) combined 
with dilution of the remaining smaller droplets and particles into the 
growing volume of air they encounter (CDC, May 7, 2021). Without 
adequate ventilation, continued exhalation can lead to the amount of 
infectious smaller droplets and particles produced by people with 
COVID-19 to become concentrated enough in the air to spread the virus 
to other people (CDC, May 13, 2021).
    Ventilation controls the transmission of COVID-19 in two ways. 
First, improving indoor ventilation by appropriately maximizing air 
exchanges and by maintaining and improving heating, ventilation, and 
air-conditioning (HVAC) systems can disperse and decrease the 
concentration of COVID-19-containing small droplets and particles 
suspended in the air. The lower the concentration, the less likely some 
of those viral particles can be inhaled into an employee's lungs; 
contact their eyes, nose, or mouth; or fall out of the air to 
accumulate on surfaces. Protective ventilation practices and 
interventions can reduce the airborne concentration, which reduces the 
overall viral dose to occupants (CDC, March 23, 2021). Improved 
ventilation can also significantly reduce the airborne time of 
respiratory droplets (Somsen et al., May 27, 2020; CDC, March 23, 
2021). As a result, the risk of transmission of COVID-19 indoors is 
reduced, which makes workplaces safer (Schoen, May 2020; CDC, April 7, 
2021; CDC, March 23, 2021; Honein et al., December 11, 2020). 
Ventilation systems alone cannot completely prevent airborne 
transmission (EPA, July 16, 2020; CDC, March 23, 2021), but are 
particularly effective when implemented in conjunction with additional 
control measures in a layered approach, including other engineering 
controls and other protections required in this ETS.
    Second, air filters in HVAC systems remove particles, including 
aerosolized particles containing COVID-19, from

recirculated air streams before returning the air to workspaces. 
Increased filter efficiency is a component of the HVAC system which can 
be adjusted to reduce the risk of COVID-19 transmission (Schoen, May 
2020; ASHRAE, April 14, 2020; CDC, May 7, 2021; CDC, March 8, 2021; 
CDC, March 23, 2021; Morawska et al., May 27, 2020). Minimum Efficiency 
Reporting Values (MERV) report a filter's ability to capture larger 
particles between 0.3 and 10 microns ([micro]m). MERV ratings range 
from 1 to 16, and a higher rating indicates a more efficient filter. 
The virus that causes COVID-19 is approximately 0.125 [micro]m in 
diameter; however, the virus is contained in infectious particles, 
droplets, and droplet nuclei (dried respiratory droplets) that are 
predominantly 1 [micro]m in size and larger.
    The CDC recommends increasing filtration to the highest extent 
possible that is compatible with the design of the HVAC system (CDC, 
March 23, 2021). The American Society of Heating, Refrigeration, and 
Air-Conditioning Engineers (ASHRAE) recommends using filters with a 
MERV rating of at least 13, where feasible, or the highest level 
compatible with the specified HVAC system, to help capture the 
infectious aerosols containing COVID-19 (Schoen, May 2020; ASHRAE, 
December 8, 2020). The use of filtration has also been supported by 
others, including Mousavi et al., August 26, 2020. A MERV rating of 13 
is at least 85-percent efficient at capturing particles from 1 [micro]m 
to 3 [micro]m in size (Schoen, May 2020; CDC, March 8, 2021; CDC, March 
23, 2021), which is the size of the particles carrying COVID-19. A 
MERV-14 filter is at least 90% efficient at capturing particles of this 
same size, and efficiencies for MERV-15 and MERV-16 filters are even 
greater. As such, filters with MERV ratings of 13 or greater are much 
more efficient at capturing particles of this size than a MERV 8 filter 
(CDC, March 23, 2021).
    The ability of HVAC systems to reduce the risk of exposure depends 
on many factors, including design features, operation and maintenance 
practices, and the quality and quantity of outdoor air supplied to the 
space. The CDC has emphasized that building owners and operators should 
ensure that ventilation systems are functioning properly and providing 
acceptable levels of indoor air quality for the occupancy level of the 
given space. Consultation with an HVAC professional will help ensure 
that improvements to ventilation systems are implemented in accordance 
with the capacity and design of the HVAC system, according to state and 
local building codes and guidelines, and to avoid imbalances that could 
negatively alter other indoor air quality parameters (e.g., 
temperature, humidity, moisture) (EPA, July 16, 2020; CDC, March 23, 
2021).
    The CDC has also recommended increasing airflow (CDC, March 23, 
2021) to occupied spaces, if possible. One way to achieve this is by 
opening windows and doors (Howard-Reed et al., February 2002; CDC, 
March 23, 2021), where feasible and as weather conditions permit. 
However, decisions to open windows and doors should be done after 
evaluating other safety and health risks for occupants, such as risk of 
falling or breathing outdoor environmental contaminants (e.g., carbon 
monoxide, molds, and pollens) (CDC, April 7, 2021; CDC, March 8, 2021; 
CDC, March 23, 2021). In order for this type of ventilation to serve as 
an effective COVID-19 control, the air flow must be directed so that 
contaminated air is not funneled through workspaces toward another 
person.
    Based on the best available evidence, the agency concludes that 
implementation of improved ventilation and maintaining HVAC system 
performance is an effective and necessary approach to reduce incidence 
of COVID-19 both on its own and also when complemented by other 
measures as part of a multi-layered strategy to minimize employee 
exposure to the grave COVID-19 danger.
References
American Industrial Hygiene Association (AIHA). (2020, September 9). 
Reducing the Risk of COVID-19 Using Engineering Controls: Guidance 
Document. https://aiha-assets.sfo2.digitaloceanspaces.com/AIHA/resources/Guidance-Documents/Reducing-the-Risk-of-COVID-19-using-Engineering-Controls-Guidance-Document.pdf. (AIHA, September 9, 
2020).
American Society of Heating, Refrigerating and Air-Conditioning 
Engineers (ASHRAE). (2020, April 14). ASHRAE Position Document on 
Infectious Aerosols. https://www.ashrae.org/file%20library/about/position%20documents/pd_infectiousaerosols_2020.pdf. (ASHRAE, April 
14, 2020).
American Society of Heating, Refrigerating and Air-Conditioning 
Engineers (ASHRAE). (2020, December 8). Debunking myths about MERV, 
air filtration. https://www.ashrae.org/news/ashraejournal/debunking-myths-about-merv-air-filtration. (ASHRAE, December 8, 2020).
Centers for Disease Control and Prevention (CDC). (2021, March 8). 
Guidance for Businesses and Employers Responding to Coronavirus 
Disease 2019 (COVID-19). https://www.cdc.gov/coronavirus/2019-ncov/community/guidance-business-response.html. (CDC, March 8, 2021).
Centers for Disease Control and Prevention (CDC). (2021, March 23). 
Ventilation. https://www.cdc.gov/coronavirus/2019-ncov/community/ventilation.html. (CDC, March 23, 2021).
Centers for Disease Control and Prevention (CDC). (2021, April 7). 
COVID-19 Employer Information for Office Buildings. https://www.cdc.gov/coronavirus/2019-ncov/community/office-buildings.html. 
(CDC, April 7, 2021).
Centers for Disease Control and Prevention (CDC). (2021, May 7). 
Scientific Brief: SARS-CoV-2 Transmission. https://www.cdc.gov/coronavirus/2019-ncov/more/scientific-brief-sars-cov-2.html. (CDC, 
May 7, 2021).
Centers for Disease Control and Prevention (CDC). (2021, May 13). 
How COVID-19 Spreads. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/how-covid-spreads.html. (CDC, May 13, 2021).
Environmental Protection Agency (EPA). (2020, July 16). Ventilation 
and Coronavirus (COVID-19). https://www.epa.gov/coronavirus/ventilation-and-coronavirus-covid-19. (EPA, July 16, 2020).
Honein, MA et al., (2020, December 11). Summary of Guidance for 
Public Health Strategies to Address High Levels of Community 
Transmission of SARS-CoV-2 and Related Deaths, December 2020. MMWR 
Morb Mortal Wkly Rep 2020; 69: 1860-1867. DOI: http://dx.doi.org/10.15585/mmwr.mm6949e2. (Honein et al., December 11, 2020).
Howard-Reed, C. et al., (2002, February). The effect of opening 
windows on air change rates in two homes. Journal of Air and Waste 
Management Association 52: 147-159. (Howard-Reed et al., February 
2002).
Morawska, L. et al, (2020, May 27). How can airborne transmission of 
COVID-19 indoors be minimized? Environmental International 142: 
105832. https://doi.org/10.1016/j.envint.2020.105832. (Morawska et 
al., May 27, 2020).
Mousavi, ES et al., (2020, August 26). COVID-19 Outbreak and 
Hospital Air Quality: A Systematic Review of Evidence on Air 
Filtration and Recirculation. Environmental Science and Technology. 
acs.est.0c03247. https://doi.org/10.1021/acs.est.0c03247. (Mousavi 
et al., August 26, 2020).
Schoen, LJ. (2020, May). Guidance for building operations during the 
COVID-19 pandemic. ASHRAE Journal. (Schoen, May 2020).
Somsen, GA. et al., (2020, May 27). Small droplet aerosols in poorly 
ventilated spaces and SARS-CoV-2 transmission. The Lancet 8: 658-
659. https://doi.org/10.1016/. (Somsen et al., May 27, 2020).
Tang, S. et al., (2020, August 7). Aerosol transmission of SARS-CoV-
2? Evidence, prevention and control. Environmental International 
144: 106039. https://doi.org/10.1016/j.envint.2020.106039. (Tang et 
al., August 7, 2020).

World Health Organization (WHO). (2020, May 10). Considerations for 
public health and social measures in the workplace context of COVID-
19: Annex to Considerations in adjusting public health and social 
measures in the context of COVID-19, May 2020. https://www.who.int/publications-detail-redirect/considerations-for-public-health-and-social-measures-in-the-workplace-in-the-context-of-covid-19. (WHO, 
May 10, 2020).

M. Health Screening and Medical Management

    As discussed in more detail in Grave Danger (Section IV.A. of the 
preamble), COVID-19 is a disease that is primarily transmitted from 
person to person through respiratory droplets that are produced when 
someone breaths, talks, sneezes, or coughs, and the droplets contact 
the eyes, nose, or mouth of another person. It may also infrequently be 
transmitted by someone touching a contaminated surface and then 
touching their eyes, nose, or mouth. Consequently, to effectively 
reduce the transmission of COVID-19 in the workplace, it is necessary 
to have a medical management program that identifies and removes 
infected or likely infected employees from the workplace, and notifies 
employees about possible exposures to COVID-19 so they can take 
appropriate steps to further reduce transmission.
I. Employee Screening
    Regular health screening for possible indications of COVID-19 is a 
first step in detecting employees who might be COVID-19-positive so 
those employees can seek medical care or testing, or inform the 
employer if they have certain symptoms. While pre-symptomatic and 
asymptomatic infections and the non-specificity of COVID-19 symptoms 
make it difficult to quantify the accuracy of symptom screening in 
predicting COVID-19, health screening is a strategy supported by the 
CDC and the American College of Occupational and Environmental Medicine 
(ACOEM). ACOEM recommends that employers implement a medical 
surveillance program that includes educating and training employees on 
how to recognize when they may have COVID-19, in order to prevent 
employees with infections from entering the workplace (ACOEM, August 
19, 2020).
    The CDC recommends that employers conduct screening at the 
worksite, or train employees to be aware of and recognize the signs and 
symptoms of COVID-19 and to follow CDC recommendations to self-screen 
for symptoms before coming to work (CDC, March 8, 2021). Screening for 
employee symptoms, particularly when combined with their recent 
activities (e.g., the likelihood they have had a recent exposure to 
COVID-19), can help determine if the employee is suspected to have 
COVID-19 or should be tested. Testing can be useful in guiding the 
treatment that employees receive for their illness as well as 
triggering isolation to prevent exposure to others (NASEM, November 9, 
2020). The FDA (March 11, 2021) has issued a number of emergency use 
authorizations for COVID-19 tests that detect infections with the SARS-
CoV-2 virus. CDC recommends prompt COVID-19 testing of anyone who has 
had a known exposure to someone with COVID-19, has had a possible 
exposure to someone with COVID-19, or has symptoms of COVID-19, as a 
strategy to reduce SARS-CoV-2 transmission (Honein et al., December 11, 
2020). Based on medical advice and information provided by testing, 
employees can learn if they are suspected or confirmed to have COVID-
19. The earlier employees learn whether they are infected, the more 
likely that workplace exposures can be prevented.
    As explained below, it is necessary that employees who are 
suspected or confirmed to have COVID-19 be removed from the workplace 
to prevent transmission to other employees. However, because COVID-19 
symptoms are non-specific and common with other infectious and non-
infectious conditions, not all individuals experiencing these symptoms 
will necessarily have COVID-19. Thus, Struyf et al., (2021) concluded 
that using a single sign or symptom of COVID-19 will result in low 
diagnostic accuracy and that combinations of symptoms increase 
specificity while decreasing sensitivity (explained in further detail 
below); however the authors also noted that studies are lacking on 
diagnostic accuracy of combinations of signs and symptoms.
    The success of a screening strategy in identifying whether an 
employee has COVID-19 is based on two factors: Sensitivity and 
specificity for identifying COVID-19. Sensitivity refers to the ability 
of the symptom screening strategy to correctly identify persons who 
have COVID-19. Specificity refers to the ability of the symptom 
screening strategy to correctly identify persons who do not have COVID-
19. As an example, a systematic review and meta-analysis by Pang et 
al., (2020) determined a sensitivity of 0.48 and specificity of 0.93 
for smell disorders in identifying COVID-19. This means that under the 
scenarios in which the studies were conducted, screening for smell 
disorders would correctly identify around 48% of individuals who have 
COVID-19 (sensitivity), and would correctly identify 93% of individuals 
who do not have COVID-19 (specificity).
    A number of studies have been conducted to determine common 
symptoms associated with COVID-19, along with their sensitivity and 
specificity. In addition to the Pang et al., (2020) study, there have 
been several other studies strongly linking smell and taste disorders 
as a symptom indicative of COVID-19. In a review of 18 studies of 
COVID-19 patients, Printza and Constantidis (2020) reported that loss 
of either smell or smell and taste was reported in most studies, and 
that that symptom is more prevalent in COVID-19 patients than in 
patients suffering from other respiratory infections. The report also 
found that the loss of smell was more prevalent among patients with a 
less severe case of COVID-19 disease. Four systematic reviews, three of 
which included meta-analyses, reported that for smell or taste 
disorders, sensitivity ranged from 0.41 to 0.65 and specificity ranged 
from 0.90 to 0.93 (Pang et al., 2020; Printza and Constantidis, 2020; 
Kim et al., 2021; Struyf et al., 2021).
    A systematic review found that while loss of taste or smell is the 
most specific symptom of COVID-19, the most commonly reported symptoms 
of COVID-19 were fever, cough, fatigue, shortness of breath, and sputum 
production (Alimohamadi et al., 2020). In another review of a 
convenience sample (i.e., a non-randomly selected sample based on 
availability, opportunity, or convenience) of COVID-19 patients in the 
United States, 96% of patients reported having a fever, a cough, or 
shortness of breath (Burke et al., 2020). The review also found that 
68% of hospitalized patients experienced all three of those symptoms, 
but only 31% of non-hospitalized patients reported all three symptoms. 
A systematic review by Kim et al., (2021) determined sensitivity and 
specificity, respectively, for fever (0.6, 0.55), cough (0.59, 0.39), 
and difficulty breathing (0.18, 0.84).
    Although not intended to identify individuals who could potentially 
have COVID-19, and the diagnostic accuracy of the approach is not 
known, the surveillance definition used by the Council of State and 
Territorial Epidemiologists (CSTE) provides insight on an approach to 
using symptoms to identify possible cases of COVID-19 in the absence of 
a more likely determination by a healthcare provider. The CSTE 
surveillance definition for COVID-19 includes: (1) At least two of

the following symptoms: Fever (measured or subjective), chills, rigors 
(i.e., shivering), myalgia (i.e., muscle aches), headache, sore throat, 
nausea or vomiting, diarrhea, fatigue, congestion or runny nose; or (2) 
any one of the following symptoms: Cough, shortness of breath, 
difficulty breathing, new olfactory (i.e., smell) disorder, new taste 
disorder; or (3) severe respiratory illness with a least one of the 
following: Clinical or radiographic evidence of pneumonia, acute 
respiratory distress syndrome (ARDS) (CSTE, 2020).
    Given the non-specificity of COVID-19 symptoms, consultation with a 
licensed healthcare provider can provide more insight on the likelihood 
that an employee with certain symptoms has COVID-19. A licensed 
healthcare provider can elicit key clinical information, such as 
timing, frequency, intensity, and other factors in diagnosing the 
patient, after considering different medical explanations. A licensed 
healthcare provider can also elicit additional clinical information 
(e.g., pre-existing medical conditions), elicit epidemiologic 
information (e.g., exposure to COVID-19, travel history, rates of 
community transmission), and order laboratory testing to assist with 
the diagnosis of COVID-19 and differentiation from other medical 
conditions.
    In general, the presence of COVID-19 symptoms can alert employees 
that they may have COVID-19, which will allow them to take appropriate 
next steps. Thus, by monitoring for COVID-19 symptoms through regular 
health screening, employees can better address their personal health 
and avoid potentially infecting other people by seeking medical 
attention and getting tested for COVID-19 as appropriate; informing 
their employer if they are suspected or confirmed to have COVID-19, 
including concerning symptoms; and remaining away from the workplace 
where appropriate. Therefore, health screening is an effective strategy 
for preventing the transmission of COVID-19 in the workplace.
II. Employee Notification to Employer of COVID-19 Illness or Symptoms
    Employers can reduce workplace exposures by preventing employees 
who are, or could be, COVID-19 positive from entering the workplace and 
transmitting the disease to others. But to do so, employers must be 
aware that an employee is suspected or confirmed to have COVID-19 or is 
symptomatic. The Summary and Explanation (Section VIII of the preamble) 
includes more discussion of the precise criteria and rationale for when 
an employee is required to notify an employer that they are suspected 
or confirmed to have COVID-19 or are experiencing certain types of 
symptoms. It is critical that employees make their employers aware 
promptly after the employee is suspected or confirmed to have COVID-19 
through test, medical diagnosis, or the specific symptoms of concern 
discussed in the Summary and Explanation (Section VIII of the 
preamble). With this information the employer can act to help prevent 
transmission in the workplace.
III. Employer Notification to Employees of COVID-19 Exposure in the 
Workplace
    Notifying employees of a possible exposure to someone confirmed to 
have COVID-19 is an important and effective intervention to reduce 
transmission. Under the ETS, this includes any employee who was not 
wearing a respirator and any other required PPE while in close contact 
with the individual with COVID-19 or while working in the same physical 
space around the same time as the individual with COVID-19 and 
consequently may have had contact with that individual or touched a 
contaminated surface. As the CDC has recognized, notification is 
important because it allows for an exchange of information with the 
person exposed to someone with COVID-19 and helps ensure that person 
can pursue quarantine, timely testing, medical evaluation, and other 
necessary support services (CDC, February 26, 2021). Notification also 
acts as a complement to an employer's regular health screening program 
by informing employees who may have been exposed to COVID-19 in the 
workplace, so that they can appropriately assess and monitor their 
health and report any symptoms that may develop to their employer. It 
is also important for employers to notify other employers whose 
employees may have had close contact or been in the same area as those 
infected individuals while not wearing required PPE so those employers 
can notify their employees.
    The impact that notification of possible COVID-19 exposures can 
have in reducing COVID-19 transmission was demonstrated in a study by 
Kucharski et al., (2020), which found that when location-specific 
contact tracing and notification was used to make decisions on 
isolation and home quarantine, transmission of COVID-19 was reduced by 
64% when contact tracing was performed manually and 47% when performed 
by an app. However, the authors found that while notification is 
effective in helping to decrease the spread of COVID-19 by making 
individuals aware of potential infections, it is not a standalone 
measure. Notification must be used in a layered approach in order to 
create an effective infection control plan.
IV. Medical Removal From the Workplace
    Employers can substantially reduce disease transmission in the 
workplace by removing employees who are suspected or confirmed to have 
COVID-19 based on a COVID-19 test or diagnosis by a healthcare 
provider, or who have developed certain symptoms or combinations of 
symptoms associated with COVID-19. Employers can also reduce the risk 
of COVID-19 in the workplace by removing employees who are at risk of 
developing COVID-19 because they were recently exposed to someone with 
COVID-19 in the workplace. According to the CDC, a major mitigation 
effort for COVID-19 is ``to reduce the rate at which someone infected 
comes in contact with someone not infected. . . .'' (CDC, February 16, 
2021b).
    The ETS focuses on removing employees from the workplace, rather 
than specifying requirements for quarantine or isolation that are 
typically outside the control of the employer because they would occur 
away from the workplace, but the concept of separating infected or 
potentially infected individuals from others is the same. Both the CDC 
and ACOEM endorse the use of isolation and quarantine as measures 
needed to reduce this rate of contact and consequently slow the spread 
of COVID-19. Isolation ensures that persons known or suspected to be 
infected with the virus stay away from all healthy individuals. 
Isolating contagious, or potentially contagious, employees from their 
co-workers can prevent further spread at the workplace and safeguard 
the health of other employees. Quarantine is used to keep persons at 
risk of developing COVID-19 away from all other people until it can be 
determined whether the individual is infected following an exposure to 
someone with suspected or confirmed COVID-19 (Honein et al., 2020).
    The first two categories of employees who should be removed from 
the workplace are those employees who are suspected to be or are 
confirmed to have COVID-19 based on a COVID-19 test or diagnosis by a 
healthcare provider and those employees who develop certain

COVID-19 symptoms.\25\ Removal of these two categories of employees is 
consistent with isolation guidance from the CDC (February 11, 2021). 
Employers also prevent further transmission of COVID-19 in the 
workplace by providing employees a place to isolate from other workers 
until they can go home if they arrive with, or develop, COVID-19 
symptoms at work (CDC, February 16, 2021a; CDC, March 8, 2021). ACOEM 
(August 19, 2020) also recommends that symptomatic employees stay home 
to protect healthy workers. Several studies have focused on the impact 
of isolating persons with COVID-19 from others during their likely 
known infectious period, and those studies show that isolation is a 
strategy that reduces the transmission of infections. For example, 
Kucharski et al., (2020) found that transmission of SARS-CoV-2 would 
decrease by 29% with self-isolation within the household, which would 
extend to 37% if the entire household quarantined. Similarly, Wells et 
al., (2021) found that isolation of individuals at symptom onset would 
decrease the reproductive rate (R0) of COVID-19 from an R0 of 2.5 to an 
R0 of 1.6. However, the study authors noted that when assuming low 
levels of asymptomatic transmission the R0 never fell below one, 
meaning there is a need for isolation to be used in concert with a more 
robust and layered infection control program, as is required by other 
provisions in the ETS.
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    \25\ Evidence on the sensitivity and specificity of certain 
symptom triggers is discussed above. The Summary and Explanation 
(Section VIII of the preamble) includes more discussion of the 
symptoms that trigger removal from the workplace and the rationale 
for selection of those symptoms.
---------------------------------------------------------------------------

    The third category of employees who should be removed from the 
workplace to further reduce disease transmission are those who are at 
risk of developing COVID-19 because they have had recent close contact 
in the workplace with someone who is COVID-19-positive while not 
wearing a respirator and all required PPE (CDC, March 12, 2021). The 
need for removal of these employees is based on quarantine guidance 
from CDC (December 2, 2020) and is consistent with CDC recommendations 
for quarantine as a means of reducing workplace transmission (CDC, 
February 16, 2021a). Such removal is important because infected 
individuals are capable of transmitting the virus before they start 
experiencing symptoms and are aware that they are ill, and many 
(estimated to be 17% in one analysis) may never experience symptoms at 
all (Byambasuren et al., December 11, 2020). Therefore, ensuring that 
exposed employees are removed from work until it is unlikely that they 
have developed COVID-19 is critical for preventing the transmission of 
infections. CDC defines exposure through unprotected close contact as 
being within 6 feet of an infected person for a cumulative total of at 
least 15 minutes over a 24-hour period starting at 2 days before 
illness onset (or 2 days before samples are collected for testing in 
asymptomatic patients) and until the infected person meets the criteria 
for ending isolation (CDC, March 1, 2021). The risk level of the 
exposure depends on factors such as whether the healthcare provider was 
wearing a facemask or respirator, if an AGP was being performed without 
all recommended PPE, or if the patient had source control in place.
    However, CDC does not recommend quarantine following close contact 
with someone who is suspected or confirmed to have COVID-19, if the 
person who had close contact meets all of the following criteria: (1) 
They have been fully vaccinated for COVID-19; (2) it has been at least 
2 weeks since the full vaccination was completed; and (3) they do not 
develop any symptoms (CDC, May 13, 2021; CDC, March 12, 2021). CDC also 
has analyzed accumulating evidence indicating that persons who have 
recovered from laboratory-confirmed COVID-19 and remain symptom-free 
may not have to quarantine again if exposed within three months of the 
illness. CDC (March 16, 2021) concluded that although the evidence does 
not definitively demonstrate the absence of reinfection within a three-
month period, the benefits of avoiding unnecessary quarantine likely 
outweigh the risks of reinfection as long as other precautions such as 
physical distancing, facemasks, and hygiene continue to be implemented.
    CDC's recommendation was based on a review of more than 40 studies 
examining evidence of re-infection in recovered individuals (complete 
reference list included in CDC, (March 16, 2021). While many studies 
demonstrated that reinfection can occur at least 90 days after 
infection (e.g., Colson et al., 2020; Van Elslande et al., 2021), other 
studies suggest re-infection is possible as early as 45 days after 
infection (e.g., Abu-Raddad et al., 2020; Larson et al., 2020; Tillet 
et. al., 2020). Although antibodies to the virus that causes COVID-19 
have not been definitively correlated with protection from reinfection 
and it is not clear what level of antibodies would be required for 
protection, increasing numbers of studies are suggesting that the 
majority of recovered patients develop antibodies specific for the 
virus that causes COVID-19 (e.g., Deeks et al., 2020; Gudbjartsson et 
al., 2020). Antibody responses have been reported to last for six 
months or more in some studies (e.g., Choe et al., 2021; Dan et al., 
2021), but other studies suggested lower levels of antibodies or 
detection of antibodies for shorter periods of time (e.g., Ibarrondo et 
al., 2020; Seow et al., 2020). In addition to the production of 
antibodies, immunity can be achieved through virus-specific T- and B-
cells (e.g., Kaneko et al., 2020), and some studies show that T- and B-
cell immunity can last for 6 months or more (e.g., Dan et al., 2021; 
Hartley et al., 2020). Some studies suggest that T- and B-cell 
responses could be higher in symptomatic versus asymptomatic adults 
(e.g., Zuo et al., 2021). Results from animal challenge studies (e.g., 
Chandrashekar et al., 2020; Deng et al., 2020), and seropositive adults 
in outbreak settings (Abu-Raddad et al., 2020; Lumley et al., 2021) 
provide additional evidence that initial infection might protect 
against reinfection.
    In addition to the uncertainty noted above, CDC notes that risk of 
reinfection may be increased in the future, with the circulation of 
variants (e.g., CDC, March 16, 2021; Nonaka et al., 2021; Harrington et 
al., 2021; Zucman et al., 2021). Because of the uncertainty regarding 
reinfection and increased possibility of reinfection following exposure 
to variants, the CDC recommends that employees be removed from the 
workplace if they develop symptoms after close contact with someone who 
has COVID-19, even if the employee is fully vaccinated or was confirmed 
to have COVID-19 in the previous three months (CDC, May 13, 2021; CDC, 
April 2, 2021).
V. Medical Removal Protection Benefits
    Notification and removal will be most effective if the employees 
responsible for reporting do not face potential financial hardships for 
accurate reporting of symptoms and illnesses. As noted above, employers 
must know that an employee is suspected or confirmed to have COVID-19 
or has certain symptoms of COVID-19 before they can remove those 
employees from the workplace. But removing employees from the workplace 
based on their own reports is likely to prove an effective control for 
COVID-19 only if the employees are not afraid they will be penalized 
for making those reports. OSHA's experience demonstrates that employees 
will self-report at a sufficient level to make removal program 
effective only when removed employees do not face a significant 
financial penalty--

such as lost income during the removal period--and when employees may 
return to work after their removal period without any adverse action or 
deprivation of rights or benefits because of the removal. Because the 
employer will often have no other way to learn whether an employee is 
suspected or confirmed to have COVID-19, or has certain symptoms of 
COVID-19, medical removal protections are necessary to ensure that 
employees are not disincentivized to report suspected or confirmed 
COVID-19 or symptoms of COVID-19. Because infectious employees pose a 
direct hazard to their co-workers, removing barriers to reporting 
symptoms or confirmed diagnoses protects not only the reporting 
employee but also every other employee who would otherwise be exposed 
to infection.
    OSHA's experience shows that the threat of lost earnings, benefits, 
and/or seniority protection provides a significant disincentive for 
employees to participate in workplace medical screening and reporting 
programs (see United Steelworkers of America v. Marshall, 647 F.2d 
1189, 1237 (D.C. Cir. 1981) (recognizing the importance of removing 
financial disincentives for workers exposed to lead)). In the lead 
rulemaking, OSHA adopted a medical removal protection benefits 
provision in part due to evidence that employees were using chelating 
agents to achieve a rapid, short-term reduction in blood lead levels 
because they were desperate to avoid economic loss, despite the 
possible hazard to their health from the use of chelating agents (43 FR 
54354, 54446 (November 21, 1978)). OSHA's standards for cotton dust and 
lead contain testimony from numerous employees indicating that workers 
would be reluctant to report symptoms and participate in medical 
surveillance if they fear economic consequences (43 FR at 54442-54443; 
50 FR at 51154-51155). A major reason that OSHA included medical 
removal protection benefits in the formaldehyde standard is because the 
standard does not have a medical examination trigger, such as an action 
level, but instead relies on annual medical questionnaires and employee 
reports of signs and symptoms. Thus, the approach is completely 
dependent on employee cooperation (57 FR at 22293). Literature reviews 
have similarly reported that lack of compensation is one reason why 
employees might go into work while sick (Heymann et al., 2020; Kniffen 
et al., 2021). Based on this evidence, OSHA concludes that protection 
of benefits for removed employees is necessary to maximize employee 
reporting of suspected or confirmed COVID-19 and symptoms associated 
with COVID-19. This in turn maximizes protection for all employees at 
the workplace.
VI. Return to Work
    After employees have been removed from the workplace as required by 
this standard, the employer must ensure that they do not return to the 
workplace until there is no longer a risk of disease transmission. 
Scientific evidence is available to determine the appropriate duration 
of isolation for COVID-19, which can be used to determine the 
appropriate duration of removal from the workplace. As general 
guidance, CDC recommends isolating symptomatic people with COVID-19 for 
at least 10 to 20 days after symptom onset, dependent on factors such 
as the severity of infection and health of the immune system. In most 
cases, the CDC states that a person can end isolation when (i) 10 days 
have passed since symptom onset; (ii) fever has been resolved (without 
fever-reducing medications) for at least 24 hours; and (iii) other 
symptoms (except loss of taste and smell) have improved. In cases of 
severe illness, the decision to end isolation may require consultation 
with an infection control expert. For persons who are confirmed 
positive but never develop symptoms, CDC recommends ending isolation at 
10 days after the first positive test (CDC, March 16, 2021). These 
recommendations are based on scientific evidence reviewed by CDC which 
suggest that levels of viral RNA in upper respiratory tract samples 
begin decreasing after the onset of symptoms (CDC, March 16, 2021; CDC, 
unpublished data, 2020, as cited in CDC, March 16, 2021; Midgley et 
al., 2020; Young et al., 2020; Zou et al., 2020; W[ouml]lfel et al., 
2020; van Kampen et al., 2021). Levels of replication-competent viruses 
(i.e., viruses that are able to infect cells and produce more 
infectious viral particles) also decrease over time; with only two 
possible exceptions, no replication-competent virus was detected after 
10 days of symptom onset in individuals with mild-to-moderate disease 
(CDC, unpublished data, 2020, as cited in CDC, March 16, 2021; 
W[ouml]lfel et al., 2020; Arons et al., 2020; Bullard et al., 2020; Liu 
et al., 2020a; Lu et al., 2020; personal communication with Young et 
al., 2020, as cited in CDC, March 16, 2021; Korea CDC, May 19, 2020; 
Quicke et al., 2020). In a study of persons with severe disease 
(possibly complicated in some individuals by an immunocompromised 
status), the median duration of shedding infectious virus was 8 days 
after onset of symptoms, and the probability of shedding virus after 15 
days was estimated at 5% or less (van Kampen et al., 2021). In severely 
immunocompromised patients, ``sub-genomic virus RNA'' or replication 
competent virus was detected beyond 20 days and as much as 143 days 
after a positive virus test (e.g., Avanzato et al., 2020; Choi et al., 
2020). A large contact-tracing study found no evidence of infections in 
individuals who had contact with infectious individuals in a household 
or hospital when exposure occurred at least 6 days after illness onset 
(Cheng et al., 2020). Accordingly, these studies support the CDC's 
recommended isolation guidance (CDC, February 16, 2021a; CDC, February 
18, 2021a; CDC, February 18, 2021b). However, as noted, CDC's 
recommendations for isolation are broad guidance; the appropriate 
duration for any given individual may differ depending on factors such 
as disease severity or the health of the employee's immune system.
    As a general rule, CDC does not recommend a testing strategy as a 
means for determining when to end isolation, with the possible 
exception of severely immunocompromised persons (CDC, March 16, 2021). 
This is because tests to detect viral genetic material may yield 
positive results after a person is no longer infectious. Except in a 
very limited number of cases, studies have demonstrated that although 
some individuals were observed to persistently shed virus (for up to 12 
weeks), replication-competent virus has not been recovered at three 
weeks past illness (Korea CDC, May 19, 2020; CDC, March 16, 2021; Li et 
al., 2020; Xiao et al, 2020; Liu et al., 2020a; Quicke et al., 2020). 
In addition, a study of 285 persons with persistent virus shedding, 
including 126 who experienced recurrent symptoms, found no evidence 
that any of the 790 contacts were infected from exposures to the people 
with persistent virus shedding (Korea CDC, May 19, 2020; CDC, March 16, 
2021).
    On the other hand, testing conducted after onset of sensitive 
symptoms associated with COVID-19 can identify individuals who are not 
infected. Peak virus shedding has been reported to occur just before 
and as symptoms are developing (Beeching et al., 2020; He et al., 
2020). Testing for COVID-19 soon after the onset of symptoms has been 
estimated to result in a low false-negative rate of 10%, based on the 
reported Polymerase Chain Reaction test sensitivity (Grassley et al., 
2020).

    Return-to-work criteria for employees who are removed from the 
workplace because they are at risk of developing COVID-19 after 
exposure to someone with COVID-19 in the workplace, but have not yet 
developed symptoms or tested positive themselves, are based on the 
CDC's quarantine guidance. Based on available scientific evidence, the 
CDC generally recommends a 14-day quarantine period for individuals who 
have been exposed to a confirmed case of COVID-19 and are therefore at 
risk of developing COVID-19 (CDC, December 2, 2020; CDC, March 12, 
2021). The 14-day quarantine period is based on the conclusion that the 
upper bound of the incubation period (the period between the point of 
infection and symptom onset) for COVID-19 is 14 days, and that there is 
a possibility that an unknowingly infected person can transmit the 
disease if quarantine is discontinued before 14 days (CDC, December 2, 
2020). The scientific community agrees that a 14-day quarantine period 
is ideal. Linton et al., (2020) recommended a quarantine period of at 
least 14 days, based on a mean incubation period of 5 days, with a 
range of 2-14 days, in patients from and outside of Wuhan, China. Lauer 
et al., (2020) concluded that the CDC recommendation to monitor for 
symptoms for 14 days is supported by the evidence, including their 
study of patients outside the Hubei province that reported a mean 
incubation period of 5.1 days and symptom development within 11.5 days 
in 97.5% of those who develop symptoms.
    Although a 14-day quarantine is ideal and generally recommended, 
the CDC has recognized that a shorter quarantine period may be less 
burdensome and result in increased compliance. Therefore, the CDC 
reviewed emerging scientific evidence to provide shorter quarantine 
options that employers can consider if allowed by local public health 
authorities (Oran and Topol, 2020; Johansson et al., 2020; Kucirka et 
al., 2020; Clifford et al., 2020; Quilty et al., 2021; Wells et al., 
2021; Khader et al., 2020, as cited in CDC, December 2, 2020; Liu et 
al., 2020b; Ng et al., 2021; Grijalva et al., 2020). One of those 
options is testing for the virus at five days after exposure and ending 
quarantine at seven days after exposure if results are negative. 
Importantly, this option is only appropriate for individuals who do not 
develop symptoms over the quarantine period (as such individuals should 
instead be managed according to the CDC's isolation strategies). Based 
on the evidence reviewed, CDC concluded that ending quarantine after a 
negative test and seven days with no symptoms would result in a 
residual transmission risk of about 5%, with an upper limit of about 
12% (CDC, December 2, 2020).
VII. Conclusion
    As demonstrated above, the best available evidence strongly 
supports OSHA's conclusion that implementation of a comprehensive 
medical management program which includes health screening; 
notifications of potential exposures; removing employees who are COVID-
19 positive, suspected to be positive, have certain symptoms, or have 
been exposed to a person with COVID-19 from the workplace until there 
is no longer a risk of disease transmission; and protection of removed 
employees' compensation, rights, and benefits are necessary measures to 
reduce incidence of COVID-19 exposure in the workplace. Because the 
virus that causes COVID-19 is spread through exposure to infected 
individuals or surfaces contaminated by infected individuals, quickly 
identifying and removing employees from the workplace who have 
developed, likely developed, or are at heightened risk of developing 
COVID-19 will allow employers to significantly reduce the spread of 
COVID-19 in the workplace. The prompt identification and removal of 
these employees can prevent transmission of the virus to others in the 
workplace. In addition, medical removal protection provisions that 
ensure compensation and protection of rights and benefits during 
removal will encourage employees to report diagnoses of suspected or 
confirmed-positive COVID-19 and symptoms. However, as noted above, some 
employees with COVID-19 will not have symptoms, and testing to allow 
employees to return to work after exposures to COVID-19 or experiencing 
symptoms associated with COVID-19 will likely result in some false 
negatives. Therefore, a medical management program should be 
complemented by other measures as part of a multi-layered strategy to 
minimize employee exposure to the grave danger of COVID-19.
References
Abu-Raddad, LJ. et al., (2020). Assessment of the risk of SARS-CoV-2 
reinfection in an intense re-exposure setting. Clinical Infectious 
Disease. 2020 Dec 14: ciaa1846. doi: 10.1093/cid/ciaa1846. Epub 
ahead of print. PMID: 33315061; PMCID: PMC7799253. (Abu-Raddad et 
al., 2020).
Alimohamadi, Y. et al.,(2020). Determine the most common clinical 
symptoms in COVID-19 patients: A systematic review and meta-
analysis. Journal of Preventive Medicine and Hygiene. 2020 Oct 6; 
61(3): E304-E312. doi: 10.15167/2421-4248/jpmh2020.61.3.1530. PMID: 
33150219; PMCID: PMC7595075. (Alimohamadi et al., 2020).
American College of Occupational and Environmental Medicine (ACOEM). 
(2020, August 19). Coronavirus (COVID-19). https://info.mdguidelines.com/wp-content/uploads/2020/08/ACOEM-COVID-Aug-19-2020-public.pdf. (ACOEM, August 19, 2020).
Arons, MM. et al., (2020). Presymptomatic SARS-CoV-2 Infections and 
Transmission in a Skilled Nursing Facility. New England Journal of 
Medicine. 2020 May 28; 382(22): 2081-2090. doi: 10.1056/
NEJMoa2008457. Epub 2020 Apr 24. PMID: 32329971; PMCID: PMC7200056. 
(Arons et al., 2020).
Avanzato, VA. et al., (2020). Case Study: Prolonged infectious SARS-
CoV-2 shedding from an asymptomatic immunocompromised individual 
with cancer. Cell. 2020 Dec 23; 183(7): 1901-1912.e9. doi: 10.1016/
j.cell.2020.10.049. Epub 2020 Nov 4. PMID: 33248470; PMCID: 
PMC7640888. (Avanzato et al., 2020).
Beeching, NJ. et al., (2020). COVID-19: Testing times. Rapid near 
patient testing for both current and past infections is urgently 
required. BMJ 2020; 369: m1403 doi: 10.1136/bmj.m1403 (Published 8 
April 2020). (Beeching et al., 2020).
Bullard, J. et al., (2020). Predicting infectious Severe Acute 
Respiratory Syndrome Coronavirus 2 from diagnostic samples. Clin 
Infect Dis. 2020 Dec 17; 71(10): 2663-2666. doi: 10.1093/cid/
ciaa638. PMID: 32442256; PMCID: PMC7314198. (Bullard et al., 2020).
Burke, RM. et al., (2020). Symptom profiles of a convenience sample 
of patients with COVID-19--United States, January-April 2020. MMWR 
Morb Mortal Wkly Rep. 2020 Jul 17; 69(28): 904-908. doi: 10.15585/
mmwr.mm6928a2. PMID: 32673296; PMCID: PMC7366851. (Burke et al., 
2020).
Byambasuren, O. et al., (2020, December 11). Estimating the extent 
of asymptomatic COVID-19 and its potential for community 
transmission: Systematic review and meta-analysis. Official Journal 
of the Association of Medical Microbiology and Infectious Disease 
Canada: 5(4): 223-234. doi: 10.3138/jammi-2020-0030. (Byambasuren et 
al., December 11, 2020).
Centers for Disease Control and Prevention (CDC). (2020, December 
2). Options to Reduce Quarantine for Contacts of Persons with SARS-
CoV-2 Infection Using Symptom Monitoring and Diagnostic Testing. 
https://www.cdc.gov/coronavirus/2019-ncov/more/scientific-brief-options-to-reduce-quarantine.html. (CDC, December 2, 2020).
Centers for Disease Control and Prevention (CDC). (2021, February 
11). General Business Frequently Asked Questions. Suspected or 
Confirmed Cases of COVID-19 in the workplace. https://

www.cdc.gov/coronavirus/2019-ncov/community/general-business-
faq.html#Suspected-or-Confirmed-Cases-of-COVID-19-in-the-Workplace. 
(CDC, February 11, 2021).
Centers for Disease Control and Prevention (CDC). (2021a, February 
16). Criteria for return to work for healthcare personnel with SARS-
CoV-2 infection (Interim Guidance). https://www.cdc.gov/coronavirus/2019-ncov/hcp/return-to-work.html. (CDC, February 16, 2021a).
Centers for Disease Control and Prevention (CDC). (2021b, February 
16). Implementation of Mitigation Strategies for Communities with 
Local COVID-19 Transmission https://www.cdc.gov/coronavirus/2019-ncov/community/community-mitigation.html. (CDC, February 16, 2021b).
Centers for Disease Control and Prevention (CDC). (2021a, February 
18). Isolate if you are sick. https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/isolation.html. (CDC, February 18, 2021a).
Centers for Disease Control and Prevention (CDC). (2021b, February 
18). Discontinuation of isolation for persons with COVID-19 not in 
healthcare settings. https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-in-home-patients.html. (CDC, February 18, 2021b).
Centers for Disease Control and Prevention (CDC). (2021, February 
26). Notification of Exposure: A Contact Tracers Guide for COVID-19. 
https://www.cdc.gov/coronavirus/2019-ncov/php/notification-of-
exposure.html#:~:text=PDF%20%5B17%20Pages%5D-
,Overview,and%20other%20necessary%20support%20services. (CDC, 
February 26, 2021).
Centers for Disease Control and Prevention (CDC). (2021, March 1). 
Public Health Guidance for Community-Related Exposure. https://www.cdc.gov/coronavirus/2019-ncov/php/public-health-recommendations.html. (CDC, March 1, 2021).
Centers for Disease Control and Prevention (CDC) (2021, March 8). 
Guidance for business and employers responding to coronavirus 
disease 2019 (COVID-19). https://www.cdc.gov/coronavirus/2019-ncov/community/guidance-business-response.html. (CDC, March 8, 2021).
Centers for Disease Control and Prevention (CDC). (2021, March 12). 
When to Quarantine. https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/quarantine.html. (CDC, March 12, 2021).
Centers for Disease Control and Prevention (CDC). (2021, March 16). 
Interim Guidance on Duration of Isolation and Precautions for Adults 
with COVID-19. https://www.cdc.gov/coronavirus/2019-ncov/hcp/duration-isolation.html. (CDC, March 16, 2021).
Centers for Disease Control and Prevention (CDC). (2021, April 2). 
Science Brief: Background Rationale and Evidence for Public Health 
Recommendations for Fully Vaccinated People. https://www.cdc.gov/coronavirus/2019-ncov/science/science-briefs/fully-vaccinated-people.html. (CDC, April 2, 2021).
Centers for Disease Control and Prevention (CDC). (2021, May 13). 
Interim Public Health Recommendations for Fully Vaccinated People. 
https://www.cdc.gov/coronavirus/2019-ncov/vaccines/fully-vaccinated-guidance.html. (CDC, May 13, 2021).
Chandrashekar, A. et al., (2020). SARS-CoV-2 infection protects 
against rechallenge in rhesus macaques. Science. 2020 Aug 14; 
369(6505): 812-7. (Chandrashekar et al., 2020).
Cheng, HY. et al., (2020). Contact Tracing Assessment of COVID-19 
Transmission Dynamics in Taiwan and Risk at Different Exposure 
Periods Before and After Symptom Onset. JAMA Intern Med. 2020 Sep 1; 
180(9): 1156-1163. doi: 10.1001/jamainternmed.2020.2020. PMID: 
32356867; PMCID: PMC7195694. (Cheng et al., 2020).
Choe, PG. et al., (2021). Antibody Responses 8 Months after 
Asymptomatic or Mild SARS-CoV-2 Infection. Emerging Infectious 
Diseseases. 2021 Mar; 27(3): 928-931. doi: 10.3201/eid2703.204543. 
Epub 2020 Dec 22. PMID: 33350923; PMCID: PMC7920668. (Choe et al., 
2021).
Choi, B. et al., (2020). Persistence and Evolution of SARS-CoV-2 in 
an Immunocompromised Host. New England Journal of Medicine. 2020 Dec 
3; 383(23): 2291-2293. doi: 10.1056/NEJMc2031364. Epub 2020 Nov 11. 
PMID: 33176080; PMCID: PMC7673303. (Choi et al., 2020).
Clifford, S. et al., (2020). Strategies to reduce the risk of SARS-
CoV-2 reintroduction from international 
travellers.medRxiv.2020.10.1101/2020.07.24.20161281; https://doi.org/10.1101/2020.07.24.20161281. (Clifford et al., 2020).
Colson, P. et al., (2020). Evidence of SARS-CoV-2 re-infection with 
a different genotype. Journal of Infection. 2020 Nov 15: S0163-
4453(20)30706-4. doi: 10.1016/j.jinf.2020.11.011. Epub ahead of 
print. PMID: 33207255; PMCID: PMC7666873. (Colson et al., 2020).
Council of State and Territorial Epidemiologists (CSTE). (2020). 
Coronavirus Disease 2019 (COVID-19) 2020 Interim Case Definition, 
Approved August 5, 2020. https://wwwn.cdc.gov/nndss/conditions/coronavirus-disease-2019-covid-19/case-definition/2020/08/05/. 
(CSTE, 2020).
Dan, JM. et al., (2021). Immunological memory to SARS-CoV-2 assessed 
for up to 8 months after infection. Science. 2021 Feb 5; 371(6529): 
eabf4063. doi: 10.1126/science.abf4063. Epub 2021 Jan 6. PMID: 
33408181; PMCID: PMC7919858. (Dan et al., 2021).
Deeks, JJ, et al., (2020). Antibody tests for identification of 
current and past infection with SARS-CoV-2. Cochrane Database Syst 
Rev. 2020 Jun 25; 6(6): CD013652. doi: 10.1002/14651858.CD013652. 
PMID: 32584464; PMCID: PMC7387103. (Deeks et al., 2020).
Deng, W. et al., (2020). Primary exposure to SARS-CoV-2 protects 
against reinfection in rhesus macaques. Science. 2020 Aug 14; 
369(6505): 818-823. doi: 10.1126/science.abc5343. Epub 2020 Jul 2. 
PMID: 32616673; PMCID: PMC7402625. (Deng et al., 2020).
Food and Drug Administration (FDA). (2021, March 11). In Vitro 
Diagnostics EUAs. https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/in-vitro-diagnostics-euas. (FDA, March 11, 2021).
Grassly, NC. et al., (2020). Comparison of molecular testing 
strategies for COVID-19 control: A mathematical modelling study. The 
Lancet Infectious Diseases. 2020 Dec; 20(12): 1381-1389. doi: 
10.1016/S1473-3099(20)30630-7. Epub 2020 Aug 18. PMID: 32822577; 
PMCID: PMC7434438. (Grassly et al., 2020).
Grijalva, CG. et al., (2020). Transmission of SARS-COV-2 Infections 
in Households--Tennessee and Wisconsin, April-September 2020. MMWR 
Morb Mortal Wkly Rep. 2020 Nov 6; 69(44): 1631-1634. doi: 10.15585/
mmwr.mm6944e1. PMID: 33151916; PMCID: PMC7643897. (Grijalva et al., 
2020).
Gudbjartsson, DF. et al., (2020). Humoral Immune Response to SARS-
CoV-2 in Iceland. New England Journal of Medicine. 2020 Oct 29; 
383(18): 1724-1734. doi: 10.1056/NEJMoa2026116. Epub 2020 Sep 1. 
PMID: 32871063; PMCID: PMC7494247. (Gudbjartsson et al., 2020).
Harrington, D. et al., (2021). Confirmed Reinfection with SARS-CoV-2 
Variant VOC-202012/01. Clinical Infectious Diseases. 2021 Jan 9: 
ciab014. doi: 10.1093/cid/ciab014. Epub ahead of print. PMID: 
33421056; PMCID: PMC7929017. (Harrington et al., 2021).
Hartley, GE. et al., (2020). Rapid generation of durable B cell 
memory to SARS-CoV-2 spike and nucleocapsid proteins in COVID-19 and 
convalescence. Science Immunology. 2020 Dec 22; 5(54): eabf8891. 
doi: 10.1126/sciimmunol.abf8891. PMID: 33443036; PMCID: PMC7877496. 
(Hartley et al., 2020).
He, X. et al., (2020). Temporal dynamics in viral shedding and 
transmissibility of COVID-19. Nature Medicine 2020 May; 26(5): 672-
675. doi: 10.1038/s41591-020-0869-5. Epub 2020 Apr 15. Erratum in: 
Nat Med. 2020 Sep; 26(9): 1491-1493. PMID: 32296168. (He et al., 
2020).
Heymann, J. et al., (2020). Protecting health during COVID-19 and 
beyond: A global examination of paid sick leave design in 193 
countries. Global Public Health. 2020 Jul; 15(7): 925-934. doi: 
10.1080/17441692.2020.1764076. Epub 2020 May 12. PMID: 32396447. 
(Heymann et al., 2020).
Honein, MA. et al., (2020). Summary of Guidance for Public Health 
Strategies to Address High Levels of Community Transmission of SARS-
CoV-2 and Related Deaths, December 2020. MMWR Morb Mortal Wkly Rep 
2020; 69: 1860-1867. DOI: http://dx.doi.org/10.15585/mmwr.mm6949e2. 
(Honein et al., December 11, 2020).

Ibarrondo, FJ. et al., (2020). Rapid Decay of Anti-SARS-CoV-2 
Antibodies in Persons with Mild Covid-19. New England Journal of 
Medicine. 2020 Sep 10; 383(11): 1085-1087. doi: 10.1056/
NEJMc2025179. Epub 2020 Jul 21. Erratum in: New England Journal of 
Medicine. 2020 Jul 23; PMID: 32706954; PMCID: PMC7397184. (Ibarrondo 
et al., 2020).
Johansson, MA. et al., (2020). Reducing travel-related SARS-CoV-2 
transmission with layered mitigation measures: Symptom monitoring, 
quarantine, and testing. medRxiv preprint doi: https://doi.org/10.1101/2020.11.23.20237412. (Johansson et al., 2020).
Kaneko, N. et al., (2020). Loss of Bcl-6-Expressing T Follicular 
Helper Cells and Germinal Centers in COVID-19. Cell. 2020 Oct 1; 
183(1): 143-157.e13. doi: 10.1016/j.cell.2020.08.025. Epub 2020 Aug 
19. PMID: 32877699; PMCID: PMC7437499. (Kaneko et al., 2020).
Kim, DH. et al., (2021). Predictive value of olfactory and taste 
symptoms in the diagnosis of COVID-19: A systematic review and meta-
analysis. Clinical and Experimental Otorhinolaryngology 2021 Jan 25. 
doi: 10.21053/ceo.2020.02369. Epub ahead of print. PMID: 33541033. 
(Kim et al., 2021).
Kniffin, KM. et al., (2021). COVID-19 and the workplace: 
Implications, issues, and insights for future research and action. 
American Psychologist 2021 Jan; 76(1): 63-77. doi: 10.1037/
amp0000716. Epub 2020 Aug 10. PMID: 32772537. (Kniffen et al., 
2021).
Korea Centers for Disease Control and Prevention (Korea CDC). (2020, 
May 19). Findings from Investigation and Analysis of re-positive 
cases. https://www.cdc.go.kr/board/board.es?mid=a30402000000&bid=0030&act=view&list_no=367267&nPage=1external icon. (Korea CDC, May 19, 2020).
Kucharski, AJ. et al., (2020). Effectiveness of isolation, testing, 
contact tracing, and physical distancing on reducing transmission of 
SARS-CoV-2 in different settings: A mathematical modelling study. 
The Lancet Infectious Disease. 2020 Oct; 20(10): 1151-1160. doi: 
10.1016/S1473-3099(20)30457-6. Epub 2020 Jun 16. PMID: 32559451; 
PMCID: PMC7511527. (Kucharski et al., 2020).
Kucirka, LM. et al., (2020). Variation in False-Negative Rate of 
Reverse Transcriptase Polymerase Chain Reaction-Based SARS-CoV-2 
Tests by Time Since Exposure. Annals of Internal Medicine. 2020 Aug 
18; 173(4): 262-267. doi: 10.7326/M20-1495. Epub 2020 May 13. PMID: 
32422057; PMCID: PMC7240870. (Kucirka et al., 2020).
Larson, D. et al., (2020). A Case of Early Re-infection with SARS-
CoV-2. Clinical Infectious Diseases. Epub ahead of print. PMID: 
32949240; PMCID: PMC7543357. https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa1436/5908892. (Larson et al., 2020).
Lauer, SA. et al., (2020). The Incubation Period of Coronavirus 
Disease 2019 (COVID-19) From Publicly Reported Confirmed Cases: 
Estimation and Application. Annals of Internal Medicine. 2020 May 5; 
172(9): 577-582. doi: 10.7326/M20-0504. Epub 2020 Mar 10. PMID: 
32150748; PMCID: PMC7081172. (Lauer et al., 2020).
Li, N. et al., (2020). Prolonged SARS-CoV-2 RNA shedding: Not a rare 
phenomenon. Journal of Medical Virolology. 2020 Nov; 92(11): 2286-
2287. doi: 10.1002/jmv.25952. Epub 2020 May 22. PMID: 32347980; 
PMCID: PMC7267144. (Li et al., 2020).
Linton, NM. et al., (2020). Incubation Period and Other 
Epidemiological Characteristics of 2019 Novel Coronavirus Infections 
with Right Truncation: A Statistical Analysis of Publicly Available 
Case Data. Journal of Clinical Medicine. 2020 Feb 17; 9(2): 538. 
doi: 10.3390/jcm9020538. PMID: 32079150; PMCID: PMC7074197. (Linton 
et al., 2020).
Liu, WD. et al., (2020a). Prolonged virus shedding even after 
seroconversion in a patient with COVID-19. Journal of Infection. 
2020 Aug; 81(2): 318-356. doi: 10.1016/j.jinf.2020.03.063. Epub 2020 
Apr 10. PMID: 32283147; PMCID: PMC7151379. (Liu et al., 2020a).
Liu, Y. et al., (2020b). Secondary attack rate and superspreading 
events for SARS-CoV-2. The Lancet. 2020 Mar 14; 395(10227): e47. 
doi: 10.1016/S0140-6736(20)30462-1. Epub 2020 Feb 27. PMID: 
32113505; PMCID: PMC7158947. (Liu et al., 2020b).
Lu, J. et al., (2020). Clinical, immunological and virological 
characterization of COVID-19 patients that test re-positive for 
SARS-CoV-2 by RT-PCR. EBioMedicine. 2020 Sep; 59: 102960. doi: 
10.1016/j.ebiom.2020.102960. Epub 2020 Aug 24. PMID: 32853988; 
PMCID: PMC7444471. (Lu et al., 2020).
Lumley, SF. et al., (2021). Antibody Status and Incidence of SARS-
CoV-2 Infection in Health Care Workers. New England Journal of 
Medicine. 2021 Feb 11; 384(6): 533-540. doi: 10.1056/NEJMoa2034545. 
Epub 2020 Dec 23. PMID: 33369366; PMCID: PMC7781098. (Lumley et al., 
2021).
Midgley, CM. et al., (2020). Clinical and Virologic Characteristics 
of the First 12 Patients with Coronavirus Disease 2019 (COVID-19) in 
the United States. Nature Medicine 2020 Jun; 26(6): 861-868. doi: 
10.1038/s41591-020-0877-5. (Midgley et al., 2020).
National Academies of Sciences, Engineering, and Medicine (NASEM). 
(2020, November 9). Advantages and trade-offs of COVID-19 diagnostic 
tests, national testing strategies examined in new rapid response to 
government. https://www.nationalacademies.org/news/2020/11/advantages-and-trade-offs-of-covid-19-diagnostic-tests-national-testing-strategies-examined-in-new-rapid-response-to-government. 
(NASEM, November 9, 2020).
Ng, OT. et al., (2021). SARS-CoV-2 seroprevalence and transmission 
risk factors among high-risk close contacts: A retrospective cohort 
study. The Lancet Infectious Diseases. 2021 Mar; 21(3): 333-343. 
doi: 10.1016/S1473-3099(20)30833-1. Epub 2020 Nov 2. PMID: 33152271; 
PMCID: PMC7831879. (Ng, et al., 2021).
Nonaka, CKV. et al., (2021). Genomic evidence of a SARS-CoV-2 
reinfection cases with E484K spike mutation in Brazil. Pre-print 
posted January 6, 2021. doi: 10.20944/preprints202101.0132.v1. 
(Nonaka et al., 2021).
Oran, DP. and Topol, EJ. (2020). Prevalence of Asymptomatic SARS-
CoV-2 Infection: A Narrative Review. Annals of Internal Medicine. 
2020 Sep 1; 173(5): 362-367. doi: 10.7326/M20-3012. Epub 2020 Jun 3. 
PMID: 32491919; PMCID: PMC7281624. (Oran and Topol, 2020).
Pang, KW. et al., (2020). Frequency and Clinical Utility of 
Olfactory Dysfunction in COVID-19: A Systematic Review and Meta-
analysis. Current Allergy and Asthma Reports. 2020 Oct 13; 20(12): 
76. doi: 10.1007/s11882-020-00972-y. PMID: 33048282; PMCID: 
PMC7552599. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7552599/#__ffn_sectitle. (Pang et al., 2020).
Printza, A. and Constantinidis, J. (2020). The role of self-reported 
smell and taste disorders in suspected COVID19. European Archives of 
Otorhinolaryngol. 2020 Sep; 277(9): 2625-2630. doi: 10.1007/s00405-
020-06069-6. Epub 2020 May 23. PMID: 32447496; PMCID: PMC7245504. 
https://doi.org/10.1007/s00405-020-06069-6. Available at https://link.springer.com/content/pdf/10.1007/s00405-020-06069-6.pdf. 
(Printza and Constantinidis, 2020).
Quicke, K. et al., (2020). Longitudinal Surveillance for SARS-CoV-2 
RNA Among Asymptomatic Staff in Five Colorado Skilled Nursing 
Facilities: Epidemiologic, Virologic and Sequence Analysis. 
(Preprint) Medrxiv. 2020. doi: 10.1101/2020.06.08.20125989. (Quicke 
et al., 2020).
Quilty, BJ. et al., (2021). Quarantine and testing strategies in 
contact tracing for SARS-CoV-2: A modelling study. The Lancet Public 
Health. 2021 Mar; 6(3): e175-e183. doi: 10.1016/S2468-2667(20)30308-
X. Epub 2021 Jan 21. PMID: 33484644; PMCID: PMC7826085. (Quilty et 
al., 2021).
Seow, J. et al., (2020). Longitudinal observation and decline of 
neutralizing antibody responses in the three months following SARS-
CoV-2 infection in humans. Nature Microbiology. 2020 Dec; 5(12): 
1598-1607. doi: 10.1038/s41564-020-00813-8. Epub 2020 Oct 26. PMID: 
33106674. (Seow et al., 2020).
Struyf, T. et al., (2021). Signs and symptoms to determine if a 
patient presenting in primary care or hospital outpatient settings 
has COVID-19. Cochrane Database Systematic Reviews. 2021 Feb 23; 2: 
CD013665. doi: 10.1002/14651858.CD013665.pub2. PMID: 33620086. 
(Struyf et al., 2021).
Tillett, RL. et al., (2020). Genomic evidence for reinfection with 
SARS-CoV-2: A case study. The Lancet Infectious

Diseases. 2021 Jan; 21(1): 52-58. doi: 10.1016/S1473-3099(20)30764-
7. Epub 2020 Oct 12. PMID: 33058797; PMCID: PMC7550103. (Tillet et 
al., 2020).
Van Elslande, J. et al., (2021). Symptomatic SARS-CoV-2 reinfection 
by a phylogenetically distinct strain. Clinical Infectious Diseases 
ciaa1330. doi: 10.1093/cid/ciaa1330. Epub ahead of print. PMID: 
32887979; PMCID: PMC7499557. (Van Elslande et al., 2021).
Van Kampen, JJA et al., (2021) Duration and key determinants of 
infectious virus shedding in hospitalized patients with coronavirus 
disease-2019 (COVID-19). Nature Communications. 2021 Jan 11; 
12(1):267. doi: 10.1038/s41467-020-20568-4. PMID: 33431879; PMCID: 
PMC7801729. (van Kampen et al., 2021).
Wells, CR. et al., (2021). Optimal COVID-19 quarantine and testing 
strategies. Nature Communications 2021 Jan 7; 12(1): 356. doi: 
10.1038/s41467-020-20742-8. PMID: 33414470; PMCID: PMC7788536. 
(Wells et al., 2021).
W[ouml]lfel, R. et al., (2020). Virological assessment of 
hospitalized patients with COVID-2019. Nature. 2020 May; 581(7809): 
465-469. doi: 10.1038/s41586-020-2196-x. Epub 2020 Apr 1. Erratum 
in: Nature. 2020 Dec; 588(7839): E35. PMID: 32235945. (W[ouml]lfel 
et al., 2020).
Xiao, F. et al., (2020). Infectious SARS-CoV-2 in Feces of Patient 
with Severe COVID-19. Emerging Infectious Diseases. 2020 Aug; 26(8): 
1920-1922. doi: 10.3201/eid2608.200681. Epub 2020 May 18. PMID: 
32421494; PMCID: PMC7392466. (Xiao et al., 2020).
Young, BE. et al., (2020). Epidemiologic Features and Clinical 
Course of Patients Infected With SARS-CoV-2 in Singapore. Journal of 
the American Medical Association. 2020 Apr 21; 323(15): 1488-1494. 
doi: 10.1001/jama.2020.3204. Erratum in: JAMA. 2020 Apr 21; 323(15): 
1510. PMID: 32125362; PMCID: PMC7054855. (Young et al., 2020).
Zou, L. et al., (2020). SARS-CoV-2 Viral Load in Upper Respiratory 
Specimens of Infected Patients. New England Journal of Medicine. 
2020 Mar 19; 382(12): 1177-1179. doi: 10.1056/NEJMc2001737. Epub 
2020 Feb 19. PMID: 32074444; PMCID: PMC7121626. (Zou et al., 2020).
Zucman, N. et al., (2021). Severe reinfection with South African 
SARS-CoV-2 variant 501Y.V2: A case report. Clinical Infectious 
Diseases. 2021 Feb 10: ciab129. doi: 10.1093/cid/ciab129. Epub ahead 
of print. PMID: 33566076; PMCID: PMC7929064. (Zucman et al., 2021).
Zuo, J. et al., (2021). Robust SARS-CoV-2-specific T cell immunity 
is maintained at 6 months following primary infection. Nature 
Immunology. 2021 Mar 5. doi: 10.1038/s41590-021-00902-8. Epub ahead 
of print. PMID: 33674800. (Zuo et al., 2021).

N. Vaccination

    Vaccines are an important tool to reduce the transmission of COVID-
19 in the workplace. A vaccine serves three critical functions: First, 
it can reduce the likelihood that a vaccinated person will develop 
COVID-19 after exposure to SARS-CoV-2; second, it can lessen the 
symptoms and effects in cases where the vaccinated person does contract 
COVID-19; and third, although the CDC still recommends source controls 
for vaccinated healthcare workers, it also acknowledges a growing body 
of evidence that vaccination can reduce the potential that a vaccinated 
person will transmit the SARS-CoV-2 virus to non-vaccinated co-workers 
(CDC, April 12, 2021; CDC, April 27, 2021). Vaccination also serves an 
important role in reducing health disparities in employees of certain 
demographics, who may be especially vulnerable to severe health effects 
or death from COVID-19 (Dooling et al., December 22, 2020). Below OSHA 
provides a general explanation of the need for vaccination measures in 
the ETS; however, a fuller explanation of the efficacy of existing 
vaccines and their impact on the risk of COVID-19 infection and 
transmission is discussed in Grave Danger (Section IV.A. of the 
preamble).
    OSHA has long recognized the importance of vaccinating employees 
against preventable illnesses to which they may be exposed on the job. 
The Bloodborne Pathogens standard, for example, requires the hepatitis 
B vaccine be made available to any employees with occupational exposure 
to blood and other potentially infectious materials, in order to reduce 
the risk of hepatitis B infection and subsequent illness and death (56 
FR 64004, 64152 (Dec. 6, 1991)). A number of professional health 
organizations have similarly long recognized the importance of 
vaccinating employees to prevent illness. This is particularly true in 
healthcare industries, where employees are more regularly at risk of 
occupational exposure to transmissible diseases. For example, the 
Advisory Committee on Immunization Practices (ACIP), which reviews 
evidence of risk and vaccine effectiveness, recommends vaccinating 
healthcare employees against numerous diseases, including influenza, 
another viral disease spread through droplet transmission (Shefer et 
al., November 25, 2011). Similarly, both HICPAC and the American 
Hospital Association have encouraged and endorsed vaccination programs 
or policies for healthcare workers. CDC, WHO, and the National 
Academies of Science, among others, have all acknowledged that broad 
vaccination of all people for COVID-19, in combination with other 
public health measures, is a critical tool that can be used to address 
the pandemic (CDC, April 29, 2021; WHO, January 8, 2021; NASEM, 2020).
    Any vaccines offered to employees must be demonstrated to be safe 
and effective. Fortunately, over the course of the pandemic, there have 
been extensive efforts to develop COVID-19 vaccines. As discussed in 
greater detail in Grave Danger (Section IV.A. of the preamble), there 
are presently three COVID-19 vaccines authorized for emergency use by 
the FDA in the United States: the Pfizer-BioNTech COVID-19 vaccine, the 
Moderna COVID-19 vaccine, and the Janssen Biotech, Inc. Johnson and 
Johnson COVID-19 vaccine, each recommended for use by ACIP in persons 
at least 12 years of age and older for the Pfizer-BioNTech vaccines or 
18 years of age and older for the Moderna and Johnson and Johnson 
(Janssen) vaccines (Oliver et al., December 18, 2020; Oliver et al., 
January 1, 2021; FDA, April 9, 2021; FDA, April 1, 2021; FDA, February 
26, 2021; FDA, May 10, 2021). In determining whether to grant EUA for a 
new COVID-19 vaccine, the FDA considers several statutory criteria 
provided in section 564 of the Federal Food, Drug, and Cosmetic Act (21 
U.S.C. 360bbb-3). In evaluating an EUA request, FDA considers, among 
other things, the totality of scientific evidence available to 
determine if it is reasonable to believe that the vaccine may be 
effective (i.e., an efficacy of at least 50%) in preventing COVID-19 
and that the known and potential benefits of the vaccine, when used to 
prevent COVID-19, outweigh the known and potential risks of the vaccine 
(FDA, April 9, 2021; FDA, April 1, 2021; FDA, February 26, 2021). The 
product manufacturer must also demonstrate quality and consistency in 
manufacturing. Accordingly, any COVID-19 vaccine that receives an EUA 
from the FDA--including the Pfizer-BioNTech vaccine, Moderna vaccine, 
the Johnson and Johnson (Janssen) vaccine, and any future vaccine that 
receives such an authorization after the issuance of this ETS--has been 
shown to be sufficiently safe and effective.
    All three vaccines that have been authorized to date, including the 
Pfizer-BioNTech, Moderna, and Johnson & Johnson (Janssen) vaccines, 
have been found to be highly effective for the appropriate ages (Oliver 
et al., December 18, 2020; Oliver et al., January 1, 2021; Polack et 
al., December 31, 2020; FDA, December 17, 2020; FDA, December 10, 2020; 
FDA, February 26, 2021). The vaccines were also found to be effective 
in preventing disease that is severe or requires hospitalization. The 
evidence

available at this time, however, does not yet establish that the 
vaccines eliminate the potential for asymptomatic COVID-19 development; 
rather, fully vaccinated people are less likely to have asymptomatic 
infection or transmit SARS-CoV-2 to others (CDC, May 14, 2021). All 
three authorized vaccines have met the authorization standard for 
safety, with the majority of adverse effects observed to be mild or 
moderate in severity and transient, including: fatigue; headache; 
chills; muscle pain; joint pain; lymphadenopathy (swelling or 
enlargement of lymph nodes) on the same side as the injection; and 
injection site pain, redness, and swelling (CDC, December 13, 2020; 
CDC, December 20, 2020; CDC, May 14, 2021; Oliver et al., December 18, 
2020; Oliver et al., January 1, 2021; Polack et al., December 31, 2020; 
FDA, December 17, 2020; FDA, December 10, 2020; FDA, February 26, 
2021).
    Further, as discussed more extensively in the Summary and 
Explanation (Section VIII of the preamble) requirement for paid time 
off for vaccination, vaccination can only function as an effective 
control if workers have access to it. Additional explanation of the 
importance of removing barriers to controls is also discussed in 
Summary and Explanation (see discussion of requirements that employees 
receive protections of the ETS at no cost, as well as requirements for 
paid time off for vaccination, both in Section VIII of the preamble).
Vaccination References
Centers for Disease Control and Prevention (CDC). (2020, December 
13). Local reactions, systemic reactions, adverse events, and 
serious adverse events: Pfizer-BioNTech COVID-19 vaccine. https://www.cdc.gov/vaccines/covid-19/info-by-product/pfizer/reactogenicity.html. (CDC, December 13, 2020).
Centers for Disease Control and Prevention (CDC). (2020, December 
20). Local reactions, systemic reactions, adverse events, and 
serious adverse events: Moderna COVID-19 vaccine. https://www.cdc.gov/vaccines/covid-19/info-by-product/moderna/reactogenicity.html. (CDC, December 20, 2020).
Centers for Disease Control and Prevention (CDC). (2021, April 12). 
Benefits of getting a COVID-19 vaccine. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/vaccine-benefits.html. (CDC, April 
12, 2021).
Centers for Disease Control and Prevention (CDC). (2021, April 27). 
Updated Healthcare Infection Prevention and Control Recommendations 
in Response to COVID-19 Vaccination. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-after-vaccination.html. 
(CDC, April 27, 2021).
Centers for Disease Control and Prevention (CDC). (2021, April 29). 
FAQ ``Why would a vaccine be needed when we can do other things . . 
.?. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/faq.html. 
(CDC, April 29, 2021).
Centers for Disease Control and Prevention (CDC). (2021, May 14). 
Interim clinical considerations for use of COVID-19 vaccines 
currently authorized in the United States. https://www.cdc.gov/vaccines/covid-19/info-by-product/clinical-considerations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fvaccines%2Fcovid-19%2Finfo-by-product%2Fpfizer%2Fclinical-consideratio%E2%80%A6. (CDC, May 14, 2021).
Dooling, K et al., (2020, December 22). The Advisory Committee on 
Immunization Practices' updated interim recommendation for 
allocation of COVID-19 vaccine--United States, December 2020. MMWR 
Rep 2021; 69: 1657-1660. DOI: http://dx.doi.org/10.15585/mmwr.mm695152e2. (Dooling et al., December 22, 2020).
Food and Drug Administration (FDA). (2020, December 10). FDA 
briefing document. Pfizer-BioNTech COVID-19 Vaccine. https://www.fda.gov/media/144245/download. (FDA, December 10, 2020).
Food and Drug Administration (FDA). (2020, December 17). MRNA-1273 
sponsor briefing document (Moderna). https://www.fda.gov/media/144453/download. (FDA, December 17, 2020).
Food and Drug Administration (FDA). (2021, February 26). FDA 
Briefing Document: Janssen Ad.COV2.S Vaccine for the Prevention of 
COVID-19. (FDA, February 26, 2021)
Food and Drug Administration (FDA). (2021, April 1). Moderna COVID-
19 vaccine. https://www.fda.gov/emergency-preparedness-and-response/coronavirus-disease-2019-covid-19/moderna-covid-19-vaccine. (FDA, 
April 1, 2021).
Food and Drug Administration (FDA). (2021, April 9). Pfizer-BioNTech 
COVID-19 vaccine. https://www.fda.gov/emergency-preparedness-and-response/coronavirus-disease-2019-covid-19/pfizer-biontech-covid-19-vaccine. (FDA, April 9, 2021).
Food and Drug Administration (FDA). (2021, May 10). Pfizer-BioNTech 
COVID-19 vaccine EUA Letter of Authorization Reissued. https://www.fda.gov/media/144412/download. (FDA, May 10, 2021).
National Academy of Sciences, Engineering, and Medicine (NASEM). 
(2020). Framework for equitable allocation of COVID-19 vaccine. 
https://www.nap.edu/download/25917. (NASEM, 2020).
Oliver, S et al., (2020, December 18). The Advisory Committee on 
Immunization Practices' interim recommendation for use of Pfizer-
BioNTech COVID-19 vaccine--United States, December 2020. MMWR Rep 
2020; 69: 1922-1924. DOI: http://dx.doi.org/10.15585/mmwr.mm6950e2. 
(Oliver et al., December 18, 2020).
Oliver, S et al., (2020, December 20). The Advisory Committee on 
Immunization Practices' interim recommendation for use of Moderna 
COVID-19 vaccine--United States, December 2020. MMWR Rep 2021; 69: 
1653-1656. DOI: http://dx.doi.org/10.15585/mmwr.mm695152e1. (Oliver 
et al., January 1, 2021).
Polack, F et al., (2020). Safety and efficacy of the BNT162b2 mRNA 
Covid-19 vaccine. New England Journal of Medicine, 383(27), 2603-
2615. doi: 10.1056/nejmoa2034577. (Polack et al., December 31, 
2020).
Shefer, A. et al., (2011, November 25). Immunization of health-care 
personnel: Recommendations of the Advisory Committee on Immunization 
Practices (ACIP). MMWR Recommendations and Reports 60(RR07); 1-45. 
https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6007a1.htm. (Shefer et 
al., November 25, 2011).
World Health Organization (WHO). (2021, January 8). COVID-19 
vaccine. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/covid-19-vaccines. (WHO, January 8, 2021).

O. Training

    The CDC has determined that training is a necessary component of a 
comprehensive control plan for COVID-19. The WHO has also determined 
that training is an important control strategy for COVID-19 (WHO, May 
10, 2020). When providing guidance for employers, the CDC has said that 
employees need to be educated on steps they can take to protect 
themselves from potential COVID-19 exposures at work. Employers 
informing employees of the hazards to which employees may be exposed 
while working is a cornerstone of occupational health and safety (OSHA, 
2017). Employees play a particularly important role in reducing 
exposures because appropriate application of work practices and 
controls limit exposure levels. Employees therefore need to be informed 
of the grave danger of COVID-19, as well as the workplace measures 
included in their employers' COVID-19 plans because those measures are 
necessary to reduce risk and provide protection to employees. Employees 
must know what protective measures are being utilized and be trained in 
their use so that those measures can be effectively implemented.
    Training has been shown to be an effective tool to reduce injury 
and illness (Burke et al., February 2006), but training is even more 
critical when the workplace hazard includes the potential transmission 
of the potentially deadly SARS-CoV-2 virus from one employee to 
another: One improperly trained employee could increase risk for that 
employee and for all of that employee's contacts, including coworkers.

Therefore, training is an essential component of a layered approach to 
minimizing the risk of contracting COVID-19 in the workplace.
    Training and education provide employees and managers an increased 
understanding of existing safety and health programs. A thorough 
understanding of these programs is necessary so employees can more 
effectively contribute to their development and implementation. 
Training provides employers, managers, supervisors, and employees with 
the knowledge and skills needed to do their work safely and to avoid 
creating hazards that could place themselves or others at risk, as well 
as awareness and understanding of workplace hazards and how to 
identify, report, and control them. Specialized training can address 
unique hazards.
    Because OSHA has long recognized the importance of training in 
ensuring employee safety and health, many OSHA standards require 
employers to train employees (e.g., the Bloodborne Pathogen standard at 
29 CFR 1910.1030(g)(2)). When required as a part of OSHA standards, 
such as is required by this ETS, training helps to ensure that 
employees are able to conduct work in a safe and healthful manner 
(OSHA, April 28, 2010). Training is essential to ensure that both 
employers and employees understand the sources of potential exposure to 
COVID-19 and control measures to reduce exposure to the hazard.
    Employee comprehension is critical to ensuring that training is an 
effective control. If training information is not presented in a way 
that all employees understand, the training will not be effective. 
Employers must thus consider language, literacy, and social and 
cultural appropriateness when designing and implementing training 
programs for employees (O'Connor et al., 2014). Additionally, if 
employers do not offer training to employees in a convenient manner, 
employees may be less likely to participate in the training. Therefore, 
to be effective, training must be offered during scheduled work times 
and at no cost to the employee. This will ensure that all employees 
will have the time and financial resources to receive training. This is 
also consistent with other OSHA standards. For example, the Bloodborne 
Pathogen standard requires training be provided at no cost and during 
working hours (Sec.  1910.1030(g)(2)(i)) and in a manner employees 
understand (Sec.  1910.1030(g)(2)(vi)).
    Research dating back to the 1980s has found ``overwhelming 
evidence'' of the effectiveness of training programs on employee 
knowledge (NIOSH, 1998), as well as employee behaviors (NIOSH, January 
2010). With enhanced knowledge of safety and health hazards and 
controls, employees can implement safer work practices. This can result 
in reductions in workplace-related illnesses (Burke et al., February 
2006).
    The CDC has stated that information on workplace policies should be 
communicated clearly, frequently, and via multiple messages (CDC, March 
8, 2021). Training and education on safe work practices and controls 
should be used to raise awareness among employees. Emphasizing the 
effectiveness of these workplace controls helps to counteract 
misinformation. Additional training, such as on PPE and infection 
control policies and procedures, should be given to employees in those 
workplaces where there is a high risk of exposure to COVID-19 (WHO, May 
10, 2020).
    Scientific research and case studies have further reinforced the 
importance of training in responding to the COVID-19 pandemic. 
Researchers found that a COVID-19 outbreak was effectively contained as 
a result of prompt implementation of infection control measures, 
including early in-person education of employees on the signs, 
symptoms, and transmission of COVID-19 (Hale and Dayot, August 13, 
2020). Knowledge of PPE was markedly improved following training on PPE 
for healthcare employees in China during the COVID-19 pandemic (Tan et 
al., June, 2020).
    Training has been widely recognized as a key component of 
occupational safety and health. Even though the body of scientific 
evidence on the importance of training during the COVID-19 pandemic is 
limited given its ongoing nature, the evidence that does exist only 
further emphasizes the important role of training in protecting the 
health and safety of employees. As such, OSHA has concluded that 
training is necessary to ensure proper implementation of the employer's 
COVID-19 plan and all other control measures, and that such training 
will reduce incidence of COVID-19 illness both on its own and when 
complemented by other measures as part of a multi-layered strategy to 
minimize employee exposure to the grave COVID-19 danger.
References
Burke, M.J. et al., (2006, February). Relative effectiveness of 
worker safety and health training methods. American Journal of 
Public Health 96: 315-324. (Burke et al., February 2006).
Centers for Disease Control and Prevention (CDC). (2021, March 8). 
Guidance for Businesses and Employers Responding to Coronavirus 
Disease 2019 (COVID-19). https://www.cdc.gov/coronavirus/2019-ncov/community/guidance-business-response.html. (CDC, March 8, 2021).
Hale, M. and Dayot, A. (2020). Outbreak Investigation of COVID-19 in 
Hospital Food Service Workers. American Journal of Infectection 
Control. S0196-6553(20)30777-X. https://doi.org/10.1016/j.ajic.2020.08.011. (Hale and Dayot, August 13,2020).
National Institute for Occupational Safety and Health (NIOSH). 
(1998, June). Assessing Occupational Safety and Health Training: A 
literature review, June 1998. https://www.cdc.gov/niosh/docs/98-145/pdfs/98-145.pdf?id=10.26616/NIOSHPUB98145. (NIOSH, June 1998).
National Institute for Occupational Safety and Health (NIOSH) (2010, 
January). A systematic review of the effectiveness of training and 
education for the protection of workers, January 2010.https://
www.cdc.gov/niosh/docs/2010-127/pdfs/2010-127.pdf. (NIOSH, January 
2010).
O'Connor, T. et al., (2014). Occupational safety and health 
education and training for underserved populations. New 
Solutions24(1): 83-106. (O'Connor et al., 2014).
Occupational Safety and Health Administration (OSHA). (2010, April 
28). Training Standards Policy Statement. https://www.osha.gov/dep/standards-policy-statement-memo-04-28-10.html.(OSHA, April 28, 
2010).
Occupational Safety and Health Administration (OSHA). (2017). 
Workers' Rights. https://www.osha.gov/sites/default/files/publications/osha3021.pdf.(OSHA, 2017).
Tan, W. et al., (2020, June). Whole-process emergency training of 
personal protective equipment helps healthcare workers against 
COVID-19: Design and effect. Journal of Occupational and 
Environmental Medicine 62: 420-423. DOI: 10.1097/
JOM.0000000000001877. (Tan et al., June, 2020).
World Health Organization(WHO).(2020, May 10). Considerations for 
public health and social measures in the workplace context of COVID-
19: Annex to Considerations in adjusting public health and social 
measures in the context of COVID-19, May 2020. https://www.who.int/publications-detail-redirect/considerations-for-public-health-and-social-measures-in-the-workplace-in-the-context-of-covid-19.(WHO, 
May 10, 2020).

VI. Feasibility

A. Technological Feasibility

    This section presents an overview of the technological feasibility 
assessment for OSHA's Emergency Temporary Standard (ETS) for COVID-19. 
The ETS has four sections: Healthcare (29 CFR 1910.502); Mini 
Respiratory Protection Program (29 CFR 1910.504); Severability (29 CFR 
1910.505); and Incorporation by

Reference (29 CFR 1910.509). The ETS applies to all settings where any 
employee provides healthcare services or performs healthcare support 
services. The settings covered by the ETS are listed in Table VI.A.-1.
[GRAPHIC] [TIFF OMITTED] TR21JN21.001

    The mini respiratory protection program section supplements the ETS 
to provide additional protection to workers in appropriate cases. The 
healthcare and mini respiratory protection program sections of the ETS 
will be discussed below. It is not necessary to discuss the 
severability or incorporation by reference sections, as those sections 
do not by their own terms impose any requirements that raise issues of 
technological feasibility.
    Technological feasibility has been interpreted broadly to mean 
``capable of being done'' (Am. Textile Mfrs. Inst. v. Donovan, 452 U.S. 
490, 509-510 (1981)). A standard is technologically feasible if the 
protective measures it requires already exist, can be brought into 
existence with available technology, or can be created with technology 
that can reasonably be expected to be developed, i.e., technology that 
``looms on today's horizon'' (United Steelworkers of Am., AFL-CIO-CLC 
v. Marshall, 647 F.2d 1189, 1272 (D.C. Cir. 1980) (Lead I); Amer. Iron 
& Steel Inst. v. OSHA, 939 F.2d 975, 980 (D.C. Cir. 1991) (Lead II); 
American Iron and Steel Inst. v. OSHA, 577 F.2d 825 (3rd Cir. 1978)). 
Courts have also interpreted technological feasibility to mean that a 
typical firm in each affected industry or application group will 
reasonably be able to implement the requirements of the standard in 
most operations most of the time (see Public Citizen v. OSHA, 557 F.3d 
165 (3d Cir. 2009); Lead I, 647 F.2d at 1272; Lead II, 939 F.2d at 
990).
    OSHA's assessment focuses on the controls required by the ETS that 
stakeholders may believe raise issues of technological feasibility. 
These controls include the implementation of a COVID-19 plan and 
healthcare-specific good infection control practices, as well the 
following controls: Physical distancing; physical barriers; and 
ventilation.\26\ As discussed below, OSHA's finding of technological 
feasibility is supported by a large number of COVID-19 transmission 
prevention plans and best practice documents it reviewed, as well as 
physical distancing scenarios and a job matrix it developed, across the 
healthcare sector.
---------------------------------------------------------------------------

    \26\ As will be discussed later in this assessment, there are no 
technological feasibility barriers related to compliance with other 
requirements in the ETS (e.g., facemasks, respirators, cleaning and 
disinfection, health screening and medical management, employee 
notification).
---------------------------------------------------------------------------

    While OSHA focuses on certain types of evidence in specific parts 
of the analysis, much of the evidence supports other discrete findings 
made by OSHA. Thus, for example, while OSHA focuses on its review of 
plans and best practice documents in establishing the feasibility of 
developing and implementing a COVID-19 plan, that evidence also 
supports the feasibility of implementing healthcare-specific good 
infection control practices, physical distancing and physical barriers, 
and ventilation.
    In addition, this analysis discusses only a few examples of the 
plans and best practice documents it reviewed, does not recount every 
element of the

plans and best practice documents that it reviewed, and does not 
recount all details of the scenarios and job matrix it developed. OSHA 
based its technological feasibility assessment on all the evidence in 
the docket, and not just the select portions discussed here. The 
discussion below is merely illustrative of the full complement of 
evidence reviewed to demonstrate that employers have implemented the 
controls required by the ETS.
    Finally, OSHA's finding of technological feasibility should not be 
read to indicate that individual plans or best practice documents OSHA 
reviewed are ETS-compliant, that lack of inclusion of a control in a 
plan or document indicates the control is infeasible, that the use of a 
barrier by employers in a given situation indicates that physical 
distancing was not feasible in that situation, or that a particular 
control used (e.g., a plastic sheet or curtain used as a physical 
barrier) is compliant with the ETS's requirements. The plans and best 
practice documents are intended to show two things: (1) That developing 
plans to address COVID-19 in various workplaces is both common and 
feasible, and (2) that the controls required by the ETS have been 
implemented and are feasible in the healthcare settings. The specifics 
of the plans may vary, but the ETS COVID-19 plan requirements are 
written as performance requirements that provide sufficient flexibility 
to ensure that it is feasible for employers to develop and implement 
such a plan, including appropriate controls, for any given healthcare 
workplace.
I. The ETS's Approach to Employee Protection
    The ETS generally includes provisions that are based on and in 
accordance with applicable CDC and other well-established guidelines 
for good infection control practices relevant to the exposures 
encountered by employees during their job tasks. For example, the ETS 
requires the employer to develop and implement policies and procedures 
to adhere to Standard and Transmission-Based Precautions. As discussed 
in detail in the Need for Specific Provisions (Section V of the 
preamble, these requirements are consistent with well-established CDC 
and other guidelines that are routinely followed by employers subject 
to the ETS. That the ETS is based on CDC and other guidelines or 
practices that are well established and have been routinely followed by 
many employers both before and during the pandemic is compelling 
evidence supporting OSHA's finding of technological feasibility.
    Moreover, as described in more detail in the Need for Specific 
Provisions (Section V of the preamble), COVID-19 transmission control 
practices work best when used together, overlapping their protective 
impact. To this end, the COVID-19 ETS provides a multilayered approach 
in which a combination of control measures must be implemented to 
minimize the risks of exposure to COVID-19. Thus, to effectively reduce 
the risk, employers must ensure that they follow all requirements of 
the ETS that are feasible. As discussed in the Need for Specific 
Provisions (Section V of the preamble), the OSHA regulatory text 
reflects a multilayered strategy by requiring employers to implement 
multiple mitigation strategies with several layers of controls to lower 
the risks of exposure and reduce the spread of disease. Utilizing 
overlapping controls in a layered approach better ensures that no 
inherent weakness in any one approach results in an infection incident. 
OSHA emphasizes that the infection control practices required by the 
ETS work best when used together, layering their protective impact 
(Garner, 1996; Rusnak et al., September 2004; Miller et al., 2012; WHO, 
2016). For example, in addition to requiring employers to ensure that 
employees engage in physical distancing, wear facemasks and follow 
healthy hand hygiene practices, employers must ensure the use of 
physical barriers at fixed work locations outside of direct patient 
care areas where 6 feet of physical distancing is not feasible and 
ensure adequate building ventilation. No one measure can prevent 
transmission by itself, but several layers combined can significantly 
reduce the overall risk of COVID-19 transmission (e.g., a facemask 
alone will not be enough to prevent the spread of COVID-19 without 
physical distancing and other controls (Akhtar et al., December 22, 
2020)).
    Implementing multiple mitigation strategies is even more necessary 
to reduce the risk, because it will not be feasible to apply every 
control in every workplace situation. Thus, the ETS employs strategies 
to ensure that employees will be protected even when a particular 
control is not feasible. As discussed below, OSHA concludes that this 
multilayered approach to employee protection is feasible based on its 
review of commonly implemented healthcare-specific good infection 
control practices contained in nationally recognized infection control 
practices like CDC guidelines, employer plans, best practice documents, 
scenarios, and a job matrix that show these precautions are already in 
place or can be readily implemented by typical firms in the healthcare 
sector.
    OSHA emphasizes, finally, that although the ETS takes a 
multilayered approach to employee protection, it also establishes how 
and when controls must be used. For example, physical barriers are 
required only where physical distancing is not feasible because, as 
OSHA discusses in depth in Need for Specific Provisions (Section V of 
the preamble), physical barriers work by preventing droplets from 
traveling from the source (i.e., an infected person) to an employee, 
and are particularly critical when physical distancing of 6 feet is not 
feasible because most COVID-19 transmission occurs via respiratory 
droplets that are spread from an infected individual during close 
(within 6 feet) person-to-person interactions.
a. COVID-19 Plans
    Paragraph (c) of the ETS requires the employer to develop and 
implement a COVID-19 plan that includes policies and procedures to 
minimize the risk of transmission of COVID-19, as reflected in 
paragraphs (d) through (n) in the ETS. These provisions are summarized 
in Table VI.A.-2 below, and are discussed in detail in Need for 
Specific Provisions and Summary and Explanation (Sections V and VIII of 
the preamble, respectively).

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    OSHA conducted a search for existing COVID-19 plans and best 
practices developed by employers, trade associations, and other 
organizations and posted on their publicly available websites. OSHA's 
search revealed 77 plans and best practice documents from companies and 
trade associations in the Health Care and Social Assistance industry 
sector that address COVID-19 hazards using the multilayered approach 
and controls required by the ETS. To the extent individual plans are 
not discussed specifically below, a breakdown with the name of the 
company or organization, a description of the contents, and a link to 
the plan can be found in the COVID-19 Plans by NAICS spreadsheet (ERG, 
February 9, 2021).
    Based on its review of these plans, OSHA concludes that it is 
feasible for employers in typical firms in the healthcare sector to 
comply with the requirements in the ETS for a COVID-19 plan.\27\ Below, 
OSHA highlights the elements of a few of the plans and best practice 
documents it reviewed. In each case, OSHA presumes that an organization 
believes that the particular approaches contained in the organization's 
own documents are technologically feasible.
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    \27\ As stated, OSHA located 77 plans in the Health Care and 
Social Assistance industry sector. Some of these plans do not 
address protections that are covered by the ETS (i.e., they do not 
cover settings where any employee provides healthcare services or 
healthcare support services). OSHA relied on these particular plans 
to draw its conclusion that it is feasible for employers in typical 
firms in the healthcare sector to comply with the requirements in 
the ETS for a COVID-19 plan, but only to the extent they address the 
implementation of controls to protect workers in job categories 
commonly found in workplaces where healthcare services and 
healthcare support services are provided (e.g., public facing 
employees, general office workers).
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ETS Workplace-Specific Hazard Assessments Required by Different 
Healthcare Organizations
    Paragraph (c)(4)(i) of the ETS requires healthcare employers to 
conduct a workplace-specific hazard assessment to identify potential 
workplace hazards related to COVID-19. The workplace-specific hazard 
assessment requirements are discussed in detail in Need for Specific 
Provisions and Summary and Explanation (Sections V and VIII of the 
preamble, respectively).
    OSHA conducted a search for existing COVID-19 plans and best 
practices developed by employers, trade associations, and other 
organizations and posted on their publicly available websites and found 
that many required employers to conduct a workplace hazard assessment 
to determine the COVID-19 exposure risks to employees. While the 
specifics of the assessments may not mirror the full requirements for 
OSHA's COVID-19 plans, those hazard assessments indicate and provide 
additional support for OSHA's determination that it is feasible for 
healthcare employers to design and implement COVID-19 plans. The best 
practices also indicate that it is feasible for healthcare employers to 
have policies and procedures to regularly check on the proper 
implementation of

controls, which corresponds to OSHA's requirement that employers 
regularly re-assess the COVID-19 plan to ensure that it is updated and 
useful.
    The Santa Clara Valley Medical Center (SCVMC) is a 574-bed acute 
care, fully accredited public teaching hospital affiliated with 
Stanford University Medical School and provides a full range of 
inpatient, emergency rehabilitation, neonatal, intensive care, high-
risk maternity care, psychiatry, pediatric intensive care, and burn 
intensive care services. The ambulatory outpatient services include 
both primary and specialty clinics located not only at SCVMC, but also 
at satellite facilities located throughout the area (SCVMC, December 1, 
2020).
    The SCVMC plans reviewed includes guidelines for COVID-19 exposure 
and risk assessment, contact tracing, testing, and return to work for 
their employees (SCVMC, December 1, 2020). Furthermore, the COVID-19 
plan includes a policy outlining the worker exposure evaluation process 
to be conducted by each department and each ambulatory care clinic that 
is part of the SCVMC network. The assessment of exposure risk is 
required for all individuals working in the SCVMC hospitals and clinics 
including employees, volunteer, staff, physicians, contract personnel, 
or other workers. The assessment required by the COVID-19 plan should 
evaluate physical distancing, period or duration of exposure, as well 
as the implementation of controls such as facemasks and respiratory 
protection, and other PPE necessary to protect employees from COVID-19 
exposure.
    OSHA also reviewed the COVID-19 plan for Michigan Medicine, one of 
the largest fully accredited academic medical centers in Michigan made 
up of the University of Michigan health system and medical school. The 
Michigan Medicine COVID-19 plan includes specific requirements for each 
department to conduct employee COVID-19 job hazard assessments to 
evaluate and mitigate the risk of COVID-19 for University of Michigan 
workers (Michigan Medicine U-M, May 18, 2021).
    The U-M COVID-19 plan also requires each department to create a 
departmental specific COVID-19 work plan for its area to document their 
COVID-19 employee job hazard assessment and plan. The plan also 
provides departments with resources to develop and implement the 
required COVID-19 employee job hazard assessment as well as a 
departmental COVID-19 work plan including blank templates for both. The 
hazard assessment and subsequent plan required by each department must 
evaluate and address for each employee, the ability to maintain 
physical distance from all other persons, employee requirements for 
facemasks, respiratory protection, and other PPE, hand hygiene and 
respiratory etiquette, workplace cleaning and disinfection within the 
department or unit. The requirements of the job hazard assessment cover 
employees, vendors, contractors, and all other workers performing task 
in the department.
    Additionally, OSHA reviewed the COVID-19 plan of Johns Hopkins 
Medicine, which is made up of the Johns Hopkins University Health 
System with six academic and community hospitals, four suburban health 
care and surgery centers, over 40 patient care locations, and a home 
care group that offers an array of health care services. The Johns 
Hopkins Medicine COVID-19 plan includes requirements that assess the 
COVID-19 transmission hazards in the workplace to determine the proper 
implementation of controls (Johns Hopkins Medicine, 2021). The plan 
also includes policies and procedures to implement a daily COVID-19 
safety audit program. Each day, the COVID-19 safety auditor ensures 
every hospital, outpatient clinic and care center is practicing proper 
masking, physical distancing, handwashing and disinfection of 
frequently touched surfaces. As with the SCVMC example, this supports 
the feasibility of regular reassessments that employers will need to 
conduct for their COVID-19 plans.
    Based on its review of these plans, OSHA concludes that it is 
feasible for employers in typical firms in the healthcare sector to 
comply with the requirements in the ETS for a COVID-19 workplace-
specific hazard assessment.
ETS Controls Are Included in Best Practices Recommended by Healthcare 
Professional Associations
    Some of OSHA's evidence that the COVID-19 plan, distancing, 
barriers, and ventilation modifications are feasible for healthcare 
employers is that such measures, or substantially similar measures, are 
already recommended by some of the largest professional associations in 
the healthcare industry.
    The American Society for Health Care Engineering (ASHE) is the 
largest professional membership group of the American Hospital 
Association. The ASHE is comprised of over 12,000 professionals who 
design, build, maintain, and operate healthcare facilities. ASHE 
members include health care facility managers, control specialists, and 
others. ASHE has developed best practices for minimizing the risk from 
COVID-19. These best practices can be, and have been, used by ASHE 
members' organizations to develop their individual plans. (ASHE, 
December 23, 2020)
    The ASHE best practices are a collection of strategies which can be 
implemented to reduce the spread of COVID-19. The ASHE best practices 
recommend a multilayered control strategy. ASHE states that healthcare 
organizations are working to maintain physical distance of at least six 
feet and one way that this has been achieved is by scheduling check-in 
times to limit occupancy as well as other controls such as floor 
markings. When physical distancing is not feasible, employers have 
installed physical barriers, such as clear, acrylic plexiglass or 
vinyl, along with requiring face masks. ASHE also states that 
healthcare organizations have taken a combination of approaches for 
cleaning and disinfection, such as cleaning workstations including 
high-touch surfaces daily. ASHE also discusses health screening and 
medical management. According to ASHE, some healthcare organizations 
have implemented self-screening policies and procedures, including, for 
example, having employees certify that they have not displayed symptoms 
or been in recent contact with someone that has tested positive for 
COVID-19. Finally, the ASHE best practices recommend ensuring that 
ventilation systems are working properly, including ensuring that all 
negative pressure spaces including AIIRs are properly maintained, and 
that the circulation of outdoor air is increased as much as possible. 
The ASHE best practices also provide employers with steps to verify 
that CDC recommended guidelines for air changes and time required for 
contaminate removal based on air changes are followed.
    The American Health Care Association and the National Center for 
Assisted Living (AHCA/NCAL), an association representing long term and 
post-acute care providers, with more than 14,000 member facilities 
including non-profit and proprietary skilled nursing centers, assisted 
living communities, sub-acute centers and homes for individuals with 
intellectual and development disabilities, has also developed best 
practices for minimizing the risk from COVID-19 (AHCA/NCAL, 2021). 
Similar to the ASHE best practices and other plans and best practice 
documents that were reviewed, the AHCA/NCAL best practices contain many 
of the controls that are required

by the ETS. Also similar to the ASHE and other best practice documents, 
the AHCA/NCAL membership can use the AHCA/NCAL best practices to 
develop their individual plans. For example, the AHCE/NCAL best 
practices recommend implementing controls to maintain physical distance 
including rearranging offices and workstations as needed, posting signs 
and floor markers, and limiting the number of individuals permitted in 
the workplace. In addition, the AHCA/NCAL best practices recommend the 
use of facemasks and increased cleaning and disinfection. The best 
practices also contain recommendations on health screening and medical 
management. Members have implemented recommendations on self-
questionnaire policies and procedures for employees and all other 
individuals before they can enter the site, including, for example, 
recommendations on having employees certify that they have not 
displayed symptoms or been in recent contact with someone that has 
tested positive for COVID-19. The AHCE/NCAL best practices also contain 
recommendations on conducting contact tracing while protecting the 
employee's identity, and engaging in facility-wide protocols to protect 
other employees.
    The New Mexico EMT Association (NMEMTA) is a professional 
organization supporting emergency medical technicians and others 
serving the public in the emergency services sector (NMEMTA, March 29, 
2020). Similar to other best practice documents that were reviewed, the 
NMEMTA best practices contain many of the controls that are required by 
the ETS and recommend a multilayered approach to infection control. 
Furthermore, NMEMTA members can use this guidance to develop their 
individual plans. The NMEMTA best practices recommend implementing 
physical distancing controls when responding to an emergency as well as 
when transporting patients. For example, NMEMTA provides guidance on 
limiting the number of responders by implementing policies for 
coordinating with dispatchers prior to initial assessment, and 
additional work practices such as using radio communications to 
minimize the number of responders on scene. Additionally, the NMEMTA 
best practices recommend policies and procedures to limit the number of 
EMS workers in the ambulance and provide guidance on installing 
physical barriers to separate the driver from the treatment area of the 
ambulance. The NMEMTA best practices also recommend policies for 
requiring the proper PPE and respiratory protection for EMS employees 
as well as for placing facemasks on patients and family members 
traveling in the ambulance.
    The National Association for Home Care & Hospice (NAHC) is a 
nonprofit organization that represents the nation's 33,000 home care 
and hospice organizations. NAHC also advocates for the more than two 
million nurses, therapists, aides, and other caregivers employed by 
such organizations to provide in-home services to some 12 million 
Americans each year who are infirm, chronically ill, or disabled (NAHC, 
March 3, 2020). NAHC developed best practices for home health and 
hospice employers. The NAHC best practices recommend a multilayered 
infection control plan to protect employees from COVID-19. These best 
practices include strategies for maintaining physical distance, 
including ways to limit instances where caregivers are within 6 feet of 
other persons. For example, the NAHC best practices contain policies 
for requiring household members to stay in separate rooms of the home 
as much as possible and to maintain at least 6 feet of distance from 
the caregiver when they must be in the same room. In addition, the best 
practices recommend procedures to ensure the home space has good air 
flow via an HVAC system or by opening windows and doors during the 
visit. The best practices also provide guidance on implementing 
protocols for performing hand hygiene and cleaning and disinfection of 
the workspace, tools, equipment and other high touch surfaces. The best 
practices also recommend requirements for the use of facemasks, 
respirators, and other PPE for home health and hospice caregivers, 
patients, and members of the household during the home visit. 
Additionally, the best practices provide strategies for the 
implementation of patient telehealth, as well as self-screening before 
visits to prevent employee exposure to known or suspected COVID-19 
patients without taking appropriate precautions (e.g., PPE and 
respirators).
Examples of Existing Healthcare Employer Plans and Controls
    OSHA also reviewed a number of existing plans prepared by hospitals 
and other healthcare providers that also illustrate that employers in 
the healthcare sector have implemented a multilayered approach to 
protect their workers from COVID-19. MedStar Health, a not-for-profit 
community health system comprised of physician offices, urgent care 
centers, regional ambulatory care centers, and 10 community hospitals, 
has developed and implemented a COVID-19 plan (MedStar, May 5, 2021). 
The plan adopts a multilayered approach to protect workers from COVID-
19 across MedStar's facilities and contains many of the provisions also 
required by the ETS. For example, MedStar requires controls to ensure 
physical distancing, including, for example, restricting the entry of 
visitors and non-essential employees to reduce occupancy. Additionally, 
MedStar requires the use of facemasks by employees, patients, and 
visitors. MedStar also requires employees to self-screen and monitor 
for signs and symptoms of COVID-19 and for visitors to utilize the 
telephone triage system when scheduling visits to isolate known or 
suspected cases of COVID-19 infection. Finally, MedStar requires 
cleaning and disinfection of the workplace daily, as well as hand 
hygiene protocols before, during, and after all appointments and 
procedures.
    Other employer plans reviewed also adopt a multilayered approach to 
COVID-19 protection (see, e.g., Cambridge Health Alliance, 2021; Johns 
Hopkins Medicine, 2021; HCA Healthcare, 2021; Dignity Healthcare, 
2021). With respect to physical distancing, employer plans include 
strategies to reduce and restrict occupancy at facilities. For example, 
employers have implemented staggered shifts for employees, as well as 
teleworking arrangements, to help reduce occupancy and ensure physical 
distancing. Employers have also expanded remote telemedicine 
consultations so fewer patients with non-emergency conditions need to 
visit hospitals and other facilities where patient care occurs to 
receive medical care. In this respect, where video conferencing systems 
cannot be used, employers have used other virtual options, such as 
online secured patient portals with chat and messaging features, to 
reduce the occupancy of healthcare facilities. Employers have also 
implemented telephone triage systems, and, in this way, patients 
identified as low risk for COVID-19 can be cared for virtually, if 
appropriate, while patients identified as higher risk for COVID-19 can 
be routed to the appropriate care. In addition, employers have reduced 
or completely eliminated patient visiting hours for those patients with 
suspected or confirmed COVID-19. Finally, employers have installed 
floor markings as visual cues to stay six feet apart throughout the 
facility, including common areas such as waiting rooms and cafeterias, 
spaced public seating six

feet apart, and limited the number of people in a space, whenever 
possible.
    The employer plans cited above also include policies and procedures 
for the installation of physical barriers to protect workers outside of 
direct patient care areas when physical distancing may not be possible 
at all times. For example, some hospitals have installed physical 
barriers at checkpoints, to protect security guards, as well as at 
reception desks and patient/visitor information counters, to protect 
the employees working there, from exposure to visitors, patients, and 
co-workers.
    The employer plans reviewed also include policies and procedures 
for the use of facemasks. Moreover, the plans include policies on 
increased cleaning and disinfection. For example, the plans include 
requirements that surfaces and equipment are thoroughly cleaned and 
disinfected daily using products that are effective against COVID-19. 
The plans also include policies on maintaining HVAC systems and using 
system filters with a MERV rating of 13 or higher, as well as polices 
for pre-screening patients and employees for COVID-19 (including 
requirements for self-questionnaires designed to identify anyone who 
has or is suspected to have COVID-19 before their arrival at the 
facility).
    OSHA has determined that developing a COVID-19 plan, as required by 
the ETS, is feasible based on the evidence that employers in the health 
care sector have developed plans that address many of the requirements 
of the ETS. Additionally, national trade associations and other 
organizations in the health care sector have developed best practices 
to aid in the development of these plans (ERG, February 9, 2021). As 
discussed in the Summary and Explanation (section [VIII]), the plan 
must address the hazards identified per the hazard assessment required 
by paragraph (c)(4) of the ETS and the employer must do regular 
inspections to ensure ongoing effectiveness of the plan and update as 
needed.
b. Implementation of Good Infection Control Practices
    The ETS contains four provisions for good infection control 
practices, each of which is discussed in detail in Need for Specific 
Provisions and Summary and Explanation (Sections V and VIII of the 
preamble, respectively):
    Sec.  1910.502(d)--Patient screening and management. The purpose of 
this provision is to limit contact with potentially infectious persons 
by, for example, requiring screening and triage of everyone entering a 
healthcare setting and limiting and monitoring points of entry to the 
setting.
    Sec.  1910.502(e)--Standard and transmission-based precautions. The 
ETS requires that, in settings where healthcare services, healthcare 
support services, are provided, the employer must develop and implement 
policies and procedures to adhere to Standard and Transmission-Based 
Precautions. Standard and Transmission-Based Precautions are 
established and commonly used practices for reducing the risk of 
transmission of infectious agents such as COVID-19.
    Sec.  1910.502(f)--Personal protective equipment (PPE). The ETS 
requires employers to provide and ensure employees use facemasks or 
respirators in specified situations, and also requires the use of other 
PPE, such as gloves and eye protection, in appropriate circumstances.
    Sec.  1910.502(g)--Aerosol-generating procedures on a person with 
suspected or confirmed COVID-19. Because aerosol-generating procedures 
are known to be high risk activities for exposure to respiratory 
infections such as COVID-19, the ETS contains special requirements to 
address this hazard. For example, the employer must limit the number of 
employees present during the procedure to only those essential for 
patient care and procedure support.
    Some of these controls are obviously feasible simply because of the 
nature of the control. The process of screening, for example, can 
typically be accomplished simply through questioning, so there are no 
technological feasibility barriers to implementing those controls. To 
support its assessment of the technological feasibility of other 
controls in the ETS, OSHA reviewed evidence that shows that the 
healthcare-specific good infection control practices identified in 
Sec.  1910.502(d) through (g) are commonly implemented by employers who 
have employees in healthcare settings. This evidence includes: CDC 
infection control guidance documents, many of which are COVID-19 
specific; regulations issued by the Centers for Medicare & Medicaid 
Services (CMS); and accreditation of these settings by The Joint 
Commission; and OSHA's Bloodborne Pathogens (BBP) Standard, 29 CFR 
1910.1030. For example, Sec.  1910.502(e) requires compliance with the 
CDC's Standard and Transmission-Based Precautions. As detailed below, 
OSHA can show that this is technologically feasible by demonstrating 
that at least some hospitals and other healthcare settings follow these 
precautions (thereby showing it is capable of being done and can be 
implemented in other healthcare settings).
    To demonstrate that, OSHA points to two reasons why healthcare 
employers comply with these precautions. First, OSHA's BBP standard 
already requires hospitals and other healthcare facilities to implement 
a parallel framework, often with similar systems and controls, to 
comply with many of the same precautions. Even where the requirements 
for some controls must be implemented somewhat differently under this 
ETS than under the BBP standard, OSHA is not aware of technological 
feasibility challenges that arise from these differences. For example, 
a hospital's COVID-19 plan will be different from its BBP Exposure 
Plan, but the planning process will already be familiar to the hospital 
and there should be enough similarities in the construction of plans 
identifying and addressing hazards that there will not be any 
feasibility issues with formulating the COVID-19 plan.
    Second, healthcare employers must have an infection control program 
that includes Standard and Transmission-Based Precautions to be 
eligible for certain government funds (CMS distribution of Medicare and 
Medicaid funds) or accreditation (The Joint Commission). CMS 
regulations only cover providers that accept or collect payments from 
Medicare or Medicaid. Compliance with the CMS regulations is generally 
validated through periodic accreditation surveys of facilities by CMS-
approved accreditation organizations, including The Joint Commission, 
state survey agencies, and other accrediting organizations (e.g., 
Accreditation Association for Ambulatory Health Care (AAAHC)). CMS and 
The Joint Commission reliance on largely the same criteria as this ETS 
means that the technological feasibility of the ETS is supported by 
those hospitals and other healthcare settings who do have to comply by 
proving that the requirements are capable of being done.\28\
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    \28\ OSHA notes that its assessment in this section addresses 
only whether the ETS is technologically feasible. The fact that many 
health care facilities have already implemented some version of the 
controls required by the ETS does not mean that there is no need for 
the ETS to apply to healthcare. Again, CMS regulations only cover 
providers that accept or collect payments from Medicare or Medicaid. 
In addition, OSHA has in place enforcement mechanisms that CMS does 
not have and that would work in concert with CMS to achieve a 
greater level of compliance. For example, OSHA can respond to 
complaints, conduct random unannounced inspections, and conduct 
worksite inspections in response to complaints filed by workers. As 
described elsewhere in this preamble, the ETS is necessary to 
address the grave danger posed by COVID-19. See Rationale for the 
ETS, Grave Danger and Need for the ETS (Section IV of the preamble).

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CDC Infection Control Guidance Documents
    The CDC has issued infection control guidance, listed in Table 
VI.A.-3, that apply to the following settings and industry groups: 
Hospitals and ambulatory care, plasma and blood collection facilities 
and dialysis facilities, home health care, emergency responders and 
prehospital care, autopsies, long-term care, and dental and oral care. 
These guidelines provide infection-control recommendations for use in 
the settings covered by the ETS (listed in Table VI.A.-3). The guidance 
provides recommendations for implementing policies and practices to 
minimize the risk of exposure to respiratory pathogens, and many are 
recently issued guidelines specific to COVID-19.
BILLING CODE 4510-26-P
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BILLING CODE 4510-26-C
    The CDC guidelines in Table VI.A.-3 are commonly implemented, 
longstanding, and essential elements of infection control in healthcare 
settings (i.e., the settings listed in Table VI.A.-1), evidenced by the 
CDC's 2007 Guideline for Isolation Precautions: Preventing Transmission 
of Infectious Agents in Healthcare Settings (Item 8 in Table VI.A.-3, 
above), which incorporates Standard and Transmission-Based Precautions 
into its recommendations. This 2007 Guideline updated 1996 guidelines, 
which introduced the concept of Standard Precautions, and also noted 
the existence of infection control recommendations dating back to 1970.
    The implementation of the CDC guidelines is also evidenced by 
regulations issued by the Centers for Medicare & Medicaid Services 
(CMS) that apply to settings in Table VI.A.-1 and the accreditation of 
settings in Table VI.A.-1 by The Joint Commission, as described below.
    OSHA notes that guidelines that are grouped with one setting in 
Table VI.A.-1 may apply to other settings as well. For example, the 
Interim Infection Prevention and Control Recommendations for Healthcare 
Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic (Item 
1 in Table VI.A.-3) applies to Emergency Medical Personnel, Home Health 
Care, and Long-Term Care, in addition to applying to Hospitals and 
Ambulatory Care.\29\
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    \29\ The guidance is applicable to all U.S. settings where 
healthcare is delivered, and defines ``healthcare setting'' as 
places where healthcare is delivered. According to the guidance, 
this includes acute care facilities, long-term acute care 
facilities, inpatient rehabilitation facilities, nursing homes and 
assisted living facilities, home healthcare, vehicles where 
healthcare is delivered (e.g., mobile clinics), and outpatient 
facilities, such as dialysis centers, physician offices, and 
others.'' Moreover, the guidance defines ``healthcare personnel,'' 
or HCP, as all paid and unpaid persons serving in healthcare 
settings who have the potential for direct or indirect exposure to 
patients or infectious materials, including body substances (e.g., 
blood, tissue, and specific body fluids); contaminated medical 
supplies, devices, and equipment; contaminated environmental 
surfaces; or contaminated air. According to the guidance, HCP 
include emergency medical service personnel, nurses, nursing 
assistants, home healthcare personnel, physicians, technicians, 
therapists, phlebotomists, pharmacists, students and trainees, 
contractual staff not employed by the healthcare facility, and 
persons not directly involved in patient care, but who could be 
exposed to infectious agents that can be transmitted in the 
healthcare setting (e.g., clerical, dietary, environmental services, 
laundry, security, engineering and facilities management, 
administrative, billing, and volunteer personnel).

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CMS Regulations That Condition Participation in Medicare and Medicaid 
on Implementation of Nationally Recognized Infection Control Guidelines
    The Centers for Medicare & Medicaid Services (CMS) administers 
healthcare programs for the elderly (Medicare) and needs-based state 
programs that help with medical costs (Medicaid). As a condition for 
participation in Medicare or Medicaid, medical providers must comply 
with regulations issued by the Department of Health and Human Services 
(DHHS), 42 CFR Pts. 400-699. A number of these regulations, which apply 
to a broad spectrum of the settings listed in Table VI.A.-1, condition 
participation in Medicare and Medicaid on the implementation of 
nationally recognized infection control practices like the CDC 
guidelines listed in Table VI.A.-3. The applicable CMS regulations are 
summarized in Table VI.A.-4.
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BILLING CODE 4510-26-C
Accreditation by The Joint Commission
    Founded in 1951, The Joint Commission is an independent, not-for-
profit organization that accredits and certifies more than 22,000 
healthcare organizations and programs in the United States (The Joint 
Commission, 2021a). Joint Commission accreditation and certification is 
recognized nationwide as a symbol of quality that reflects an 
organization's commitment to meeting certain performance standards. 
Joint Commission standards are the basis of an objective evaluation 
process that can help healthcare organizations measure, assess and 
improve performance. The standards focus on important patient, 
individual, or resident care and organization functions that are 
essential to providing safe, high-quality care (The Joint Commission, 
2021b). To maintain accreditation, organizations undergo an on-site 
survey by a Joint Commission survey team at least every three years 
(laboratories are surveyed every two years). In these surveys, The 
Joint Commission monitors compliance with its standards for the 
implementation of good infection control and biosafety practices 
(including, for example, adherence to Standard and Transmission-Based 
Precautions, as recommended by the CDC Guidelines in Table VI.A.-3) 
(The Joint Commission, 2021c). The Joint Commission offers 
accreditation for the following settings (many of which are contained 
in Table VI.A.-1) (The Joint Commission, 2021c):
     Ambulatory care facilities;
     Critical access hospitals;
     Behavioral health care;
     Hospitals;
     Home care services;
     Nursing care centers; and
     Office-based surgery centers.
OSHA's Bloodborne Pathogens Standard, 29 CFR 1910.1030
    Employers subject to the ETS have also been subject to requirements 
in the Bloodborne Pathogens (BBP) standard for 30 years, since it was 
promulgated in 1991. As the BBP standard was promulgated, OSHA found 
``with

respect to the technological feasibility of the standard that its 
provisions permit practical means to reduce the risk now faced by those 
employees working with blood and other infectious materials and that 
there do not appear to be any major obstacles to implementing the 
rule.'' (56 FR 64004, 64039 (Dec. 6, 1991)). OSHA's finding of 
technological feasibility during the BBP standard rulemaking is 
additional evidence that there are no technological feasibility 
barriers to complying with the ETS.
    For example, Standard Precautions, which are required by the ETS, 
are similar to, but more extensive than, ``Universal Precautions'', 
which are required by the BBP standard to prevent contact with blood or 
other potentially infectious materials (see definitions in the BBP 
standard). The BBP standard defines ``Universal Precautions'' as an 
approach to infection control wherein all human blood and certain human 
body fluids are treated as if known to be infectious for HIV, HBV, and 
other bloodborne pathogens. Standard Precautions were developed to 
integrate principles of Universal Precautions into broader principles 
pertaining to routes of exposure other than the bloodborne route, such 
as via the contact, droplet, or airborne routes. For example, although 
the BBP standard might not apply, Standard Precautions would be 
utilized when workers are exposed to urine, feces, nasal secretions, 
sputum, vomit, and other body fluids, and also when workers are exposed 
to mucous membranes and non-intact skin. Using Standard Precautions 
when there is exposure to these materials, it should be assumed that 
the materials potentially contain infectious agents that could be 
transmitted via the contact, droplet, or airborne routes. Standard 
Precautions not only include the infection control methods specified as 
Universal Precautions (e.g., hand hygiene, the use of certain types of 
PPE based on anticipated exposure, safe injection practices, and safe 
management of contaminated equipment and other items in the patient 
environment), but also include, for example, respiratory and cough 
etiquette. The respiratory and cough etiquette and other additional 
controls for Standard Precautions are minor expansions on the Universal 
Precautions already applicable to most healthcare facilities, and OSHA 
is not aware of any technological barriers for employers subject to the 
ETS.
    In addition to the above requirements, the BBP standard contains 
requirements for an exposure control plan, engineering and work 
practice controls, hand hygiene, personal protective equipment, 
housekeeping (e.g., cleaning and decontamination), and vaccination, 
which all have corollaries in the ETS. While there are differences 
between the BBP standard and the ETS, there is overlap. For example, 
although the requirements for a COVID-19 plan in the ETS are different 
than those for the exposure control plan required by the BBP standard, 
the process for developing and implementing these plans should be 
similar. Based on this overlap, there should not be any technological 
feasibility barriers to complying with the corollary provisions in the 
ETS.
c. Physical Distancing and Physical Barriers
    Physical Distancing: The ETS (paragraph (h)) requires the employer 
to ensure that each employee is separated from all other people by at 
least 6 feet unless the employer can demonstrate that such physical 
distancing is not feasible for a specific activity, and that, when the 
employer establishes it is not feasible for an employee to maintain a 
distance of at least 6 feet from all other people, the employer must 
ensure that the employee is as far apart from all other people as 
feasible.
    Physical Barriers: The ETS (paragraph (i)) requires that at each 
fixed work location outside of direct patient care areas where an 
employee is not separated from all other people by at least 6 feet of 
distance, the employer must install cleanable or disposable solid 
barriers, except where the employer can demonstrate it is not feasible 
(or the paragraph (a)(4) exception for vaccinated employees applies).
    As discussed above, OSHA reviewed a number of plans and best 
practice documents developed and employed by the healthcare sector to 
reduce the risk of COVID-19 exposure. These plans included 
recommendations and requirements for the implementation of physical 
distancing and physical barriers in the settings covered by the ETS. 
These plans and best practice documents provide strong evidence that it 
is technologically feasible to implement these controls in the 
healthcare sector. Moreover, OSHA developed physical distancing 
scenarios and a job matrix spreadsheet, discussed below, which also 
provide strong evidence that the implementation of physical distancing 
and physical barriers is technologically feasible in the healthcare 
sector.
Physical Distancing Scenarios
    OSHA developed ``physical distancing'' scenarios for a variety of 
workplaces covering a wide range of situations to describe the controls 
that have been put in place to maintain not only physical distancing 
but also physical barriers at each fixed work location outside of 
direct patient care areas (e.g., entryway/lobby, check-in desks, 
triage, hospital pharmacy windows, bill payment), as well as other 
controls required by the ETS as part of a multilayered strategy to 
reduce or eliminate the transmission of SARS-CoV-2. As OSHA discusses 
in more depth below, these scenarios are based primarily on COVID-19 
plans developed by employers.
    OSHA uses these scenarios (and by extension the plans on which they 
are based) to support its feasibility determination regarding the 
physical distancing and physical barrier requirements of the ETS, and 
also to show that other controls required by the ETS are being, or can 
be implemented, by typical employers across affected workplaces.
    OSHA also uses these scenarios to explore ways to mitigate the 
remaining risk of exposure when it is infeasible to comply with the 
requirements for physical distancing. While this portion of the 
analysis falls outside the pure examination of the technological 
feasibility of the required controls, it is intended to demonstrate the 
steps that employers are expected to take to reduce exposure risk. Some 
of the plans that OSHA consulted in developing these scenarios include 
examples of controls that would not meet the requirements of the ETS, 
but OSHA has attempted to incorporate some of these examples into the 
scenarios while noting that some of the controls may only be used when 
the other controls are infeasible.
    Thus, for example, some scenarios describe the use of both physical 
distancing and physical barriers by employers. OSHA's description of 
the scenarios below should not be read to mean that OSHA sanctions the 
use of physical barriers in lieu of physical distancing, when physical 
distancing is feasible. For an in-depth discussion on the rationale 
underlying OSHA's rulemaking decisions, please see Need for Specific 
Provisions (Section V of the preamble).
    As another example, some scenarios describe facemasks, ventilation, 
and other controls required by the ETS as additional controls when 
physical distancing is not feasible. But these controls are not 
alternatives to physical distancing under the ETS. Again, physical 
distancing (or physical barriers at fixed workstations outside of 
direct patient care areas, when physical distancing is not feasible) 
must be

implemented alongside these controls under the ETS as part of a 
multilayered approach to infection control.
    Finally, OSHA emphasizes that physical distancing is feasible for 
the vast majority of situations employers may face in their daily job 
duties. There are a select number of situations where physical 
distancing is not feasible, and for these situations, employers must 
implement physical barriers if feasible at fixed work locations outside 
of direct patient care areas. And, again, employers must implement the 
other controls as required by the standard (e.g., facemasks, and 
respirators, cleaning and disinfection, health screening and medical 
management, employee notification).
    In reviewing the record, OSHA found that, while exposure to COVID-
19 can occur from contact with co-workers or the public as part of 
healthcare workers' job duties in a wide range of workplaces covered by 
the ETS, many of the processes and controls used to minimize risk are 
the same or similar.
    The physical distancing scenarios OSHA's contractor--a safety and 
health subject matter expert--developed include examples of policies 
and procedures implemented to maintain physical distancing, physical 
barriers, and other controls based on a review of guidance and existing 
pandemic plans and other sources. This information was supplemented 
where needed with additional internet searches, for instance, from news 
articles, industry surveys, or articles in industry publications that 
demonstrate how companies in different industries have been 
implementing physical distancing. The contractor also relied on its 
professional expert judgment (ERG, February 25, 2021). The scenarios 
identify groups of workers who face similar work situations with regard 
to physical proximity (within 6 feet) of another person (e.g., 
visitors, members of the public), and for whom the same or similar 
precautions to limit physical proximity can be implemented. In this 
respect, some of the evidence on which OSHA relies in this assessment 
(with respect to the offices, law enforcement, security guards, and 
protective services, home healthcare, personal care, and companion 
service providers, and postmortem services scenarios) rely on plans and 
best practices from both industries affected by this ETS and other 
industries not affected by the ETS. In analyzing the evidence of 
physical distancing and barriers across multiple industry sectors, OSHA 
observed that the feasible methods of implementing physical distancing 
and physical barriers for employees with similar exposures was similar 
regardless of industry (for example, employing physical distancing and 
barriers to protect administrative and clerical staff, receptionists, 
those who are exposed to human remains, and those who enter personal 
residences to provide care). To this end, OSHA's assessment of the 
feasibility of implementing physical distancing and physical barriers 
in the healthcare section is based on evidence from other industries to 
the extent that workers share similar job roles and perform similar job 
tasks such that the feasibility of distancing and barriers would be the 
same in either case.
    OSHA also developed a job matrix spreadsheet to identify groups of 
workers facing similar work situations. To develop this spreadsheet, 
OSHA first found and reviewed 418 plans from employers representing 
various separate 3-digit North Industry Classification System (NAICS) 
codes, and 286 best practice documents from trade associations and 
other organizations covering 46 3-digit NAICS codes (ERG, February 9, 
2021). As part of the review, OSHA included plans and best practices 
from industries outside of healthcare to clearly demonstrate the 
feasibility of implementing a multilayered approach to COVID-19 
infection control (including facemasks and the installation of physical 
barriers where distancing is not feasible) for similar work situations.
    Next, OSHA identified unique job categories across the industry 
sectors with many categories present across multiple NAICS codes. These 
job categories were cross-referenced with the scenarios to develop the 
job matrix spreadsheet (February 25, 2021). This job matrix spreadsheet 
was used to identify job categories facing similar situations regarding 
the ability to maintain physical distance with coworkers and/or members 
of the public. OSHA expects that, for these situations, employers can 
implement the same or similar precautions, for not only limiting 
physical proximity, but also for the other multilayered controls 
required by the ETS. Workers with public-facing job duties, such as 
receptionists and security guards, share many of the same or similar 
exposure control challenges, and employers of these job categories over 
a wide variety of industry sectors have implemented similar 
multilayered controls such as physical distancing, the installation of 
barriers, requirements for face masks, and hand hygiene, among others, 
as discussed below (February 25, 2021). OSHA concludes, based on the 
job matrix that evidence of feasibility for one scenario also 
establishes feasibility for other scenarios to the extent job 
categories cut across scenarios.
    The scenarios OSHA developed for the healthcare sector are listed 
in Table VI.A.-5.

[GRAPHIC] [TIFF OMITTED] TR21JN21.008

    Below, OSHA highlights some of the elements of these scenarios and 
portions of the job matrix on which it relied. In the discussion below, 
OSHA will first describe some of the types of jobs workers conduct in 
most workplaces in the scenarios discussed (or across scenarios to the 
extent this is supported by the job matrix), and identify some of the 
unique work processes that are already conducted in a physically 
distanced manner or that can be easily modified to avoid or reduce 
physical proximity for each scenario discussed (or, as applicable, 
across scenarios). OSHA then describes some of the discrete activities 
where physical contact with others (i.e., the public or other workers) 
may be necessary or unavoidable, along with the precautions and 
controls that can still feasibly be implemented for the scenarios (or, 
as applicable, across scenarios) as part of a multilayered approach to 
protection, such as facemasks, ventilation, and the use of physical 
barriers.
    In this respect, OSHA's analysis found employers have implemented 
physical barriers at fixed work locations outside of direct patient 
care areas (e.g., entryway/lobby, check-in desks, triage, hospital 
pharmacy windows, bill payment). Physical barriers are required as part 
of the multi-layered approach to infection control that is at the heart 
of the ETS. As discussed more fully in the Need for Specific Provisions 
(Section V of the preamble), physical barriers, when properly 
installed, are effective at intercepting respiratory droplets and 
minimizing the risk of exposure to COVID-19, especially in areas where 
employees cannot maintain a minimum of 6 feet of distance from 
coworkers, customers, and members of the general public.
    The ETS does not specify the type of material that must be used for 
physical barriers, but the material must be impermeable to infectious 
droplets that are transmitted when an infected individual is sneezing, 
coughing, breathing, talking, or yelling. In addition, physical 
barriers must be made from materials that can be easily cleaned and 
disinfected unless in lieu of cleaning the employer may opt to replace 
the barrier. Using replaceable materials would allow an employer to 
dispose of and replace barriers between uses, instead of cleaning and 
disinfecting more permanent barriers. The effective design and 
implementation of physical barriers will differ among workplaces based 
on job tasks, work processes, and even potential users. Physical 
barriers must be designed, constructed, and installed to prevent 
droplets from reaching employees when they are in their normal sitting 
or standing location relative to the workstation. For example, under 
the provision, plastic sheeting can qualify as a physical barrier only 
in situations where it is fixed in place and blocks face-to-face 
pathways of air between the users on either side while those workers 
are performing all of their assigned tasks.
    Examples of physical barriers across a variety of workplaces are 
discussed in the scenarios below. Further considerations for the design 
and implementation of physical barriers to properly block face-to-face 
pathways of breathing zones, including whether plastic sheeting, films, 
curtains, and other non-rigid materials are acceptable materials, as 
well as installation, are discussed in the summary and explanation of 
Physical Barriers.
    Employers subject to the ETS share a common challenge: Finding ways 
to limit physical proximity (of less than 6 feet) between each worker 
and other workers, as well as visitors and other non-employees in the 
workplace. In the limited situations where physical distancing is not 
feasible, employers often face similar challenges and employ similar 
solutions in designing and installing physical barriers to help protect 
their employees, even though the types of products or services they 
offer or the work they do vary. For example, employers often install 
physical barriers with a pass-through space at the bottom.
    A barrier is thus an effective tool in helping to protect a 
security guard at a check point at a hospital's entrance, a 
receptionist in the billing department, and any other public-facing 
employee. Physical barriers have also been installed to shield 
healthcare workers and others from individuals with suspected or 
confirmed COVID-19 (for example in triage areas of an emergency 
department). Employers have also installed barriers between urinals and 
sinks in restrooms both as separations between persons using the 
facility and as a splash guard (ERG, February 9, 2021; ERG, February 
25, 2021).
    As the assessment below makes clear, OSHA has found no feasibility 
issues with the implementation of physical distancing or physical 
barriers in typical operations in the healthcare sector.
General Office Settings
    General office settings are common across a number of industry 
sectors, and many healthcare facilities have areas

with administrative offices similar to general office settings. OSHA 
developed a physical distance scenario for offices by identifying 
industry sectors where office worksites are common. OSHA found that 
employers have successfully implemented a variety of physical 
distancing measures (measures to keep people 6 feet apart) by 
incorporating administrative and engineering controls for the various 
job categories that work in offices such as supervisors and managerial 
staff, administrative and clerical staff, and receptionists.
    Administrative and clerical workers are a common job category 
within office worksites across a wide variety of industries. In 
addition to the offices scenario, administrative and clerical workers 
were identified in a number of other physical distancing scenarios 
including: Law enforcement, security guards, and protective services; 
postmortem care; and long-term care (although OSHA believes 
administrative and clerical workers likely work within most scenarios, 
given that administrative and clerical work is usually necessary 
regardless of industry sector).
    A number of strategies for maintaining physical distancing as part 
of a multilayered approach have been implemented for administrative and 
clerical staff, including establishing remote work, altering the work 
environment to limit the number of chairs and workstations, relocating 
workers to locations that ensure proper physical distancing, and 
arranging visitor seating areas to be at least 6 feet away from 
employees' desks. Employers can also adopt telehealth services to 
completely isolate clerical and administrative staff from the patients, 
clients, and other people they might otherwise be interacting with in 
person. Meetings can be conducted virtually, or conference tables and 
chairs can be relocated to areas of the office where physical 
distancing can be ensured. Employers may also establish occupancy 
limits for certain rooms (e.g., bathrooms, breakrooms, elevators, 
lunchrooms, and changing areas), stagger breaks to limit the number of 
workers on break at the same time, and use signs and markings to 
communicate occupancy limits and to remind workers to keep 6 feet 
apart. Shared equipment, such as copiers or printers, can also be 
located more than 6 feet apart so that different employees can use that 
equipment at the same time without having to be close to each other.
    OSHA notes that many supervisors and managers (e.g., hospital 
administrators) have many of the same types of exposures as 
administrative and clerical staff. They commonly work in communal 
office areas, engage in collaborative group work, and hold office 
meetings in conference rooms. Moreover, as supervisors and managers, 
they implement the physical distancing strategies described above for 
the facilities where they work, and not just to apply to administrative 
and clerical staff.
    While receptionists are a common job category within office 
worksites, they are also employed in a variety of industry sectors. 
Receptionists are public-facing employees and their jobs include tasks 
which routinely put them in contact with the public, such as greeting 
and directing patients and families appropriately, responding to 
inquiries, coordinating with first responders or law enforcement, 
working with patients to process medical billing and paperwork, and 
maintaining security and telecommunications systems.
    OSHA identified a number of physical distancing strategies that 
have been commonly used to increase physical distancing for 
receptionists. When telework is not possible, employers have eliminated 
reception seating areas, closed lobbies, and required patients and 
visitors to phone or text ahead for entry into the workplace. In 
addition, signs and floor marks indicating 6-foot spaces where lines 
can form in reception areas have been found to help maintain physical 
distance between visitors and receptionists. When limiting access to 
reception areas is difficult, employers have reduced occupancy by only 
allowing seating at every other chair in waiting areas. Touchless or 
remote payment and scheduling options have been successfully used to 
limit face-to-face interactions with customer clients.
    As discussed above there are many options of potential controls to 
provide physical distancing for supervisors and managers, 
receptionists, administrative and clerical workers, and other office 
workers who work in office settings. However, there may be limited 
instances where employees might be unable to physically distance all of 
the time. As part of a multilayered approach to transmission control, 
physical barriers have been installed in office settings across all 
industry sectors. For example, workers in office settings (e.g., 
medical billing and financial service, transcription, and medical 
records departments) often spend the majority of the day at their desks 
or other fixed workstations. For these situations, employers have 
installed plexiglass barriers or partitions between workstations and 
between public-facing staff and patients, families, customers, clients, 
and other non-employees. At public facing workstations, physical 
barriers with small openings have been installed to enable the passing 
of paperwork and payment machines, for example. Under the ETS, when it 
is not feasible for employees to be properly distanced from each other, 
barriers must also be installed between the employees.
Law Enforcement, Security Guards, and Protective Services
    A physical distance scenario developed particularly for law 
enforcement, security guards, and protective services identified a 
number of industry sectors where job categories within the scenario are 
common. OSHA found that employers of security guards have successfully 
implemented a variety of physical distancing controls to maintain 6 
feet of physical distance from other people.
    Common physical distancing controls for security guards include 
staggering work shifts and limiting or ending in-person meetings. The 
use of walk-through metal detectors instead of hand-held wands and 
electronic mobile credentials to avoid the need for security officers 
to physically check individuals have also been implemented (if wands 
are used, the person being wanded should face away from the security 
guard). Electronic mobile credentials can also be centrally managed 
from a remote location, limiting the need for personnel to visit 
badging offices. Employers have utilized signs, floor markings, and 
ropes to mark a 6-foot distance around security guard stations to 
remind people who are standing in line to maintain appropriate distance 
from the security officer and other people in line.
    As part of a multilayered approach to transmission control, 
employers have also installed physical barriers to protect these 
workers when they are at fixed workstations. Across healthcare 
workplaces, employees working in security checkpoints are commonly 
unable to maintain physical distance from non-employees who need to be 
checked-in or are waiting in line (for example, during identification 
screenings at hospital entrances). In such circumstances, the 
installation of barriers helps protect security personnel interacting 
with the public.
Emergency Medical Services
    OSHA developed a physical distancing scenario for Emergency Medical 
Service (EMS) organizations. EMS workers cover a number of job 
categories including emergency medical

technicians (EMTs), paramedics, and cross-trained firefighters serving 
in the capacity of paramedics or EMTs.
    OSHA identified a number of common physical distancing controls 
implemented by EMS providers, which limit the number of onsite workers 
within physical proximity of patients and others, and also limit crowd 
size during emergency response. First, to limit the number of EMS 
workers that respond to a call to those absolutely necessary, EMS 
employers have implemented polices to coordinate with the emergency 
response operator (e.g., the 911 operator/dispatcher) on how many EMS 
responders are needed. Also, employers have implemented policies to 
ensure that the emergency response operator coordinates with law 
enforcement to disburse or move unnecessary people before the ambulance 
arrives. Additionally, employers have instituted work practices where 
one EMS worker conducts the initial patient evaluation and performs 
medical treatment, remaining in radio communication with the other EMS 
worker, who will enter to assist only if necessary. EMS employers have 
also instituted policies to limit the number of workers in the 
ambulance to those who are medically necessary and to encourage family 
members to follow the ambulance in their own vehicle rather than riding 

in the ambulance.
    EMS workers cannot always avoid proximity to coworkers or patients 
during some operations including, for example, engaging in emergency 
medical care, transporting patients in ambulances, and transferring 
patients to healthcare facilities. When EMS workers respond to an 
emergency, they are involved in evaluating and treating the patient 
onsite before transporting the patient as necessary. EMS workers may 
need to work as a team in order to perform some tasks (e.g., while 
performing cardiopulmonary resuscitation (CPR) and using a bag valve 
mask also known as an Ambu bag). In addition, arriving EMS workers 
could be within 6 feet of people at the site, including family members 
and the general public who may have gathered.
    Employers of emergency medical services (EMS) workers have 
installed physical barriers to protect their workers in at least some 
of these situations. For example, physical barriers are often installed 
between the workstations of emergency response operators, who assist in 
coordinating the response to emergency situations (e.g., for the EMS 
system or the public health system, and in 911 call centers or 
healthcare facilities). Employers have also installed physical barriers 
between the treatment compartment of ambulances and the driver's 
compartment to protect drivers and other workers who need not be 
exposed to patients.
    OSHA also identified a number of strategies that have been used by 
EMS providers as part of a multilayered approach to infection control. 
Employers have implemented policies for requiring employees to wear 
appropriate respiratory protection and other PPE, placing a face 
covering or facemask on the patient when possible, and requiring family 
members to wear face coverings or leave the area while EMS workers 
respond to emergencies in patient homes. In addition, employers have 
instituted protocols for moving a patient with confirmed or suspected 
COVID-19 outside or in a more ventilated area for treatment where 
medically possible (note that the ETS requires healthcare workers to 
wear respirators when treating a patient who is confirmed or suspected 
to have COVID-19 as well as when they are exposed to aerosol-generating 
procedures conducted on a patient who is confirmed or suspected to have 
COVID-19).
    In some situations, EMS workers might need to ride in the cab 
within 6 feet of each other as well as the patient being transported. 
In these situations, overlapping controls, such as requiring all EMS 
workers in the patient compartment to wear appropriate PPE and to wash 
their hands or use an alcohol-based hand sanitizer that contains at 
least 60% alcohol, have been implemented. Moreover, as stated, where 
feasible, physical barriers can be constructed to isolate the driver's 
cab from the rear patient care area. In addition, patients riding in 
the rear compartment can wear a face covering and face shield, when 
possible, or at least a face shield when a face covering is not 
possible. Employers have also established procedures to open outside 
air vents in the cab and turn on the rear exhaust ventilation fans to 
the highest setting to create a pressure gradient toward the patient 
area.
    It is also common that EMS operations must quickly return an 
ambulance to service after responding to an emergency involving, or 
transporting patients who are, COVID-19 positive. In such 
circumstances, multiple EMS workers must often concurrently participate 
in cleaning and disinfection of the patient area in the ambulance. In 
these situations, employers have used outdoor cleaning areas or indoor 
exhaust ventilation, in addition to following widely-established 
polices requiring PPE and face coverings.
Long-Term Care
    Long-term care employers operate nursing homes, retirement 
communities, assisted living facilities, and intermediate and 
continuing care facilities. There are a wide range of job titles for 
workers in this industry including healthcare providers (e.g., 

physicians, nurses, nurses' assistants, orderlies, physical, 
occupational, and speech therapists, personal care aides, and 
psychiatric aides), as well as support staff (e.g., facility 
administration, reception, engineering and maintenance, housekeeping, 
laundry, food service, transportation, pharmacy, and security).
    OSHA identified a number of physical distancing strategies that 
have been implemented in various areas of long-term care facilities 
such as reception areas, waiting rooms, dining rooms, and common areas. 
These strategies include: Restricting the number of visitors; limiting 
access to the residential area to essential workers (i.e., maintenance 
workers performing non-critical tasks and staff performing billing 
services would not be granted access); increasing the number of meal 
services; limiting the number of residents in the dining area at one 
time; and providing room service.
    Although physical distancing can be feasibly maintained most of the 
time, there are some situations where workers in long-term care 
facilities cannot always avoid physical proximity with residents, 
visitors, or co-workers. Long-term care employers have installed 
physical barriers to protect employees in many of these situations. For 
example, resident care and front desk staff may need to be within 6 
feet of visitors during visitor check-in or when providing information 
or assistance, and administrative staff may have a central counter for 
information and resources for residents. In these situations, employers 
have installed physical barriers between workstations and visitor or 
resident areas. Food servers and aides may need to be within 6 feet of 
a resident when serving food, servicing or clearing buffet food lines, 
and when providing assistance. In these situations as well, employers 
have installed physical barriers between employees and residents.
    Healthcare providers may also need to provide care or therapy in 
resident rooms or other care/therapy areas. As part of a multilayered 
approach to infection control, some employers have required workers 
caring for residents to wear a gown, safety glasses, gloves, and either 
a surgical mask or N95 respirator (depending on whether the worker is

providing care to residents with suspected or confirmed COVID-19, for 
example). Also, in accordance with American Health Care Association/
National Center for Assisted Living (AHCA/NCAL) recommendations, 
employers have, to the extent possible, reduced the frequency of 
routine procedures, such as taking vital signs and weights, and have 
also required residents to wear a face covering when staff enter their 
rooms or when receiving care/therapy from a healthcare provider, unless 
they are medically unable to do so. Many employers have also 
implemented cohorting procedures for staff and patients (i.e., 
assigning staff to specific residents and only those residents) while 
minimizing staff working across units (AHCA and NCAL, April 21, 2020).
Home Healthcare, Personal Care, and Companion Service Providers
    OSHA developed a physical distancing scenario for organizations 
that visit private residences to provide healthcare services and health 
care support services. Employers in this industry use a wide range of 
job titles for their workers including professional home healthcare 
practitioners (e.g., physicians, nurses, medical technicians); personal 
care providers (e.g. self-care aides); and other workers who offer 
companion services for disabled persons, the elderly, and persons 
diagnosed with intellectual and developmental disabilities.
    To help ensure physical distancing, employers in this industry have 
switched to virtual services when possible by determining whether some 
clients' needs can be met through telehealth or with online technology, 
such as video conferencing. Many physical distancing strategies have 
also been implemented by employers of this sector when services must be 
conducted at a patient's private residence. These include implementing 
protocols for workers to maintain 6 feet of distance from clients and 
other household members, and for workers providing service in teams to 
maintain 6 feet of distance from each other, as much as possible while 
they perform their work. Employers have also implemented procedures to 
instruct all people within the household (other than the direct client 
receiving services) to go to another room, or at a minimum, maintain at 
least 6 feet of distance from workers.
    Workers performing in-home healthcare or personal care services 
cannot always feasibly maintain 6 feet of physical distance from their 
clients or co-workers. In these situations, companies have successfully 
implemented a multi-layered suite of controls such as requiring all 
workers to wear facemasks, respiratory protection, or other PPE, and 
requiring patients and members of households to self-screen for COVID-
19 before the visit. Also employers have required all workers to wash 
their hands or use an alcohol-based hand sanitizer that contains at 
least 60% alcohol before and after each visit, and have implemented 
administrative controls such as assigning workers to ``bubbles'' or 
cohorts to reduce the number of other individuals with whom a worker 
comes in physical proximity. Finally, employers have taken steps to 
ensure that private residences have adequate airflow by way of either 
an HVAC system or open windows and doors.
Postmortem Services
    OSHA developed a physical distancing scenario to address the 
conduct of autopsies. Jobs involved in conducting medical autopsies 
generally fall within the following categories; medical examiners, 
forensic pathologists, and autopsy technicians who examine bodies 
postmortem; and administrative and clerical staff who may be essential 
for support purposes.
    The postmortem care industry has implemented a variety of physical 
distancing controls to prevent physical proximity (within 6 feet) of 
other people when performing autopsies. Physical distancing controls 
for these situations are meant to keep professional healthcare 
practitioners and, in some cases guests (e.g., law enforcement, family 
members of the deceased), at least 6 feet apart. These strategies 
include posting reminders of the need to maintain at least 6 feet of 
physical distance from other persons, where possible, training workers 
on proper physical distancing relative to other workers and guests, and 
establishing work schedules (e.g., alternating days, extra shifts) that 
reduce the total number of workers in a facility at any given time. In 
addition, many employers require workers to limit the number of staff 
in the prep/exam room at any given time to the minimum number 
necessary.
    In workplaces where autopsies are performed, physical proximity 
cannot always be avoided. In these situations, facilities have 
successfully implemented a multi-layered suite of controls, such as 
wearing appropriate PPE, to protect workers from other people (e.g., 
guests or other staff) during postmortem medical examination, for 
example. Physical barriers have also been installed in other areas 
where physical distancing may be difficult to maintain including, at 
reception counters, in restrooms, in consultation rooms, and in 
offices, for example.
Summary of Feasibility Challenges for Distancing and Physical Barriers
    While OSHA strongly emphasizes the use of physical distancing and 
physical barriers, it recognizes that there are a few situations where 
employers have found that it is not feasible to implement either or 
both. Physical distancing and physical barriers may not be feasible 
during direct patient care, including the conduct of Emergency Medical 
Services (EMS) while treating a patient in the back of an ambulance, 
for example. Physical barriers may also be infeasible where they 
obstruct an emergency egress path or interfere with a facility's fire 
safety systems (e.g., fire alarm notification devices, fire sprinklers, 
fire pull stations).
    OSHA emphasizes a multilayered approach for employers to protect 
their workers: Physical distancing and, if necessary, physical barriers 
at fixed work locations outside of direct patient care areas must be 
used in conjunction with other controls, such as facemasks, hand 
hygiene, and ventilation, and not as the sole means of control. When 
confronting the rare situations where both physical distancing and 
physical barriers are not feasible, employers can still implement the 
remaining layers of overlapping controls, including facemasks, hand 
hygiene, and ventilation, required by the standard to reduce the risk 
of COVID-19 transmission.
    Based on the evidence that physical distancing and physical 
barriers are already being implemented across a broad range of 
healthcare settings, OSHA concludes that it is feasible to implement 
the ETS's requirements for physical distancing and for physical 
barriers at fixed work locations outside of direct patient care areas 
(e.g., entryway/lobby, check-in desks, triage, hospital pharmacy 
windows, bill payment). In the few cases where physical distancing and 
physical barriers are both not feasible, work can be conducted to 
maintain as much distance as possible, and the additional controls such 
as facemasks, ventilation, and hygiene required by the ETS will still 
provide some measure of protection.
d. Ventilation
    Ventilation systems are another necessary part of a multilayered 
strategy to control transmission of COVID-19 (CDC, March 23, 2021). As 
will be discussed in more detail below, the

ability of heating, ventilation, and air conditioning (HVAC) systems to 
reduce the risk of exposure depends on many factors, including design 
features, operation and maintenance practices, and the quality and 
quantity of outdoor air supplied to the space. Paragraph (k) of the ETS 
require employers who own or control buildings or structures with 
existing heating, ventilation, and air conditioning (HVAC) systems to 
ensure that: (1) Each HVAC system is used in accordance with the HVAC 
manufacturer's instructions and its design-specifications; (2) the 
amount of outside air circulated through its HVAC system and the number 
of air changes per hour (ACHs) are maximized to the extent appropriate; 
(3) all air filters are rated Minimum Efficiency Reporting Value (MERV) 
13 or higher, if compatible with the HVAC system (or, alternatively, 
rated at the highest compatible filtering efficiency); (4) all air 
filters are maintained and replaced as necessary; and (5) all outside 
air intake ports are clean, maintained, and cleared of any debris that 
may affect the function and performance of the HVAC system. Moreover, 
where an employer has an existing airborne infection isolation room 
(AIIR), the employer must maintain and operate it in accordance with 
its design and construction criteria.
    In the remainder of this section, OSHA discusses how employers can 
comply with these requirements and then draws its conclusion on 
technological feasibility.
Using HVAC Systems in Accordance With Manufacturer's Instructions and 
Design Specifications
    To meet the ETS's requirements, employers must verify that the 
system is functioning as designed. Because each building and its 
existing HVAC systems will be different, the employer might need to 
consult a professional engineer or HVAC specialist to determine the 
best way to maximize the system's ventilation and air filtration 
capabilities for each specific room in the building and thereby ensure 
the system is operating according to design specifications.
    The American Society of Heating, Refrigeration and Air Conditioning 
Engineers (ASHRAE) Standard 180-2018 Standard Practice for Inspection 
and Maintenance of Commercial Building HVAC Systems provides guidance 
on preventive maintenance for HVAC systems, including checklists that 
employers can use to verify the system is operating as designed 
(ASHRAE, June 11, 2018). Additional guidance can be found in CDC's 
Guidance for Businesses and Employers Responding to Coronavirus Disease 
2019 (COVID-19) (CDC, March 8, 2021), and the ASHRAE Guidance for Re-
Opening Buildings (ASHRAE, October 5, 2020).
    Healthcare settings have additional HVAC design parameters for 
meeting specifications for directional airflow and relative pressure 
differentials. For example, according to ASHRAE's Standard 170 
Ventilation of Health Care Facilities, ventilation systems that provide 
air movement from clean areas (e.g., nursing stations) to potentially 
contaminated areas (e.g., patient airborne infection isolation rooms) 
are recommended for preventing airborne transmission. Thus, the air 
pressure of the room or space would be maintained at a negative 
pressure relative to the hallways and surrounding spaces. This means 
that when the door is opened, potentially contaminated air or other 
dangerous particles from inside the room will not flow outside into 
non-contaminated areas. (ASHRAE, 2017). Normally functioning existing 
isolation rooms should already be able to serve this function because 
Joint Commission accreditation and Centers for Medicare & Medicaid 
Services (CMS) regulations have requirements for negative pressure 
airborne infection isolation rooms design.
Using AIIRS in Accordance With Design and Construction Criteria
    AIIRs are designed to prevent the transmission of airborne 
transmissible agents to areas outside a patient's room. These rooms 
have a high air exchange rate and are under negative air pressure, 
meaning that the room air has a slight negative pressure compared to 
the surrounding rooms. The high air exchange rate (at least 12 air 
changes per hour (ACH) for new construction or renovation, 6 ACH 
otherwise) helps change the room air frequently and reduces (but does 
not eliminate) buildup of airborne disease agents, such as the virus 
that causes COVID-19. The negative air pressure differential (0.01 inch 
of water [2.5 Pa]) helps reduce the chance that the remaining airborne 
virus will exit the room door and contaminate air in adjacent hallways. 
An anteroom is a beneficial room feature that helps further isolate the 
AIIR from the adjacent hallway. When the AIIR has an anteroom, the 
AIIR's air pressure should be negative to the anteroom, while the 
anteroom air pressure should be negative to the adjacent hallway. This 
arrangement means air from the hallway will flow into the anteroom each 
time the door is opened, and air from the anteroom will flow into the 
AIIR--minimizing the amount of airborne disease agents (virus) that 
exits the room. ASHRAE Standard 170, Ventilation of Health Care 
Facilities offers detailed guidance for designing and operating AIIRs 
(ASHRAE, 2017).
Maximizing Outside Air Circulated Through HVAC System(s) and the Number 
of Air Changes per Hour (ACHs) to the Extent Appropriate
    Building HVAC systems are designed to draw in a certain amount of 
outdoor air into the building to maintain indoor air quality. By 
introducing fresh air into the building, HVAC systems can prevent the 
buildup of airborne contaminants through dilution.
    The introduction of outdoor air into the building can also help 
limit the potential for the virus that causes COVID-19 to accumulate in 
the building. The more outdoor air the HVAC system is capable of 
drawing into the building, the greater the impact may be on limiting 
the potential for the virus to accumulate. Maximizing the amount of 
outdoor air introduced to the system can be achieved by fully opening 
the building's outdoor air intake dampers; however, this may introduce 
other indoor air quality or comfort concerns resulting from humidity, 
temperature extremes, or outdoor pollution. Employers should work with 
building managers or HVAC professionals to adjust the HVAC system to 
bring in as much outdoor air as possible, while taking into 
consideration outdoor pollution levels and ensuring that the HVAC 
system is capable of maintaining building temperature and humidity 

levels within acceptable occupant comfort ranges. OSHA notes that it 
does not expect employers to reconfigure duct work to comply with this 
provision. When maximizing the outside air, employers should take into 
account not to draw in air from potential pollution sources such as 
smoking areas, loading docks, vehicle traffic areas, or active 
construction zones, or air being re-entrained from the building exhaust 
itself.

    Balancing refers to the process of measuring the air flow through 
the supply ducts and adjusting the dampers to provide an even 
distribution of air through the HVAC system duct work and supply vents. 
According to ASHRAE Standard 111 Measurement, Testing, Adjusting, and 
Balancing of Building HVAC Systems, testing and balancing an HVAC 
system provides the means to determine and monitor system performance. 
Proper balancing ensures that outdoor air brought into the building 
will be evenly supplied to all areas of the building and limit the 
potential for ventilation dead zones or stagnant air to accumulate 
(ASHRAE, October 31, 2017).
    In addition to considering the factors discussed above with respect 
to maximizing outside air, employers must also consider how to maximize 
ACHs. ACHs are a measure of the air volume that is added to or removed 
from a space in one hour divided by the volume of the space. The more 
frequently the air within that space is replaced per hour, or the more 
ACHs, the more the overall potential concentration of COVID-19 in the 
work environment will be reduced. Building owner/operators or employers 
can seek assistance from HVAC professionals on maximizing ACHs based on 
the workspace and the design capabilities of the HVAC system(s) 
(ASHRAE, 2017).
Using Air Filters Rated MERV 13 or Higher, if Compatible With the HVAC 
System(s), or, Alternatively, to the Highest Compatible Filtering 
Efficiency
    Building HVAC systems are equipped with air filters that remove 
particles from recirculated air streams before returning the air to 
occupied spaces. Air filters are available in a variety of materials 
such as pleated paper, cloth, woven fiberglass, and polyester. A 
filter's efficiency is measured by the fraction of particles the filter 
is able to remove from the air stream. The higher the filter's 
efficiency the better it is at removing particles from the air. There 
are several systems for rating filter efficiencies. The most common is 
the MERV rating system, which was developed by ASHRAE.
    Many existing HVAC systems are designed and installed to operate 
with filters ranging from MERV 6 to MERV 8. MERV 8 filters are only 
about 20 percent efficient in removing particles in the 1 [micro]m to 3 
[micro]m size range (the size range of concern for aerosol droplets 
containing the virus that causes COVID-19). Employers and building 
managers can improve this efficiency by upgrading to MERV 13 or higher 
filters, to the extent those filters are currently compatible with 
system components (e.g., filter housing slot type, size, and shape). 
MERV 13 filters are at least 85 percent efficient at capturing 
particles in the 1 [micro]m to 3 [micro]m size range. Increasing filter 
efficiency, however, can increase pressure drop across the filters 
leading to increased fan energy use, reduced airflow rates, and or/
issues controlling indoor temperature and humidity levels. As a result, 
employers and building owners may need to consult an HVAC professional 
to optimize filter efficiency consistent with their HVAC system's 
capabilities.
Maintaining and Replacing All Air Filters as Necessary
    The required frequency for changing filters will vary depending on 
the characteristics of the HVAC system, and therefore the ETS does not 
specify a frequency for filter changing.
Ensuring All Outside Air Intake Ports Are Clean, Maintained, and 
Cleared of Any Debris That May Affect the Function and Performance of 
the HVAC System(s)
    To comply with this provision, a visual inspection of the outside 
air intakes, which can be accomplished as part of a routine maintenance 
program, is required.
Additional Ventilation Measures
    A note to the ETS's ventilation requirements provides that, in 
addition to the requirements for existing HVAC systems and AIIRs, all 
employers should also consider other measures to improve ventilation in 
accordance with CDC guidance. Below are some additional measures that 
an employer should consider to increase total airflow supply to 
occupied spaces:
     Disabling demand-control ventilation (DCV) controls that 
reduce air-supply based on temperature or occupancy;
     Using natural ventilation (i.e., opening windows if 
possible and safe to do so) to increase outdoor air dilution of indoor 
air when environmental conditions and building requirements allow;
     Running the HVAC system at maximum outside airflow for 2 
hours before and after occupied times;
     Generating clean-to-less-clean air movements, re-
evaluating the positioning of supply and exhaust air diffusers and/or 
dampers, and adjusting zone supply and exhaust flow rates to establish 
measurable pressure differentials;
     Requiring that staff work in ``clean'' ventilation zones 
and not in higher-risk areas (e.g., visitor reception) to the extent 
feasible;
     Using portable high-efficiency particulate air (HEPA) fan/
filtration systems to help enhance air cleaning especially in higher-
risk areas; and
     Ensuring exhaust fans in restroom facilities are 
functional and operating at full capacity when the building is 
occupied.
    The terms of the ETS make clear that there are no technological 
hurdles to compliance with its ventilation requirements. First, the 
ventilation requirements apply only to existing systems. A note in the 
ETS emphasizes that the requirements do not require installation of new 
HVAC systems or AIIRS, or upgrades of existing systems to replace or 
augment functioning systems. Therefore, the ventilation requirements do 
not raise the questions of feasibility typically associated with 
employers needing to install new engineering controls to come into 
compliance with a new standard.
    Second, the HVAC requirements apply only to employers who own or 
control buildings or structures. Thus, for example, the requirements do 
not apply to employers who lease space and do not control the building 
or structure, and the ETS does not raise questions as to how these 
employers would comply with the ventilation requirements.
    Third, employers covered by the general section are required only 
to ensure that HVAC systems operate with a sufficient filter (MERV-13 
where possible) in accordance with manufacturer's instructions and 
design specifications, and only in a manner that is appropriate for the 
system using methods that are compatible with the system, and that 
AIIRs are maintained and operated in accordance with their design and 
construction criteria. As such employers are not required by the ETS to 
modify their HVAC systems or AIIRs in any manner, only to ensure that 
they are operating as designed, which negates questions as to how the 
employer would make modifications.
    Fourth, a number of the plans, best practice documents, and 
scenarios discussed above reference HVAC systems and ventilation. The 
use of HVAC systems to manage building air filtration and circulation 
of fresh air as part of overlapping controls to address the COVID-19 
hazard illustrate that there is no technological feasibility barrier to 
compliance with the ETS's ventilation requirements in typical firms in 
all affected industries. The ETS's filter requirements are inherently 
technologically feasible because they only require the installation of 
the

maximum filter that is compatible with the applicable HVAC system.
    The design and complexity of HVAC systems can vary widely depending 
on a range of factors including the use, size, and age of the building, 
and, as discussed, deciding on the maximum appropriate amount of 
outside air to circulate through the HVAC system(s) and number of ACHs 
can be a complex task. However, larger buildings have dedicated 
facilities management staff who are responsible for regular ventilation 
system maintenance and adjustment and will have the prerequisite 
experience to evaluate the capabilities of the HVAC system, while in 
other cases, employers may need to consult with an HVAC professional to 
ensure that facilities HVAC is functioning in accordance with the HVAC 
manufacturer's instructions and the design specifications of the HVAC 
system(s). Based on these factors, OSHA concludes that there are no 
technological barriers to compliance with the ETS's ventilation 
requirements.
e. Other Provisions
    There are no technological feasibility barriers related to 
compliance with other requirements in the ETS (e.g., facemasks, and 
respirators, cleaning and disinfection, health screening and medical 
management, employee notification). Indeed, as explained above, many of 
the plans, best practice documents, and scenarios reviewed by OSHA 
indicate that these controls have been implemented by employers across 
industry sectors as part of a multilayered approach to protecting 
workers from the COVID-19 hazard. OSHA highlights a few of the ETS's 
other requirements below, but only to point out administrative issues 
that will be explored in more depth in other sections of the preamble.
     Facemasks. The ETS requires employers to provide, and 
ensure that employees wear, facemasks that are FDA-cleared, authorized 
by an FDA EUA, or offered or distributed as described in an FDA 
enforcement policy. Facemasks that meet these requirements are 
currently widely available.
     There may be situations where wearing a facemask presents 
a hazard to an employee of serious injury or death (e.g., arc flash, 
heat stress, interfering with the safe operation of equipment). The 
relevant section of the Summary and Explanation provides further 
discussion on this topic.
     Respirators. As noted in Need for Specific Provisions and 
Summary and Explanation (Sections V and VIII of the preamble, 
respectively), the increased need for respirators by healthcare workers 
during the pandemic has resulted in shortages of N95 filtering 
facepiece respirators (FFRs). The ETS addresses these shortages by 
encouraging employers to use not only N95 FFRs, but also other 
respirators such as elastomeric respirators and powered air-purifying 
respirators (PAPRs), where feasible. For further details, see paragraph 
(f) of the ETS, as well as relevant sections of Need for Specific 
Provisions and Summary and Explanation.
     Notification. Paragraphs (l)(2) and (l)(3) of the ETS 
contain COVID-19-connected notification requirements for both the 
employer and the employee. OSHA identifies no technological feasibility 
issues in connection with the ETS's notification requirements. It is 
the employer's responsibility to ensure that appropriate instructions 
and procedures are in place so that designated representatives of the 
employer (e.g., managers, supervisors) and employees conform to the 
rule's requirements.
    There are also no technological barriers to compliance with the 
mini respiratory protection program section of the ETS. That section 
requires employers, many of whom have never developed or implemented a 
respiratory protection program under the Respiratory Protection 
standard, 29 CFR 1910.134, to develop and implement one if their 
employees wear respirators. However, the mini respiratory protection 
program section will require a program that is far less extensive, and 
thus easier to comply with, than what is required under 29 CFR 
1910.134. For example, the mini respiratory protection program section 
will not require quantitative fit testing or medical evaluations 
regarding employees' ability to use respirators, both of which are 
required under 29 CFR 1910.134. Therefore, OSHA concludes that 
compliance with the mini respiratory protection program section does 
not raise issues of technological feasibility. OSHA discusses the 
administrative cost of complying with the mini respiratory protection 
program section in its economic feasibility analysis.
II. Conclusions
    OSHA has reviewed the requirements imposed by the ETS and has 
determined that achieving compliance with the rule is technologically 
feasible for typical operations in the settings that are covered by the 
ETS. In reaching this determination, OSHA reviewed evidence that shows 
that healthcare-specific good infection control practices are routinely 
implemented by employers who have employees in covered settings. This 
evidence includes: Readily available CDC infection control guidance 
documents, many of which are COVID-19 specific; regulations issued by 
the Centers for Medicare & Medicaid Services (CMS), compliance with 
which is typically required for accreditation of these settings by The 
Joint Commission; and the application of similar requirements in OSHA's 
Bloodborne Pathogens Standard, 29 CFR 1910.1030.
    OSHA's assessment also analyzed the technological feasibility of 
complying with the requirements of the ETS for developing a COVID-19 
Plan: Maintaining physical distancing; installing physical barriers; 
and ensuring existing ventilation systems are operating as designed. As 
noted, the ETS requires employers to develop and implement a COVID-19 
plan through a multilayered approach to addressing the spread of COVID-
19 by taking feasible measures to reduce or eliminate the transmission 
of COVID-19. This includes requirements for employers to implement 
procedures to ensure employees maintain at least 6 feet of physical 
distancing from others to the extent feasible and, when distancing is 
not feasible, to install physical barriers, again to the extent 
feasible. It also allows flexibility in the material of barriers.
    OSHA recognizes that sometimes it may not be feasible to implement 
either physical distancing or physical barriers for particular work 
activities, but even if this is the case, employers must still protect 
their employees through the other provisions of the flexible 
multilayered approach required by the ETS. The regulatory text allows 
for alternatives in some situations, and OSHA has identified a variety 
of alternatives that it believes would be technologically feasible in 
those situations most of the time. As explained, there are no 
technological feasibility barriers related to compliance with 
requirements in the ETS for facemasks and respirators, cleaning and 
disinfection, health screening and medical management, or employee 
notification. Based on the combination of OSHA's evaluation of 
technological feasibility of controls in the various scenarios 
examined, OSHA finds that the ETS is technologically feasible.
References
Akhtar, J et al., (2020, December 22). Can face masks offer 
protection from airborne sneeze and cough droplets in close-up, 
face-to-face human interactions?--A quantitative study. American 
Institute of Physics 32: 127112. https://

aip.scitation.org/doi/10.1063/5.0035072. (Akhtar et al., December 
22, 2020).
American Health Care Association (AHCA) and National Center for 
Assisted Living (NCAL). (2020, April 21). Steps to Limit COVID-19 
Spread and Outbreaks in Long Term Care. https://www.ahcancal.org/Survey-Regulatory-Legal/Emergency-Preparedness/Documents/COVID19/When-COVID-Gets-In.pdf. (AHCA and NCAL, April 21, 2020).
American Society for Health Care Engineering (ASHE). (2020, December 
23). COVID-19 Resources for Health Care Facilities. https://www.ashe.org/COVID19resources. (ASHE, December 23, 2020).
American Society of Heating, Refrigerating and Air-Conditioning 
Engineers (ASHRAE). (2017). ASHRAE Standard 170 Ventilation of 
Health Care Facilities. (ASHRAE, 2017).
American Society of Heating, Refrigerating and Air-Conditioning 
Engineers (ASHRAE). (2017, October 31). Standard 111 Measurement, 
Testing, Adjusting, and Balancing of Building HVAC Systems. (ASHRAE, 
October 31, 2017).
American Society of Heating, Refrigerating and Air-Conditioning 
Engineers (ASHRAE). (2018, June 11). Standard 180-2018 Standard 
Practice for Inspection and Maintenance of Commercial Building HVAC 
Systems. ANSI/ASHRAE/ACCA Standard 180-2018. (ASHRAE, June 11, 
2018).
American Society of Heating, Refrigerating and Air-Conditioning 
Engineers (ASHRAE). (2020, October 5). Guidance for Re-Opening 
Buildings. https://www.ashrae.org/technical-resources/resources. 
(ASHRAE, October 5, 2020).
Cambridge Health Alliance. (2021). COVID Alerts. https://www.challiance.org/patients-visitors/covid-19-alerts. (Cambridge 
Health Alliance, 2021).
Centers for Disease Control and Prevention (CDC). (2016, September). 
Guide to Infection Prevention for Outpatient Settings: Minimum 
Expectations for Safe Care. https://www.cdc.gov/infectioncontrol/pdf/outpatient/guide.pdf. (CDC, September 2016).
Centers for Disease Control and Prevention (CDC). (2018, December 
27). Core Infection Prevention and Control Practices for Safe 
Healthcare Delivery in All Settings--Recommendations of the 
Healthcare Infection Control Practices Advisory Committee (HICPAC). 
https://www.cdc.gov/hicpac/recommendations/core-practices.html. 
(CDC, December 27, 2018).
Centers for Disease Control and Prevention (CDC). (2019,October 28). 
Infection Control in Healthcare Personnel, Infrastructure and 
Routine Practices for Occupational Infection Prevention and Control 
Services. https://www.cdc.gov/infectioncontrol/guidelines/healthcare-personnel/index.html. (CDC, October 28, 2019).
Centers for Disease Control and Prevention (CDC). (2020, April 10). 
Interim Infection Control Guidance for Public Health Personnel 
Evaluating Persons Under Investigation (PUIs) and Asymptomatic Close 
Contacts of Confirmed Cases at Their Home or Non-Home Residential 
Settings. https://www.cdc.gov/coronavirus/2019-ncov/php/guidance-evaluating-pui.html. (CDC, April 10, 2020).
Centers for Disease Control and Prevention (CDC). (2020, April 24). 
Considerations for Alternate Care Sites, Infection Prevention and 
Control Considerations for Alternate Care Sites. https://www.cdc.gov/coronavirus/2019-ncov/hcp/alternative-care-sites.html. 
(CDC, April 24, 2020).
Centers for Disease Control and Prevention (CDC). (2020, April 28). 
Summary of Infection Prevention Practices in Dental Settings: Basic 
Expectations for Safe Care. https://www.cdc.gov/oralhealth/infectioncontrol/summary-infection-prevention-practices/index.html. 
(CDC, April 28, 2020).
Centers for Disease Control and Prevention (CDC). (2020, April 29). 
Guidance for Blood and Plasma Facilities, Interim Infection Control 
Guidance on COVID-19 for Personnel at Blood and Plasma Collection 
Facilities. https://www.cdc.gov/coronavirus/2019-ncov/hcp/blood-and-plasma-collection.html. (CDC, April 29, 2020).
Centers for Disease Control and Prevention (CDC). (2020, May 12). 
Considerations for Memory Care Units in Long-term Care Facilities. 
https://www.cdc.gov/coronavirus/2019-ncov/hcp/memory-care.html.(CDC, 
May 12, 2020).
Centers for Disease Control and Prevention (CDC). (2020, May 17). 
Hand Hygiene Recommendations, Guidance for Healthcare Providers 
about Hand Hygiene and COVID-19. https://www.cdc.gov/coronavirus/2019-ncov/hcp/hand-hygiene.html. (CDC, May 17, 2020).
Centers for Disease Control and Prevention (CDC). (2020, May 28). 
Nursing Homes and Assisted Living (Long-Term Care Facilities 
[LTCFs]) Infection Prevention Tools. https://www.cdc.gov/longtermcare/prevention/index.html. (CDC, May 28, 2020).
Centers for Disease Control and Prevention (CDC). (2020, May 29). 
Considerations for Preventing Spread of COVID-19 in Assisted Living 
Facilities. https://www.cdc.gov/coronavirus/2019-ncov/hcp/assisted-living.html. (CDC, May 29, 2020).
Centers for Disease Control and Prevention (CDC). (2020, June 10). 
Using Telehealth to Expand Access to Essential Health Services 
during the COVID-19 Pandemic. https://www.cdc.gov/coronavirus/2019-ncov/hcp/telehealth.html. (CDC, June 10, 2020).
Centers for Disease Control and Prevention (CDC). (2020, July 15). 
Interim Recommendations for Emergency Medical Services (EMS) Systems 
and 911 Public Safety Answering Points/Emergency Communication 
Centers (PSAP/ECCs) in the United States During the Coronavirus 
Disease (COVID-19) Pandemic. https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-for-ems.html. (CDC, July 15, 2020).
Centers for Disease Control and Prevention (CDC). (2020, August 19). 
Using Personal Protective Equipment (PPE). https://www.cdc.gov/coronavirus/2019-ncov/hcp/using-ppe.html. (CDC, August 19, 2020).
Centers for Disease Control and Prevention (CDC). (2020, October 
16). Interim Guidance for Implementing Home Care of People Not 
Requiring Hospitalization for Coronavirus Disease 2019 (COVID-19). 
https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-home-care.html. (CDC, October 16, 2020).
Centers for Disease Control and Prevention (CDC). (2020, November 
6). What Firefighters and EMS Providers Need to Know about COVID-19. 
https://www.cdc.gov/coronavirus/2019-ncov/community/organizations/firefighter-EMS.html. (CDC, November 6, 2020).
Centers for Disease Control and Prevention (CDC). (2020, November 
10). What do funeral home workers need to know about handling 
decedents who had COVID-19? https://www.cdc.gov/coronavirus/2019-ncov/community/funeral-faqs.html. (CDC, November 10, 2020).
Centers for Disease Control and Prevention (CDC). (2020, November 
13). Guidance for Pharmacies, Guidance for Pharmacists and Pharmacy 
Technicians in Community Pharmacies during the COVID-19 Response. 
https://www.cdc.gov/coronavirus/2019-ncov/hcp/pharmacies.html. (CDC, 
November 13, 2020).
Centers for Disease Control and Prevention (CDC). (2020, December 
2). Collection and Submission of Postmortem Specimens from Deceased 
Persons with Confirmed or Suspected COVID-19, Postmortem Guidance. 
https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-postmortem-specimens.html. (CDC, December 2, 2020).
Centers for Disease Control and Prevention (CDC). (2020, December 
4). Guidance for Dental Settings: Interim Infection Prevention and 
Control Guidance for Dental Settings During the Coronavirus Disease 
2019 (COVID-19) Pandemic. https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html. (CDC, December 4, 2020).
Centers for Disease Control and Prevention (CDC).(2020, December 
16). Guidance for Direct Service Providers. https://www.cdc.gov/coronavirus/2019-ncov/hcp/direct-service-providers.html. (CDC, 
December 16, 2020).
Centers for Disease Control and Prevention (CDC). (2020, December 
17). Interim Additional Guidance for Infection Prevention and 
Control Recommendations for Patients with Suspected or Confirmed 
COVID-19 in Outpatient Hemodialysis Facilities. https://www.cdc.gov/coronavirus/2019-ncov/hcp/dialysis.html. (CDC, December 17, 2020).

Centers for Disease Control and Prevention (CDC). (2021a, February 
16). Implementation of Mitigation Strategies for Communities with 
Local COVID-19 Transmission. https://www.cdc.gov/coronavirus/2019-ncov/community/community-mitigation.html. (CDC, February 16, 2021a).
Centers for Disease Control and Prevention (CDC). (2021b, February 
16). Interim Clinical Guidance for Management of Patients with 
Confirmed Coronavirus Disease (COVID-19). https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html. (CDC, February 16, 2021b).
Centers for Disease Control and Prevention (CDC). (2021, February 
23). Interim Infection Prevention and Control Recommendations for 
Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) 
Pandemic. https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html. (CDC, February 23, 2021).
Centers for Disease Control and Prevention (CDC). (2021, March 8). 
Interim Guidance for Businesses and Employers Responding to 
Coronavirus Disease (COVID-19). https://www.cdc.gov/coronavirus/2019-ncov/community/guidance-business-response.html. (CDC, March 8, 
2021).
Centers for Disease Control and Prevention (CDC). (2021, March 11). 
Interim U.S. Guidance for Risk Assessment and Work Restrictions for 
Healthcare Personnel with Potential Exposure to COVID-19. https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html. (CDC, March 11, 2021).
Centers for Disease Control and Prevention (CDC). (2021, March 16). 
Infection Prevention and Control Assessment Tool for Nursing Homes 
Preparing for COVID-19. https://www.cdc.gov/coronavirus/2019-ncov/hcp/assessment-tool-for-nursing-homes.html. (CDC, March 16, 2021).
Centers for Disease Control and Prevention (CDC). (2021, March 17). 
Healthcare Facilities: Managing Operations During the COVID-19 
Pandemic. https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/guidance-hcf.html. (CDC, March 17, 2021).
Centers for Disease Control and Prevention (CDC). (2021, March 23). 
Ventilation in Buildings. https://www.cdc.gov/coronavirus/2019-ncov/community/ventilation.html. (CDC, March 23, 2021).
Centers for Disease Control and Prevention (CDC). (2021, March 29). 
Interim Infection Prevention and Control Recommendations to Prevent 
SARS-CoV-2 Spread in Nursing Homes. https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html. (CDC, March 29, 2021).
Centers for Disease Control and Prevention (CDC). (2021, April 2). 
Post Vaccine Considerations for Healthcare Personnel, Infection 
Prevention and Control Considerations for Healthcare Personnel with 
Systemic Signs and Symptoms Following COVID-19 Vaccination. https://www.cdc.gov/coronavirus/2019-ncov/hcp/post-vaccine-considerations-healthcare-personnel.html. (CDC, April 2, 2021).
Dignity Healthcare. (2021). Coronavirus (COVID-19) Resources. 
https://www.dignityhealth.org/coronavirus-disease-2019. (Dignity 
Healthcare, 2021).
Eastern Research Group, Inc. (ERG). (2021, February 9). COVID-19 
Plans by NAICS. (ERG, February 9, 2021).
Eastern Research Group, Inc. (ERG). (2021, February 25). Physical 
Distancing Scenarios. (ERG, February 25, 2021).
Garner, J. (1996). Guideline for isolation precautions in hospitals. 
The Hospital Infection Control Practices Advisory Committee. 
Infection Control and Hospital Epidemiology 17(1): 53-80. https://doi.org/10.1086/647190. (Garner, 1996).
HCA Healthcare. (2021). Our COVID-19 response. https://hcahealthcare.com/covid-19/index.dot. (HCA Healthcare, 2021).
The Joint Commission. (2021a). About our Standards. https://www.jointcommission.org/standards/about-our-standards/. (The Joint 
Commission, 2021a).
The Joint Commission. (2021b). Facts about the Joint Commission. 
https://www.jointcommission.org/about-us/facts-about-the-joint-commission/. (The Joint Commission, 2021b).
The Joint Commission. (2021c). Accreditation and Certification. 
https://www.jointcommission.org/accreditation-and-certification/. 
(The Joint Commission, 2021c).
Johns Hopkins Medicine. (2021). Coronavirus (COVID-19) Information 
and Updates: COVID-19 Testing and Care. https://www.hopkinsmedicine.org/coronavirus/testing-and-care.html. (Johns 
Hopkins Medicine, 2021).
MedStar Health. (2021, May 5). Information from MedStar Health on 
COVID-19. https://www.medstarhealth.org/mhs/about-medstar/covid-19-info/. (MedStar, May 5, 2021).
Michigan Medicine, University of Michigan (Michigan Medicine U-M). 
(2021, May 18). U-M COVID-19 Preparedness and Response Plan. https://ehs.umich.edu/wp-content/uploads/2020/05/UM-COVID-19-Preparedness-and-Response-Plan.pdf. (Michigan Medicine U-M, May 18, 2021).
Miller, J et al., (2012, January 6).Guidelines for Safe Work 
Practices in Human and Animal Medical Diagnostic Laboratories. MMWR 
2012; 61(01); 1-101. https://www.cdc.gov/mmwr/preview/mmwrhtml/su6101a1.htm. (Miller et al., January 6, 2012).
National Association for Home Care & Hospice (NAHC). (2020, March 
3). Guide for Household Members, Intimate Partners, and Caregivers. 
https://www.nahc.org/wp-content/uploads/2020/03/Coronavirus-Caregiver-Guide-Customizable.docx. (NAHC, March 3, 2020).
New Mexico EMT Association (NMEMTA). (2020, March 29). Coronavirus 
Guidelines. http://www.nmemta.org/CoronavirusGuideline03-29-2020.pdf. (NMEMTA, March 29, 2020).
Rusnak, J et al., (2004, September). Laboratory exposures to 
staphylococcal enterotoxin B. Emerging Infectious Diseases, 10(9): 
1544-1549. https://doi.org/10.3201/eid1009.040250. (Rusnak et al., 
September 2004).
Santa Clara Valley Medical Center (SCVMC). (2020, December 1). 
COVID-19 Exposure, Risk Assessment, Contact Tracing, Testing, and 
Return to Work Guidelines for Healthcare Workers (HCWs). https://www.scvmc.org/COVID19/Employee/12012020%20COVID%20Exposure%20Policy.pdf. (SCVMC, December 1, 2020).
Siegel, J, Rhinehart, E, Jackson, M, Chiarello, L, and the 
Healthcare Infection Control Practices Advisory Committee. (2007). 
2007 Guideline for isolation precautions: preventing transmission of 
infectious agents in healthcare settings. https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf. (Siegel 
et al., 2007).
World Health Organization (WHO). (2016). Guidelines on Core 
Components of Infection Prevention and Control Programmes at the 
National and Acute Health Care Facility Level. (WHO, 2016).

B. Economic Feasibility

I. Introduction
    This section presents OSHA's estimates of the costs, benefits, and 
other impacts anticipated to result from the ETS. The estimated costs 
are based on employers achieving full compliance with the requirements 
of the ETS. They do not include prior costs associated with firms whose 
current practices are already in compliance with the ETS requirements. 
The purpose of this analysis is to:
     Identify the establishments and industries affected by the 
ETS;
     Estimate and evaluate the costs and economic impacts that 
regulated establishments will incur to achieve compliance with the ETS;
     Evaluate the economic feasibility of the rule for affected 
industries; and
     Estimate the benefits resulting from employers coming into 
compliance with the rule in terms of the reduction in COVID-19 disease 
and resulting fatalities.
    In this analysis, OSHA is fulfilling the requirement under the OSH 
Act to show the economic feasibility of this ETS. This analysis is 
different from a benefit-cost analysis prepared in accordance with E.O. 
12866 in that the agency is focused only on costs to employers when 
evaluating economic feasibility. In a true benefit-cost analysis, the 
costs to all parties (e.g., employees,

governments) are included. Throughout this analysis, there are places 
where OSHA estimates there are no costs borne by employers. This does 
not necessarily mean that there are no costs or burdens imposed on 
others but, from the standpoint of establishing feasibility, these are 
not being assessed as part of OSHA's analysis of economic 
feasibility.\30\
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    \30\ For example, there are places in the analysis where OSHA 
specifically accounts for costs being shifted away from employers 
through tax credits and other programs aimed at responding to the 
pandemic. While the direct costs to employers are reduced for 
purposes of evaluating feasibility, those costs would be 
attributable to the ETS in a true benefit-cost analysis.
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    A standard must be economically feasible in order to be 
``necessary'' under section 6(c)(1)(B) of the OSH Act. Cf. Am. Textile 
Mfrs. Inst., Inc. v. Donovan, 452 U.S. 490, 513 n. 31 (1981) (Cotton 
Dust) (``any standard that was not economically . . . feasible would a 
fortiori not be `reasonably necessary or appropriate' under the Act''); 
Nat'l Maritime Safety Ass'n v. Occupational Safety & Health Admin., 649 
F.3d 743, 752 (D.C. Cir. 2011). A standard is economically feasible 
when industries can absorb or pass on the costs of compliance without 
threatening industry's long-term profitability or competitive 
structure, Cotton Dust, 452 U.S. at 530 n. 55, or ``threaten[ing] 
massive dislocation to, or imperil[ing] the existence of, the 
industry.'' United Steelworkers of Am. v. Marshall, 647 F.2d 1189, 1272 
(D.C. Cir. 1981) (Lead I). Given that section 6(c) is aimed at enabling 
OSHA to protect workers in emergency situations, the agency is not 
required to make the showing with the same rigor as in ordinary section 
6(b) rulemaking. Asbestos Info. Ass'n/N. Am. v. OSHA, 727 F.2d 415, 424 
n.18 (5th Cir. 1984). In Asbestos Information Association, the Fifth 
Circuit concluded that the costs of compliance were not unreasonable to 
address a grave danger where the costs of the ETS did not exceed 7.2% 
of revenues in any affected industry. Id. at 424.
    OSHA's evaluation of the overall costs and benefits of the ETS has 
been performed for the purposes of complying with requirements outside 
of the OSH Act (e.g., Executive Orders 12866 and 13563, the Unfunded 
Mandates Reform Act). ``[T]he Supreme Court has conclusively ruled that 
economic feasibility [under the OSH Act] does not involve a cost-
benefit analysis.'' Pub. Citizen Health Research Grp. v. U.S. Dept. of 
Labor, 557 F.3d 165, 177 (3d Cir. 2009); see also Asbestos Info. Ass'n, 
727 F.2d at 424 n.18 (noting that formal cost benefit is not required 
for an ETS, and indeed may be impossible in an emergency). The OSH Act 
``place[s] the `benefit' of worker health above all other 
considerations save those making attainment of this `benefit' 
unachievable.'' Cotton Dust, 452 U.S. at 509. Therefore, ``[a]ny 
standard based on a balancing of costs and benefits by the Secretary 
that strikes a different balance than that struck by Congress would be 
inconsistent with the command set forth in'' the statute. Id. While 
this case law arose with respect to health standards issued under 
section 6(b)(5) of the Act, which specifically require feasibility, 
OSHA finds the same concerns applicable to emergency temporary 
standards issued under section 6(c) of the Act. An ETS ``serve[s] as a 
proposed rule'' for a section 6(b)(5) standard, and therefore the same 
limits on any requirement for cost-benefit analysis should apply. 
Indeed, OSHA has also rejected the use of formal cost benefit analysis 
for safety standards, which are not governed by section 6(b)(5). See 58 
FR 16612, 16622-23 (Mar. 30, 1993) (``in OSHA's judgment, its statutory 
mandate to achieve safe and healthful workplaces for the nation's 
employees limits the role monetization of benefits and analysis of 
extra-workplace effects can play in setting safety standards.'').\31\
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    \31\ To support its Asbestos ETS, OSHA conducted an economic 
feasibility analysis on these terms. 48 FR 51086, 51136-38 (Nov. 4, 
1983). In upholding that analysis, the Fifth Circuit said that OSHA 
was required to show that the balance of costs to benefits was not 
unreasonable. Asbestos Info. Ass'n, 727 F.2d at 423. As explained 
above, OSHA does not believe that is a correct statement of the 
economic feasibility test. However, even under that approach this 
ETS easily passes muster.
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    The scope of judicial review of OSHA's determinations regarding 
feasibility (both technological and economic) ``is narrowly 
circumscribed.'' N. Am.'s Bldg. Trades Unions v. OSHA, 878 F.3d 271, 
296 (D.C. Cir. 2017) (Silica). ``OSHA is not required to prove economic 
feasibility with certainty, but is required to use the best available 
evidence and to support its conclusions with substantial evidence.'' 
Amer. Iron & Steel Inst. v. OSHA, 939 F.2d 975, 980-81 (D.C. Cir. 1991) 
(Lead II); 29 U.S.C. 655(b)(5), (f). ``Courts, [moreover], `cannot 
expect hard and precise estimates of costs.' '' Silica, 878 F.3d at 296 
(quoting Lead II, 939 F.2d at 1006). Rather, OSHA's estimates must 
represent ``a reasonable assessment of the likely range of costs of its 
standard, and the likely effects of those costs on the industry.'' Lead 
I, 647 F.2d at 1266. The ``mere `possibility of drawing two 
inconsistent conclusions from the evidence,' or deriving two divergent 
cost models from the data `does not prevent [the] agency's finding from 
being supported by substantial evidence.' '' Silica, 878 F.3d at 296 
(quoting Cotton Dust, 452 U.S. at 523).
    Executive Orders 12866 and 13563 direct agencies to assess the 
costs and benefits of the intended regulation and, if regulation is 
necessary, to select regulatory approaches that maximize net benefits 
(including potential economic, environmental, and public health and 
safety effects; distributive impacts; and equity). Executive Order 
13563 emphasized the importance of quantifying both costs and benefits, 
of reducing costs, of harmonizing rules, and of promoting flexibility. 
OSHA has prepared this ETS and the accompanying economic analysis on an 
extremely condensed timeline and has complied with E.O. 12866 and E.O. 
13563 only to the extent practicable under the circumstances (see Exec. 
Order No. 13999, Jan. 21, 2021, 86 FR 7211 (Jan. 26, 2021)). This rule 
is an economically significant regulatory action under Sec. 3(f) of 
Executive Order 12866 and has been reviewed by the Office of 
Information and Regulatory Affairs in the Office of Management and 
Budget, as required by executive order.
II. Healthcare Industry Profile
a. Introduction
    In this section, OSHA provides estimates of the number of affected 
entities, establishments, and employees for the industries that have 
settings covered by 29 CFR 1910.502. The term ``entity'' describes a 
legal for-profit business, a non-profit organization, or a local 
governmental unit, whereas the term ``establishment'' describes a 
particular physical site of economic activity. Some entities own and 
operate more than one establishment.
    Throughout this analysis, where estimates were derived from 
available data those sources have been noted in the text. Estimates 
without sources noted in the text are based on agency expertise.
b. Scope of the ETS
    The ETS applies to all settings where any employee provides 
healthcare or healthcare support services except:
     The provision of first aid by an employee who is not a 
licensed healthcare provider;
     the dispensing of prescriptions by pharmacists in retail 
settings;
     non-hospital ambulatory care settings where all non-
employees are screened prior to entry and people with suspected or 
confirmed COVID-19 are not permitted to enter those settings;

     well-defined hospital ambulatory care settings where all 
employees are fully vaccinated and all non-employees are screened prior 
to entry and people with suspected or confirmed COVID-19 are not 
permitted to enter those settings;
     home healthcare settings where all employees are fully 
vaccinated and all non-employees are screened prior to entry and people 
with suspected or confirmed COVID-19 are not present;
     healthcare support services not performed in a healthcare 
setting (e.g., off-site laundry, off-site medical billing); or
     telehealth services performed outside of a setting where 
direct patient care occurs.
    In well-defined areas of covered settings where there is no 
reasonable expectation that any person with suspected or confirmed 
COVID-19 will be present, paragraphs (f), (h), and (i) do not apply to 
employees who are fully vaccinated.
    Healthcare services are delivered through various means including, 
but not limited to: Hospitalization, long-term care, ambulatory care 
(e.g., treatment in physicians' offices, dentists' offices, and medical 
clinics), home health and hospice care, and emergency medical response. 
Healthcare support services include, but are not limited to, patient 
intake/admission, patient food services, equipment and facility 
maintenance, housekeeping, healthcare laundry services, medical waste 
handling services, and medical equipment cleaning/reprocessing 
services.
    In order to determine which employers are covered by the ETS, OSHA 
identified both the occupations where workers would be providing 
healthcare and healthcare support services and the setting where those 
tasks would be done. For example, a social worker in a hospital may be 
working in conjunction with healthcare providers and therefore 
providing healthcare or healthcare support services. However, a social 
worker working for a children and family services or social advocacy 
organization would not be covered by the ETS since neither they nor 
anyone else at their organization would be providing healthcare or 
healthcare support services.
    OSHA's methodology for determining which establishments and 
employees are covered by the ETS focuses on job tasks and settings. 
OSHA did not assign costs to certain categories of job tasks because 
they are excluded from the scope of the ETS by paragraph (a). These 
include: Employees who are teleworking; employees who are providing 
services via telehealth; employees providing healthcare support 
services at off-site locations; employees who are in uncovered portions 
of settings (e.g., retail stores with health clinics, schools with 
school nurses) that are not fully covered by the ETS; and employees who 
work in parts of hospitals that would meet the ambulatory care 
exemption in paragraph (a)(2)(iv). Numerous employees of hospitals, 
long-term care facilities, and nursing homes are likely to fall into 
one of these categories. While these workers are included in Table 
VI.B.3 as employees of covered establishments, OSHA has not assigned 
employee-based costs to their employers in this analysis.
    Furthermore, OSHA has not determined how many non-hospital 
ambulatory care providers will screen patients for COVID-19 infections 
and symptoms, and therefore be fully exempt from this rule under 
paragraph (a)(2)(iii). To the extent that providers meet these 
exemption criteria, they will incur no costs for compliance with 
respect to these settings. Therefore, for this subset of 
establishments, the costs presented in OSHA's analysis will be dramatic 
overestimates (i.e., OSHA assumes full costs where costs should be 
zero). Overall, however, OSHA believes that the number of workers 
estimated to be covered by the ETS is reasonable and leads to 
reasonable aggregate estimates of the average costs of compliance for 
employers in covered settings.
    Table VI.B.1 summarizes the individual North American Industry 
Classification System (NAICS) codes, along with OSHA's estimated 
percentage of entities and employees, covered by the ETS. The 
percentage of entities covered were generally estimated as the 
percentage of firms reporting having employees whose occupation would 
have them providing healthcare and healthcare support services (see 
Appendix VI.B.A). In some healthcare industries (e.g., many of those in 
NAICS 62 Health Care and Social Assistance), 100 percent of entities 
are estimated to be affected, but for industries outside of the 
healthcare sector, no more than 25 percent of entities were estimated 
to be covered by the ETS. The percent of employees covered by the ETS 
in covered, non-healthcare entities is estimated based on the 
percentage of employees in those industries who are reported to be 
employed in the occupation categories identified in Appendix VI.B.A.
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BILLING CODE 4510-26-C
    Only some state- and local-government entities are included in this 
analysis. State- and local-government entities are specifically 
excluded from coverage under the OSH Act (29 U.S.C. 652(5)). Workers 
employed by these entities only have OSH Act protections if they work 
in states that have an OSHA-approved State Plan. (29 U.S.C. 667). 
Consequently, this analysis excludes public entities in states that do 
not have OSHA-approved State Plans.

Table VI.B.2 presents the states that have OSHA-approved State Plans 
and their public entities are included in the analysis.
[GRAPHIC] [TIFF OMITTED] TR21JN21.010

c. Affected Entities and Employees
    OSHA used data from the U.S. Census' 2017 County Business Patterns 
(CBP) to identify private sector entities and employees, including for-
profit and non-profit entities affected by the ETS (U.S. Census Bureau, 
November 21, 2019, U.S. Census Bureau, March, 2020); and uses the 
Bureau of Labor Statistics' (BLS) 2017 Quarterly Census of Employment 
and Wages (QCEW) to characterize state and local government entities 
(BLS, May 23, 2018). For covered public fire departments and 
firefighters cross-trained as EMTs, OSHA relied on data from the U.S. 
Fire Administration (USFA) National Fire Department Registry (USFA, 
2018).
    OSHA similarly obtained estimates of the number of employees in 
entities from CBP and QCEW. OSHA used the BLS 2018 Occupational 
Employment Statistics (OES), which provides NAICS-specific estimates of 
employment by occupation, to determine the subset of employees 
performing the tasks outlined in the scope of the ETS (BLS, March 29, 
2019). Within the affected NAICS industries, OES includes approximately 
700 unique occupations. Of these, OSHA identified 90 occupations 
representing jobs where workers would perform healthcare or healthcare 
support services (see Appendix VI.B.A). OSHA then calculated the 
proportion of total employees that these occupations represented for 
the NAICS industries that reported employing these occupations in OES 
data, and applied those proportions to the CBP and QCEW employee 
estimates for the covered entities. This results in an estimate of the 
subset of employees by NAICS industry where workers are covered by the 
ETS.
    For many regulatory economic analyses, the agency uses the most up-
to-date economic data as its baseline to describe the current state of 
the economy. It then applies the anticipated changes due to the new 
OSHA standard or regulation to that baseline. However, even the most 
current data OSHA uses in a typical economic analysis--including 
employment, number of establishments, revenue, etc.--represent economic 
conditions from at least one calendar year in the past. Even with that 
lag in the data due to reporting and compilation time, the idea is that 
the basic structure of the economy changes slowly, so the recent past 
is a good predictor of the near future.
    Given the unique circumstances of the pandemic and its economic 
disruption, OSHA's usual approach is inappropriate for the present 
analysis. The agency has therefore also made adjustments to the 
baseline industry profile to account for the economic conditions that 
are expected to persist during the time period in which this ETS will 
be in effect. Specifically, OSHA takes the above data as the baseline 
for 2019, the last full year before the onset of the pandemic.\32\ Then 
the agency adjusted employment and revenue by industry in order to 
capture the current adverse conditions and provide better estimates of 
employment and revenue both currently and over the period in which the 
ETS will be in effect. The detailed methodology for these adjustments 
is presented in Appendix VI.B.D.
---------------------------------------------------------------------------

    \32\ This includes updating revenue numbers for inflation to 
2019 using the GDP deflator.
---------------------------------------------------------------------------

    Table VI.B.3 summarizes the entities and employees covered by the 
ETS. OSHA estimates a total of approximately 563,000 entities, 
including approximately 749,000 establishments, and approximately 18.1 
million total employees who are employed by establishments covered by 
the ETS. All affected establishments are assumed to incur the 
establishment-based costs of compliance. In addition, OSHA estimates 
that there are approximately 10.3 million employees in those 
establishments who would not meet any of the exemptions in paragraph 
(a) and whose employers would therefore incur per-employee costs of 
compliance as well. However, as shown in Table VI.B.3, the portion of 
employees for whom OSHA took per-employee costs varies considerably by 
NAICS industry.
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d. Affected Small Entities and Employees
    While OSHA has determined that it is impracticable to comply fully 
with the requirements of the Regulatory Flexibility Act (RFA) (see 
Additional Requirements, Section VII of the preamble), the agency has 
nevertheless examined the impact of the ETS on small and very small 
entities as part of OSHA's analysis of feasibility. There are three 
types of small entities under the

RFA: (1) Small businesses; (2) small non-profit organizations; and (3) 
small governmental jurisdictions. The Small Business Administration 
(SBA) uses characteristics of businesses classified using the NAICS as 
a basis for determining whether businesses are small within a given 
industry. SBA small entity size criteria vary by industry, but are 
usually based on either number of employees or revenue (Table of Small 
Business Size Standards (SBA, August 19, 2019)). A small non-profit 
organization is any not-for-profit enterprise that is independently 
owned and operated and not dominant in its field. A small governmental 
jurisdiction is a government of a city, county, town, township, 
village, school district, or special district with a population of less 
than 50,000.
    To determine the number of private SBA-defined small entities, OSHA 
relies on 2017 CBP data, which report total revenues by entity and 
employment size. For those industries with a revenue criterion, OSHA 
calculated the average revenue for each employment size class in the 
Census data and identified the largest size class where average revenue 
is less than the SBA-defined small entity threshold. For those 
industries with employment criterion, OSHA calculated the average 
employees per entity by employment size class and included all entities 
below the SBA threshold.
    To estimate the subset of local government entities that are small, 
OSHA uses additional QCEW data that are specified geographically by 
county at the 4-digit NAICS level along with 2017 county-level 
population data from the U.S. Census Bureau's (December 6, 2018) 
American Community Survey. Using these data, OSHA estimates the 
percentage of local government entities, by county, that are small 
local governments (i.e., in counties with a population less than 
50,000), for each affected setting. OSHA then applies these proportions 
to the prior national estimates of all local government entities, by 
NAICS industry. The RFA's definition of small nonprofits is those not 
``dominant in their field.'' As OSHA customarily does, it assumes all 
nonprofits are small based on this definition.\33\
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    \33\ While the RFA definition suggests that some nonprofits 
might not be small entities, there is no set definition for the term 
``dominant'' or delineation of what should be considered a 
nonprofit's ``field.'' A nonprofit that is the main entity of its 
type in a given city is still unlikely to be the dominant nonprofit 
of its type in its state or region and even less likely to be 
dominant if the ``field'' encompasses the whole U.S. Given these 
ambiguities, OSHA has opted to include all non-profits as small 
entities.

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[GRAPHIC] [TIFF OMITTED] TR21JN21.012

    Lastly, Table VI.B.5 presents estimates for very small entities 
(those with fewer than 20 employees) affected by the ETS. OSHA 
estimates that the ETS affects approximately 472,000 very small 
entities, employing approximately 2.2

million workers. Of those, approximately 1.2 million are estimated to 
be workers who are in scope and covered by the ETS.
[GRAPHIC] [TIFF OMITTED] TR21JN21.013



BILLING CODE 4510-26-C
e. Summary of Affected Firms, Establishments, and Employees by NAICS 
Industry and Setting
    Table VI.B.6 presents a summary of the number of affected entities, 
establishments, and employees by NAICS industry and setting. The cost 
estimates presented in this analysis rely on assumptions that are 
specific to the type of services provided in various healthcare 
settings in each affected NAICS industry. Table VI.B.6 provides the 
mapping between the affected NAICS industries and their typical setting 
based on the type of services provided.

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[GRAPHIC] [TIFF OMITTED] TR21JN21.015


BILLING CODE 4510-26-C
III. Cost Analysis for the COVID-19 ETS
    In this section, OSHA provides estimates of the per-establishment 
costs for the requirements of the ETS. Section 6(c)(3) of the OSH Act 
states that the Secretary will publish a final standard ``no later than 
six months after publication of the emergency standard.'' Costs are 
therefore estimated over a six-month time period. However, during that 
period, to the extent OSHA finds that a grave danger from the virus no 
longer exists for the covered workforce (or some portion thereof), or 
new information indicates a change in measures necessary to address the 
grave danger, OSHA will update the ETS, as appropriate.
    In developing the cost estimates, OSHA estimates that some 
establishments are already following at least some of the ETS's 
requirements. The extent to which firms are already meeting the 
requirements of this ETS is estimated based, in part, on data presented 
in ERG (August 9, 2013), the infectious disease expert panel report 
prepared for OSHA. Because the expert panel was conducted pre-pandemic, 
OSHA determined that some compliance rates were likely too low given 
the heightened awareness of infection control practices, the amount of 
time since the pandemic started, and, especially, the outbreaks in 
healthcare settings and recognition of the importance of infection 
control measures for protecting workers and patients. In those limited 
circumstances, OSHA constrained compliance to be no less than 75 
percent for large and SBA-defined small entities and 50 percent for 
very small entities. Where establishments are already meeting ETS 
requirements, those costs are not attributable to the ETS. Throughout 
this analysis, where OSHA provides no other estimate, the agency 
assumes baseline compliance rates of 50 percent for very small entities 
and 75 percent for all other entities.34 35 OSHA recognizes 
that the estimated compliance rates are somewhat imprecise, but they 
are intended to reflect the relatively widespread adoption by employers 
of some of the practices required by the ETS in response to state OSHA 
standards, state and local government ordinances, and CDC, OSHA or 
other guidance. Exceptions to the 50 percent/75 percent compliance 
rates have been made for a few requirements that are highly specific to 
OSHA's ETS (like recordkeeping requirements, rule familiarization, and 
paid medical removal). While it is likely that levels of current 
compliance vary among the elements of this ETS, OSHA lacks data to make 
such specific determinations for each provision in the limited time 
available under these emergency circumstances. OSHA examined the impact 
of lower levels of baseline compliance on costs in a sensitivity 
analysis (see section VI.B.III.q).
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    \34\ The term ``baseline compliance'' is used to describe 
protective workplace measures that would be conducted in the absence 
of this ETS, the issuance of which establishes the meaning of and 
the parameters for ``compliance.''
    \35\ Note that the lower assumed compliance rate for very small 
entities sometimes results in the presentation of higher costs for 
very small entities than for larger entities. This result seems 
counter-intuitive given that very small entities have fewer 
employees than larger ones, and many of the costs in this analysis 
are based on an average number of employees per entity. The very 
small entities do, in fact, have lower costs when baseline 
compliance rates are not taken into account. However, because OSHA 
estimates that these employers are starting from a lower level of 
current compliance, the tables, which incorporate baseline 
compliance rates in their estimates, sometimes show higher (or only 
negligibly lower) per-establishment costs for very small entities. 
Another point on the tables which can seem counter-intuitive is that 
average costs per establishment for the category ``all,'' which 
includes large and very large entities (along with small and very 
small entities) can be smaller (or not much larger) than for, say, 
SBA-defined small entities. This is due, again, to the differing 
compliance rates which can swamp, in the average, the higher costs 
incurred by large and very large entities. Furthermore, because 
there are often fewer large entities relative to the number of SBA-
defined small and very small entities in an industry, the average 
costs for the smaller entities tend to result in lower average per 
entity costs over ``all'' establishments than one might expect.
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    Despite this estimated baseline compliance, employer compliance is 
not so widespread, nor does it incorporate enough of the practices 
required by this ETS, as to render this ETS unnecessary. As discussed 
in Section V. Need for Specific Provisions of the ETS, OSHA emphasizes 
that each of the infection control practices required by the ETS 
provides some protection from COVID-19 by itself, but the controls work 
best when used together, layering their protective impact to boost 
overall effectiveness. The ``Swiss Cheese Model of Accident Causation'' 
(Reason, April 12, 1990) argues that each control has certain 
weaknesses or ``holes.'' The ``holes'' differ between different 
controls. By stacking several controls with different weaknesses on top 
of one another, the ``holes'' are blocked by the strengths of the other 
controls. In other words, if the controls are layered, then any 
unexpected failure of a single control is protected against by the 
strengths of other controls. This model also demonstrates the necessity 
for high levels of compliance with all requirements of this ETS, since 
failure to follow the requirements may leave the ``holes'' exposed and 
lead to an increased risk of disease transmission in the workplace.
    It should be noted that this analysis deals strictly with averages 
and estimates. For any given establishment, actual costs may be higher 
or lower than the point estimate shown here, but using an average 
allows OSHA to evaluate feasibility by industry as required by the OSH 
Act. In addition, OSHA has limited data on many of the parameters 
needed in this analysis and has estimated them based on the available 
data, estimates for similar requirements for other OSHA standards, 
consultation with experts in other government agencies, and internal 
agency judgment where necessary. OSHA's estimates are therefore based 
on the best evidence available to the agency at the time this analysis 
of costs and feasibility was performed.
    Many ETS requirements result in labor burdens that are monetized 
using the labor rates described in Section VI.B.III.a OSHA 
differentiates per-establishment burden by establishment size for 
large, SBA-defined small, and very small entities with fewer than 20 
employees (which are a subset of SBA-defined small entities). In doing 
so, OSHA accounts for the fact that, in most industries, a substantial 
portion of the SBA-defined small entity population is also very small. 
In most cases, OSHA assigned different unit cost burdens to entities 
with fewer than 20 employees and to other SBA-defined small entities 
(with 20 or more employees). Both of these groups are combined when 
calculating average costs for all SBA-defined small entities.
    OSHA estimates that approximately 563,000 entities have employees 
who provide healthcare and healthcare support services and would be 
subject to the requirements of the ETS, including approximately 749,000 
establishments, and 10.3 million employees (see Table VI.B.3).
    Section VI.B.III.a describes the wage rates used to estimate the 
labor costs incurred by affected entities. Sections VI.B.III.b through 
VI.B.III.o present the estimated costs for each of the requirements of 
the ETS. Finally, section VI.B.III.p summarizes the total per-
establishment costs and total costs of the ETS.
a. Wage Rates
    OSHA estimated occupation-specific wage rates from BLS 2018 
Occupational Employment Statistics data (BLS, March 29, 2019). For each 
affected NAICS industry, OSHA used the BLS (March 29, 2019) data to 
estimate the average wages across the workers in the affected

occupations listed in Appendix VI.B.A. OSHA estimated loaded wages 
using a fringe benefit rate of 44.4 percent, the average rate for all 
civilian workers in the healthcare and social assistance industries in 
the BLS (December 14, 2018) Employer Costs for Employee Compensation 
data, as well as OSHA's standard estimate for overhead of 17 percent 
times the base wage. The loaded wage rate averages by NAICS industry 
and setting are presented in Appendix VI.B.B.
    In addition to the wages of the healthcare providers and employees 
in other covered occupations in the affected NAICS industries, the cost 
analysis also uses an estimated wage rate for occupational health 
specialists, training development specialists, and a blended wage rate 
that reflects the mix of doctors and nurse practitioners.
[GRAPHIC] [TIFF OMITTED] TR21JN21.016

b. Rule Familiarization and COVID-19 Plan
ETS Requirements--Under Sec.  1910.502(c).
    The employer must develop, implement, and update a COVID-19 plan 
that addresses the hazards identified in the hazard assessment required 
by this paragraph. The COVID-19 plan must include policies and 
procedures that minimize the risk of transmission of COVID-19 for each 
employee. This provision also requires employers to coordinate and 
communicate with other employers at sites with multiple employers in 
order to ensure that each employee is protected. Employers must have 
policies and procedures to ensure that employees who enter into private 
residences or other physical locations controlled by those not covered 
by the OSH Act are protected. Non-managerial employees must be given 
the opportunity to provide input into the hazard assessment and the 
COVID-19 plan. The plan must be written if the employer has more than 
10 employees. In order for an employer to be exempt from providing 
certain controls for fully-vaccinated employees in a well-defined area 
of a workplace where there is no reasonable expectation that any person 
with suspected or confirmed COVID-19 will be present, the COVID-19 plan 
must include policies and procedures to determine employees' 
vaccination status.
    This section of the feasibility analysis presents the estimated 
costs for developing the plan, while the costs of implementing the plan 
are presented in the subsequent sections (VI.B.III.c through 
VI.B.III.o) of this report.\36\
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    \36\ Estimates were based on the Infectious Diseases Panel 
Report (ERG, August 9, 2013).
---------------------------------------------------------------------------

Cost Analysis Assumptions
    As part of the Infectious Diseases Small Business Advisory Review 
(SBAR) Panel, OSHA estimated that the development of a full Worker 
Infection Control Plan (WICP) that included written standard operating 
procedures for all infectious disease transmission routes would take 
between 20 and 40 hours to develop, depending on the setting (OSHA, 
2014). For this ETS, which applies specifically to COVID-19, OSHA 
estimates that the written plan, including the hazard assessment, would 
take 25 percent of the time needed to develop a full WICP. The 
exception is hospitals, which are assumed to need 40 hours to develop 
their plans. OSHA has not included additional time for employee 
participation and assumes that the time estimated to develop the COVID-
19 plan is extensive enough to account for this activity. In addition 
to the costs for developing the COVID-19 plan, OSHA assumes that 
establishments with fewer than 20 employees will incur a labor burden 
of 1 hour for rule familiarization and larger establishments will incur 
a labor burden of 1.5 hours for rule familiarization.
    OSHA also assumes an additional recurring daily labor burden to 
monitor each workplace to ensure the ongoing effectiveness of the 
COVID-19 plan. OSHA estimates this will take 10 minutes per day of 
labor per large establishment on average, with 5 minutes per day for 
SBA-defined small and very small entities. This burden is incurred 
daily, seven days a week,\37\ for six months. OSHA notes that 
surveillance on the efficacy of an infection control plan is not a 
wholly new activity for healthcare settings (CDC, March 15, 2017). The 
Core Infection Prevention and Control Practices for Safe Healthcare 
Delivery in All Settings from the Healthcare Infection Control 
Practices Advisory Committee (the federal advisory committee appointed 
to provide advice and guidance to the Department of Health and Human 
Services and CDC regarding the practice of infection control in 
healthcare settings) includes performance monitoring as one of its core 
elements. Specifically, healthcare providers should ``monitor adherence 
to infection control practices'' and ``monitor the incidence of 
infections . . . to detect transmission of infectious agents in the 
facility'' (CDC, March 15, 2017). OSHA estimates that there will be 
some additional burden due to the requirements of this ETS, but that it 
would be a small amount of additional time added on to what is a 
regular activity that would be undertaken regardless of the ETS.
---------------------------------------------------------------------------

    \37\ To the extent that businesses are open fewer than seven 
days a week or do not have employees on the premises seven days a 
week, there will be some tendency toward overestimating the cost of 
complying with this provision.
---------------------------------------------------------------------------

    As part of the planning and on-going monitoring, some employers 
will need to communicate with other employers whose employees are at 
the site (e.g., contractors, vendors) about the specifics of their plan 
and additional information as necessary on an on-going basis. OSHA 
estimates that hospitals, nursing homes, and other long-term care 
facilities will spend 30 minutes one time after the promulgation of 
this ETS

to communicate with contractors and others regarding expectations for 
their activities under the requirements of this ETS. Additionally, OSHA 
estimates that hospitals, nursing homes, and other long-term care 
facilities will spend, on average, 15 minutes every week engaging in 
on-going communication with contractors under this provision. Other 
settings are estimated to only rarely use contractors, and so their 
time burden is set to zero for both initial and on-going communication.
    The total cost for this communication for hospitals, long-term care 
facilities, and nursing homes is a product of:

 One-time labor burden (half an hour for applicable settings) 
plus the on-going labor burden (0.25 hours weekly for 26 weeks)
 Wage rate (NAICS-specific wages)
Cost per Establishment, Rule Familiarization and COVID-19 Plan
    Table VI.B.8 presents a summary of the per-establishment rule 
familiarization and COVID-19 plan development, daily monitoring, and 
host employer communication time burdens and costs for all 
establishments. The baseline compliance estimates in Table VI.B.8 are 
based on the estimated compliance rates in ERG (August 9, 2013), the 
infectious disease expert panel report prepared for OSHA, and adjusted 
so that baseline compliance is no less than 50 percent for 
establishments with fewer than 20 employees and no less than 75 percent 
for larger establishments. The expert panel survey was done during non-
pandemic conditions, so OSHA assumes compliance may be higher in health 
care settings today. See the introduction to this section for more 
discussion. OSHA assumes zero current compliance for rule 
familiarization. Table VI.B.9 presents the same costs as Table VI.B.8 
by establishment size.
[GRAPHIC] [TIFF OMITTED] TR21JN21.017

[GRAPHIC] [TIFF OMITTED] TR21JN21.018


c. Patient Screening and Management
ETS Requirements--Under Sec.  1910.502(d)
    In settings where direct patient care is provided, employers must 
limit and monitor points of entry, screen and triage all non-employees 
entering the setting, and implement other applicable patient management 
strategies.
Cost Analysis Assumptions
    As noted in Summary and Explanation (Section VIII of the preamble), 
screening is a standard part of infection control practices. OSHA 
expects that healthcare settings will ask about COVID-19 infections and 
perform a quick check of existing symptoms or assessment for newly 
emerged symptoms that might suggest the presence of a COVID-19 
infection. This screening does not need to be a highly involved 
procedure and can be completed through verbal questions and answers. 
OSHA estimates the six-month incremental time burden per facility for 
screening and triaging non-employees for COVID-19 illness and symptoms 
of COVID-19 (for all establishments) as follows:

 General Hospitals: An incremental burden of 385.1 hours is 
estimated based on a burden of 1 minute per patient each day for an 
average of 1 patient per employee \38\ and a baseline compliance rate 
of 81 percent. [385.1 = (1-0.81) * (666.3/60) * (365/2); where 81% is 
the compliance rate, 666.3 is the number of patients (estimated as 
being equal to the average number of employees per establishment),\39\ 
60 is the number of minutes in an hour (which allows OSHA to calculate 
the burden in hours per day), and 365/2 is the number of days of 
burden]
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    \38\ According to AHA Data Hub 2015-2019 data, there were 
785,235,256 outpatient visits, 19,418,138 outpatient surgeries, and 
34,078,100 admissions in 2019 (AHA, 2021). These data came from 
5,141 community hospitals, which results in an average of 447 visits 
per day for each hospital. Thus, since OSHA estimates there are 492 
healthcare workers per hospital across all types of hospitals, that 
is approximately 1 patient per employee per day.
    \39\ The estimated average number of workers per hospital for 
General Hospitals is greater than the average number across all 
types of hospitals derived from the AHA data cited above.
---------------------------------------------------------------------------

 Other Hospitals: An incremental burden of 60.4 hours is 
estimated based on a burden of 1 minute per patient each day for an 
average of 1 patient per employee \38\ and a baseline compliance rate 
of 81 percent. [60.4 = (1-0.81) * (104.5/60) * (365/2); where 81% is 
the compliance rate, 104.5 is the number of patients (equal to the 
average number of employees per establishment), 60 is the number of 
minutes in an hour (which allows OSHA to calculate the burden in hours 
per day), and 365/2 is the number of days of burden]
 Nursing Homes: An incremental burden of 20.4 hours is 
estimated based on a burden of 1 minute per patient each day for an 
average of 32 patients per facility \40\ and a baseline compliance rate 
of 79 percent. [20.4 = (1-0.79) * (32/60) * (365/2); where 79% is the 
compliance rate, 32 is the number of patients, 60 is the number of 
minutes in an hour (which allows OSHA to calculate the burden in hours 
per day), and 365/2 is the number of days of burden]
---------------------------------------------------------------------------

    \40\ The number of patients per facility for Nursing Homes and 
other Long Term Care is estimated using a 2019 National Center for 
Health Statistics study on long term care facilities and their 
patients (Harris-Kojetin et al., February, 2019) and OSHA's 
estimated number of facilities (estimated using BLS (May 23, 2018), 
BLS (March 29, 2019), and U.S. Census Bureau (March, 2020)).
---------------------------------------------------------------------------

 Long Term Care (excluding nursing homes): An incremental 
burden of 14.7 hours is estimated based on a burden of 1 minute per 
patient each day for an average of 23 patients per facility 
40 and a baseline compliance rate of 79 percent. [14.7 = (1-
0.79) * (23/60) * (365/2); where 79 percent is the compliance rate, 23 
is the number of patients, 60 is the number of minutes in an hour 
(which allows OSHA to calculate the burden in hours per day), and 365/2 
is the number of days of burden]
 Other Patient Care: An incremental burden of 39.9 hours is 
estimated as 30 minutes per day \41\ and a baseline compliance rate of 
56 percent [39.9 = (1-0.56) * (30/60) * (365/2); where 56 percent is 
the compliance rate, 30 is the minutes of burden per day, 60 is the 
number of minutes in an hour (which allows OSHA to calculate the burden 
in hours per day), and 365/2 is the number of days of burden]
---------------------------------------------------------------------------

    \41\ The number of patients at hospitals and ambulatory care was 
estimated using AHA Data Hub 2015-2019 data (AHA, 2021).
---------------------------------------------------------------------------

 Correctional Facility Clinics: An incremental burden of 18.25 
hours is estimated as 30 minutes per day and a baseline compliance rate 
of 80 percent [18.25 = (1-0.80) * (30/60) * (365/2); where 80 percent 
is the compliance rate, 30 is the minutes of burden per day, 60 is the 
number of minutes in an hour (which allows OSHA to calculate the burden 
in hours per day), and 365/2 is the number of days of burden]

    The baseline compliance estimates are based on ERG (August 9, 
2013), the infectious disease expert panel report prepared for OSHA. As 
noted above, the rate of compliance with the patient screening and 
management requirements was estimated to be relatively high prior to 
the COVID pandemic. It is possible that these compliance rates are even 
higher now, given the emphasis on screening for symptoms over the 
course of the pandemic. However, while OSHA has estimated that those 
settings that were judged to have very low compliance pre-COVID are 
likely complying with screening requirements more thoroughly now, the 
agency has not adjusted those settings with higher rates of patient 
screening pre-COVID since the agency lacks data to make these 
adjustments. The estimated time spent to screen patients is based on 
the agency's evaluation of the time necessary to ask standard COVID 
screening questions.
Cost per Establishment, Patient Screening and Management
    Table VI.B.10 shows the average cost per establishment for patient 
screening and management by setting and size and incorporates the 
compliance rates as detailed above.

[GRAPHIC] [TIFF OMITTED] TR21JN21.019

d. Standard and Transmission-Based Precautions
ETS Requirements--Under Sec.  1910.502(e)
    Employers must develop and implement policies and procedures that 
adhere to standard and transmission-based precautions.
Cost Analysis Assumptions
    OSHA estimates that any time spent on the development of policies 
and procedures that are in accordance with standard and transmission-
based precautions is included in the cost of developing the COVID-19 
plan discussed earlier. OSHA does not expect that employers will need 
to deviate significantly from existing practice to account for these 
precautions and practices, and any costs associated with following 
standard and transmission-based precautions are covered under the cost 
estimates for the other sections of this ETS (PPE, hygiene and 
cleaning, etc.). Therefore, OSHA did not estimate the costs associated 
with compliance with this provision separately.
e. Personal Protective Equipment
ETS Requirements--Under Sec.  1910.502(f)
    Employers are required to provide facemasks and ensure those 
facemasks are worn by each employee over the nose and mouth when 
indoors and when occupying a vehicle with other people for work 
purposes. Employers must ensure that each employee changes their 
facemask at least once per day, whenever the facemask is soiled or 
damaged, and more frequently as necessary (e.g., patient care reasons). 
Employers must provide respirators and other PPE for workers exposed to 
people with suspected or confirmed COVID-19, for employees involved in 
aerosol-generating healthcare procedures on people with suspected or 
confirmed COVID-19, and as necessary to comply with standard and 
transmission-based precautions under paragraph (e). Required PPE 
includes gloves, an isolation gown or protective clothing, and eye 
protection.
Cost Analysis Assumptions
    The total cost to establishments to provide PPE will vary based on 
the type of care provided in a facility and the number of encounters 
workers will have with patients during a given period. The cost of 
implementing this PPE provision will also vary by the number of 
employees and the number of patients that the facility sees, as well as 
by whether employees are working with people who are suspected or 
confirmed to have COVID-19. A small practice with few employees and low 
patient volume may have very low costs for PPE while a large hospital 
with hundreds of workers and patients on any given day will likely have 
much higher costs for PPE.
    For the purposes of estimating costs for this provision, OSHA is 
assuming that 25 percent of covered employees in hospitals and nursing 
homes (which corresponds roughly with the percent of covered workers 
estimated to work in areas of a hospital where patients with suspected 
or confirmed COVID-19 infections would be seen) and three percent of 
in-scope employees in other covered settings (identified in section 
VI.B.II.b as being in the scope) will be provided with, and use, 
disposable N95 respirators. These estimates are based on OSHA's best 
professional judgment. All other workers in covered settings are 
estimated to use two disposable facemasks (surgical masks) per shift.
    The general approach for estimating the total cost of PPE used by 
employees who have exposure to persons with suspected or confirmed 
COVID-19 involves the following steps:
    1. Estimate the percentage of healthcare providers and employees 
providing healthcare or healthcare support services in each setting 
that will use each given type of PPE;
    2. For each given type of PPE, estimate how many pieces of 
equipment an employee will use over six months (e.g., estimate that 
hospital workers need 1 N95 respirator per shift, work 3 shifts per 
week on average, so they will need 78 N95 respirators over 6 months);
    3. Estimate the unit cost for each PPE item; and
    4. Calculate the product of (a) the number of covered employees, 
(b) the percent that will use a given type of PPE (step 1), (c) the 
number of items needed per affected worker over six months (step 2), 
and (d) the unit cost (step 3).
    Table VI.B.11 presents the estimated percentages of employees who 
will need the required PPE by setting.

[GRAPHIC] [TIFF OMITTED] TR21JN21.020

    Table VI.B.12 presents estimates for the units of PPE needed per 
employee shift for the employees using a given type of PPE. OSHA 
assumes that one N95 respirator and either one disposable face shield 
\42\ or protective eyewear will be used per shift. The estimated number 
of gowns and gloves needed per shift are based on estimates from Carias 
et al., (April 10, 2015) and Swaminathan et al., (October, 2007).
---------------------------------------------------------------------------

    \42\ Employers may provide reusable face shields which may be 
less costly on a per-use basis but require cleaning and storage 
which are additional costs. As a simplifying assumption, OSHA has 
assumed employers will provide disposable face shields which may 
represent a source of overestimation of compliance costs.
[GRAPHIC] [TIFF OMITTED] TR21JN21.021

    For general hospital, nursing homes, and long-term care facilities, 
OSHA estimates that employees work three twelve-hour shifts per week, 
or 78 shifts over six months. For other settings, OSHA estimates that 
employees work five eight-hour shifts per week, or 130 shifts over six 
months. Table VI.B.13 presents the total units of PPE per establishment 
that would need to be used over a six-month period, by setting and 
worker type. These estimates combine the numbers of covered workers by 
setting with the percentages presented in Table VI.B.11, the pieces of 
equipment needed from Table VI.B.12, and the number of shifts per 
worker that occur over 6 months, and were adjusted for baseline 
compliance (80 percent for general hospitals and nursing home 
respirator costs, 90 percent for all other PPE in general hospitals and 
nursing homes, and 72 percent for other settings).
[GRAPHIC] [TIFF OMITTED] TR21JN21.022



    Table VI.B.14 presents the estimated PPE unit costs. Note that 
these unit costs reflect typical costs when there is not a PPE 
shortage.
[GRAPHIC] [TIFF OMITTED] TR21JN21.023

Cost per Establishment, Personal Protective Equipment
    The results from Table VI.B.14 and Table VI.B.13 are combined to 
estimate the per-establishment compliance costs of additional PPE 
presented in Table VI.B.15.
[GRAPHIC] [TIFF OMITTED] TR21JN21.024

Cost Analysis Assumptions, Respiratory Protection Program
    Under this section of the ETS, where employers are required to 
provide respirators, they must be provided and used in accordance with 
OSHA's Respiratory Protection standard (29 CFR 1910.134). Note that 
costs related to optional respirator use under the mini respiratory 
protection program (29 CFR 1910.504) are discussed in sections VI.B.IV 
and VI.B.V below but are included in the total average costs presented 
below in Table VI.B.20 below.
    OSHA estimates that 15 percent of nursing home employers and 50 
percent of employers in NAICS 621111 Offices of Physicians who do not 
currently have a respirator program would either be required by the ETS 
to implement a respiratory protection program or would voluntarily 
determine that their employees need additional respiratory 
protection.\43\ Of those establishments, OSHA estimates that, at most, 
25 percent would, as a result of the requirements in this ETS, need to 
establish a full program under Sec.  1910.134 and the remainder would 
be able to take advantage of the mini respiratory protection program 
under Sec.  1910.504 (see section VI.B.IV.b Scope of the Mini 
Respiratory Protection section of the ETS below for additional detail). 
In establishments that already have a respirator program, OSHA 
estimates that the ETS will cause more employees to be wearing 
respirators and their employers will incur the additional costs related 
to medical evaluation, fit testing, and training for those employees.
---------------------------------------------------------------------------

    \43\ While OSHA has no hard data on how many establishments have 
or will need to develop a respiratory protection program, the agency 
has been assisting numerous nursing homes to establish programs over 
the course of the pandemic. OSHA expects that some additional 
nursing homes and long term care facilities will still need to 
establish a program after the promulgation of this ETS but that most 
will have done so already. While most offices of physicians would 
not have needed a respiratory protection program prior to the 
pandemic, OSHA's estimate for this element reflects an assumption 
that healthcare providers may decide to be cautious given the close 
proximity to others that is required in order to provide healthcare 
services.
---------------------------------------------------------------------------

    In this section, OSHA is evaluating the costs for program 
development, medical evaluation, fit testing, and training related to 
respiratory protection. As stated above, OSHA is estimating costs 
assuming that all affected employees will use disposable N95 
respirators only.

    Workers who need respiratory protection (i.e., those assumed to be 
using N95 respirators) will need to have a medical evaluation, fit 
testing, and training. These are one-time costs per affected worker. 
That is, total costs are simply calculated as the number of affected 
workers multiplied by the one-time per worker cost.
    The estimated average numbers of workers per establishment affected 
by respiratory protection requirements under the ETS are presented 
below in Table VI.B.16.
[GRAPHIC] [TIFF OMITTED] TR21JN21.025

    Table VI.B.17 presents the estimated percentage of baseline 
compliance with the respiratory protection requirements by setting. The 
baseline estimates are based on ERG (August 9, 2013), the infectious 
disease expert panel report prepared for OSHA, but as explained in the 
introduction to this section, are assumed to be at least 50 percent for 
establishments with fewer than 20 employees and at least 75 percent for 
larger establishments.
[GRAPHIC] [TIFF OMITTED] TR21JN21.026

    The per worker labor burdens and costs include those associated 
with the medical examination and the fit testing, which are described 
below.
Respiratory Protection Plan Development
    The respiratory protection standard requires employers to develop 
and maintain a written respiratory protection program. OSHA estimates 
that a physician or other licensed healthcare professional will spend 4 
hours for establishments with fewer than 20 employees and 8 hours for 
larger establishments (OSHA, 2018) to develop this plan.
Medical Evaluation
    The Respiratory Protection standard requires employers to provide a 
medical evaluation to determine the employee's ability to use a 
respirator before the employee is fit tested or required to use the 
respirator in the workplace. 29 CFR 1910.134(e)(1); (OSHA, 2018).
    While OSHA's respiratory protection standard requires medical re-
evaluation under certain circumstances, OSHA believes that, given the 
limited time this ETS will be in effect, there will not be sufficient 
time for conditions to change and trigger the requirement for the re-
evaluation and therefore OSHA did not estimate any costs associated 
with medical re-evaluation in this analysis.
    The preliminary medical evaluation (medical questionnaire) is 
estimated to take 15 minutes of the worker's time and 5 minutes of a 
physician or other licensed health care professional's (PLHCP) time. 
OSHA estimates that a follow-up medical evaluation is needed 23 percent 
of the time (OSHA, 2018). When a follow-up medical evaluation is 
needed, OSHA estimates that this has a cost of $391 plus the cost 
burden for the 1 hour of the worker's time (OSHA, 2018). In addition, 
it is estimated that a travel cost of $5 plus a half hour of the 
worker's time is incurred for all settings

except for hospitals (since the follow-up is assumed to occur off-site 
for employees in settings other than hospitals).
Fit Testing and Training
    The Respiratory Protection standard requires that, before a worker 
is required to use a respirator with a negative or positive pressure 
tight-fitting face piece, the employee must be fit tested with the same 
make, model, style, and size of respirator that will be used. Fit 
testing costs and training are estimated as one hour of the workers 
time, plus one half hour of the fit tester's time for fit testing, one 
half hour per 10 employees of the fit tester's time for training, and 
the cost of two N95 respirators (OSHA, 2018).
Summary of per Worker Respiratory Protection Costs
    Table VI.B.18 summarizes how the per worker respiratory protection 
costs are estimated.
[GRAPHIC] [TIFF OMITTED] TR21JN21.027

Cost per Establishment, Respiratory Protection
    Table VI.B.19 presents a summary of the respiratory protection 
costs per establishment, including plan development, fit testing, 
training, and medical evaluation costs.
[GRAPHIC] [TIFF OMITTED] TR21JN21.028

    Table VI.B.20 presents a summary of the average per establishment 
combined cost for PPE and respiratory protection. The costs included in 
Table VI.B.20 also include the costs associated with the

Mini Respiratory Protection Program described in section VI.B.V.0
[GRAPHIC] [TIFF OMITTED] TR21JN21.029

f. Aerosol-Generating Healthcare Procedures on a Person With Suspected 
or Confirmed COVID-19
ETS Requirements--Under Sec.  1910.502(g)
    When an aerosol-generating procedure is performed on a person with 
suspected or confirmed COVID-19, the employer must limit the number of 
employees present during the procedure to only those essential for 
patient care and procedure support and ensure that the procedure is 
performed in an existing airborne infection isolation room (AIIR), if 
available. After the procedure is completed, the employer must clean 
and disinfect the surfaces and equipment in the room or area where the 
procedure was performed.
Cost Analysis Assumptions
    Any costs associated with PPE or enhanced cleaning required under 
this provision are included in the sections addressing PPE and cleaning 
and disinfection. Costs associated with assuring properly functioning 
AIIRs are considered in section VI.B.III.j on ventilation, below.
g. Physical Distancing
ETS Requirements--Under Sec.  1910.502(h)
    The employer must ensure that each employee is separated from all 
other people by at least six feet when indoors unless the employer can 
demonstrate that such physical distancing is not feasible for a 
specific activity. When six feet of distancing is not feasible, the 
employer must ensure that the employees are as far apart as is 
feasible. This provision does not apply to momentary exposure while 
people are in movement (e.g., passing in hallways or aisles).
Cost Analysis Assumptions
    To implement physical distancing requirements, OSHA assumes 
employers post signage encouraging physical distancing: 25 Signs on 
average per large establishment, with 15 and 10 signs for SBA-defined 
small and very small establishments, respectively. OSHA estimated a 
unit cost per sign of $0.10, with the assumption that employers will 
use free downloadable signs from the CDC and self-print those signs. 
OSHA also includes costs for floor markings, based on the unit cost for 
a roll of masking tape ($4.39 (Office Depot, 2020)), and assuming 3 
rolls per large establishments, 2 rolls per SBA-defined small 
establishment, and 1 roll per very small establishments. OSHA also 
assumes 2 minutes of labor per sign, including printing and 
installation by an employee.
Cost per Establishment, Physical Distancing
    Table VI.B.21 presents a summary of the physical distancing costs 
per healthcare establishment, incorporating the baseline compliance 
rates of 50 percent for very small entities and 75 percent for all 
other entities. These include costs of the signs, the floor markings, 
and the labor of installing them (calculated using the average loaded 
wage shown in Appendix VI.B.B).

[GRAPHIC] [TIFF OMITTED] TR21JN21.030

h. Physical Barriers
ETS Requirements--Under Sec.  1910.502(i)
    The employer must install cleanable or disposable, solid barriers 
at each fixed work location outside of direct patient care areas where 
each employee is not separated from all other people by at least 6 
feet. An exception is made for where the employer can demonstrate that 
it is not feasible.
Cost Analysis Assumptions
    OSHA estimates that the ETS will result in additional clear plastic 
barriers installed in 10 percent of general hospital, other hospital, 
first aid and emergency care, and other patient care settings. Other 
facilities in these settings are assumed to have installed these 
barriers or an equivalent barrier prior to the ETS. OSHA estimates that 
each setting will install 3 clear plastic barriers with a cost of $300 
per barrier.\44\ This is an average. OSHA also assumes 15 minutes of 
labor for 2 maintenance workers for the installation of each barrier.
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    \44\ The cost of installing clear plastic barriers in response 
to COVID-19 has been reported in the following news articles: (1) 
Altoona company starts installing plexiglass cashier shields (Lim, 
April 2, 2020)--$300 per barrier, and (2) Franklin County to get 
prices on spit/sneeze shields, doors (Perry, April 21, 2020)--$140 
per barrier. The higher cost estimate is utilized in the analysis.
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    While OSHA has no data on the number of barriers that have been 
purchased and installed or how many additional barriers will need to be 
made, the agency has included what it has determined, based on agency 
judgment, to be a reasonable estimate for this requirement. It is 
likely that some workplaces will need more barriers than others; it is 
also likely that many establishments will reevaluate their current 
barrier set up as a result of this ETS and determine that they need 
additional barriers. This is an average, so it also accounts for the 
likelihood that some establishments will not need any barriers because 
the nature of the work makes spacing feasible, or because barriers are 
infeasible.
Cost per Establishment, Physical Barriers
    Table VI.B.22 presents the average total physical barrier costs for 
establishments covered by the ETS by setting and incorporates the 
baseline compliance rate of 90 percent as discussed above for 
hospitals, first aid and emergency care, and other patient care.
[GRAPHIC] [TIFF OMITTED] TR21JN21.031

i. Cleaning and Disinfection
ETS Requirements--Under Sec.  1910.502(j)
    In patient care areas and resident rooms, and for medical devices 
and equipment, the employer must follow standard practices for cleaning 
and disinfection of surfaces and equipment in accordance with 
applicable CDC guidelines. In other areas, the employer must clean 
high-touch surfaces and equipment at least once per day. When an 
employer is aware that a person who is COVID-19 positive has been in 
the workplace within the last 24 hours, the employer must clean and 
disinfect any areas, materials, and equipment under the employer's 
control that have likely been contaminated by that person. The employer 
must also provide alcohol-based hand rub or readily accessible hand 
washing facilities.
Cost Analysis Assumptions
    In settings other than hospitals, nursing homes, and long-term care 
facilities, OSHA assumes establishments will, in addition to their 
current cleaning product purchases, need to purchase a six-month supply 
of multipurpose cleaners and disinfectants, at a cost of $4.54 for each 
(i.e., a supply of multipurpose cleaner and a supply of disinfectants/
virucides), for a total of about $9 per establishment (W.B. Mason, 
2020).
    Hospitals are estimated to spend a total of $56 million annually on 
soaps and cleaning products, and nursing homes and long-term care 
settings are estimated to spend $60 million annually on these supplies 
(BEA, November, 2018). OSHA estimates that spending on cleaning 
products will increase by 5 percent as a result of the ETS, and 
accounts for these increased cleaning product costs on a per employee 
basis, which is equivalent to an additional $0.37 per hospital employee 
and an additional $0.69 per nursing home and long-term care setting 
employee. This increased spending also covers the costs of cleaning 
associated with aerosol-generating procedures under paragraph (g) of 
the ETS.
    OSHA expects that the majority of cleaning that would need to be 
done to comply with this provision is already being done in response to 
CDC guidelines or could be completed in nonproductive downtime without 
affecting worker productivity. Given the emphasis on cleaning and 
disinfection in healthcare settings (those in NAICS 622), the agency 
believes that all necessary cleaning is being done at healthcare 
establishments. However, outside of NAICS 622, OSHA has included a time 
burden of 2 additional minutes per shift for 25 percent of covered 
workers, for cleaning, in order to err on the side of being overly 
inclusive of costs.
    This provision of the ETS also requires that the employer provide 
alcohol-based hand rub (ABHR) or readily accessible hand washing 
facilities. OSHA estimates that this ETS will result in a 10 percent 
increase in the use of ABHR or an average incremental increase of 
0.0067 ounces \45\ of hand sanitizer per use of ABHR (assumed to be 10 
percent of the ABHR needed per use, which translates into a 10 percent 
increase in use overall), with an estimated incremental cost of 0.335 
cents per use.\46\ The estimated number of uses of ABHR is based on the 
estimate for the number of gloves used (see Table VI.B.13), assuming 
that there are two ABHR uses per pair of gloves used (i.e., using ABHR 
before putting on and after taking off each pair of gloves).
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    \45\ According to the makers of Purell, ``If used as directed, 
which is to apply enough PURELL[supreg] Hand Sanitizer to thoroughly 
cover hands, a consumer can get 29-30 uses out of a 2 fl. oz. 
bottle''. Thus, OSHA assumes that each use of hand sanitizer would 
be 2/30 = 0.067066667 fl oz. (GOJO US, 2020). Ten percent of 
0.067066667 fl oz, is 0.0067 fl oz, which is the incremental 
increase in ABHR use per use assumed to be attributable to the rule.
    \46\ The cost of bulk hand sanitizer is estimated as $0.50 per 
ounce (W.B. Mason, 2020).
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Cost per Establishment, Cleaning and Disinfection
    Table VI.B.23 presents the average cleaning and disinfection costs 
for healthcare establishments by setting and establishment size and 
incorporates the baseline compliance rates of 50 percent for very small 
entities and 75 percent for all other entities.
[GRAPHIC] [TIFF OMITTED] TR21JN21.032


j. Ventilation
ETS Requirements--Under Sec.  1910.502(k)
    Employers who own or control buildings or structures with an 
existing heating, ventilation, and air conditioning (HVAC) system, must 
ensure that: The system is used in accordance with the manufacturer's 
instructions and the design specifications; the amount of outside air 
circulated through the system and the number of air changes per hour 
are maximized to the extent appropriate; air filters are rated Minimum 
Efficiency Reporting Value (MERV) 13 or higher, if compatible, or the 
highest compatible filtering efficiency for the HVAC system(s); air 
filters are maintained and replaced as needed; and intake ports are 
cleaned, maintained, and cleared of debris. This provision does not 
require installation of new HVAC systems or AIIRs to replace or augment 
functioning systems. However, where an employer has an existing AIIR, 
the AIIR must be maintained and operated in accordance with its design 
and construction criteria. The regulatory text does include a note 
encouraging additional ventilation measures; however, as they are not a 
mandatory component of the ETS, costs have not been taken for those 
additional measures.
Cost Analysis Assumptions
    For all settings, OSHA assumes each establishment will need an 
average of 3 MERV 13 air filters for large establishments, with 2 for 
SBA-defined small businesses, and 1 for very small establishments. The 
unit cost is $21.50 per filter (Home Depot, 2020).\47\ OSHA assumes 
filters are replaced every three months, and this replacement requires 
10 minutes of labor per filter for an Installation, Maintenance, and 
Repair (SOC 49-0000) employee every three months. For hospitals with 20 
or more employees OSHA assumed that a larger filter would be used, with 
a unit cost of $79 (HD Supply, 2021) and a replacement labor burden of 
20 minutes of labor per filter.
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    \47\ Employers will need to upgrade to the highest efficiency 
filter compatible with their existing system. To the extent 
employers are upgrading to something less efficient than a MERV 13 
filter, there will be some tendency toward overestimating costs.
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    While it is a good business practice to maintain the HVAC system in 
good working order and OSHA believes that most establishments have HVAC 
systems that meet the requirements of the ETS, OSHA estimates that some 
small amount will need to have their HVAC systems serviced. In addition 
to the cost of purchasing and installing new air filters, OSHA 
estimates that large hospitals, nursing homes, and long-term care 
settings will require four hours of a general maintenance and repair 
worker's time to evaluate the condition of the HVAC system and to 
complete any necessary maintenance. In all other settings, 30 percent 
of large employers who need this maintenance will need 2 hours of 
maintenance work and SBA-defined small employers who need this 
maintenance will need 1 hour of maintenance work. OSHA assumes that 
very small entities will be less likely to control the HVAC system in 
their facility and therefore assigns no additional maintenance costs to 
those establishments. Any necessary HVAC work could be done by an 
outside source like an HVAC maintenance contractor or could be done by 
in-house maintenance workers if they are available.
    The draft infectious disease cost analysis prepared for SBREFA 
included engineering control costs for hospitals to maintain AIIRs to 
manufacturer's specifications (OSHA, 2014). These costs were updated to 
current dollars for the analysis of this ETS. And while the infectious 
disease cost analysis included both initial costs and annual 
maintenance costs, since the ETS is only effective for six months, OSHA 
included in this analysis only maintenance costs to bring existing 
AIIRs up to the manufacturer's specifications where they are not 
already being maintained properly. OSHA estimates that most hospitals 
(83 percent) that have AIIRs properly maintain them (ERG, August 9, 
2013).
    Based on analyses performed in conjunction with OSHA's (1997) 
proposed rule addressing occupational exposure to tuberculosis, 64 FR 
54160 (Oct. 17, 1997), the agency estimates that there would be a one-
time cost of $8,143 to perform maintenance on an AIIR so that it 
functions properly (e.g., maintains negative air pressure relative to 
the surrounding areas, completes the recommended number of hourly air 
exchanges) (WCG, November 14, 1994; updated to 2020 dollars). This is 
based on an estimated cost per square foot to purchase and install 
material, including ducting, fans, and HEPA filters, in an average 
isolation room measuring 150 square feet (WCG, November 14, 1994; 
updated to 2020 dollars). Note that since the analysis timeframe is 6 
months, there are no on-going maintenance costs attributable to the 
ETS.
Cost per Establishment, Ventilation
    Table VI.B.24 presents the average ventilation costs for healthcare 
establishments by setting and size. These estimates incorporate the 
baseline compliance rates of 50 percent for very small entities and 75 
percent for all other entities, and a baseline compliance rate of 83 
percent for maintenance of AIIRs in hospitals.

[GRAPHIC] [TIFF OMITTED] TR21JN21.033

k. Health Screening and Medical Management
ETS Requirements--Under Sec.  1910.502(l)
    The employer must screen each employee before each work day or 
shift for COVID-19 symptoms and require employees to promptly notify 
the employer when they are COVID-19 positive, have been told by a 
healthcare provider that they are suspected to be COVID-19 positive, or 
are experiencing certain specified symptoms of COVID-19. When an 
employer is notified that a person who has been in the workplace is 
COVID-19 positive, the employer must notify each employee who had, and 
other employers whose employees had, close contact with that person in 
the workplace. The employer must also notify any employee who worked 
in, and any other employers whose employees worked in, a well-defined 
portion of a workplace in which the COVID-positive person was present 
during the potential transmission period.
    This paragraph also contains a requirement that the employer 
immediately remove any employee who is positive for COVID-19. Removal, 
which in the ETS refers to temporary removal from the workplace, must 
continue until that employee meets the criteria for return to work. In 
addition, the employer must remove any employee who has been told by 
their healthcare provider that they are suspected to have COVID-19 and 
any employee who is experiencing certain COVID-19 symptoms. The 
employer must ensure that any such employee is kept out of the 
workplace until they either meet the return to work criteria or they 
test negative for COVID-19 based on a polymerase chain reaction (PCR) 
test, which the employer must provide at no cost to the employee. In 
addition, the employer must remove any employee who has had close 
contact with someone in the workplace who is COVID-19 positive (unless 
the employee has either been fully vaccinated or has recently recovered 
from COVID-19). Employees who had close contact must be removed for 14 
days or until they test negative for COVID-19 via a test provided at 
least 5 days after the exposure and paid for by the employer. Employees 
who had symptoms or were informed by a licensed healthcare provider 
they are suspected to have COVID-19, but did not have close contact, 
can return to work immediately if they test negative. Employees removed 
because of close contact must stay away from work for at least 7 
calendar days from the date of exposure, even if they test negative.
    When an employee is removed under the above criteria the employer 
must continue to pay the employee's normal earnings, as though the 
employee were still at their regular job, up to $1,400 a week for the 
first two weeks. If employees remain sick after that first two-week 
period and must stay out longer, employers with fewer than 500 
employees are only required to pay two thirds of regular pay, up to 
$200 per day, after the initial 10 working days. Pay during removal can 
be offset with any employer or public benefits, such as paid leave or 
workers' compensation, until the employee meets the return to work 
criteria.\48\ The requirement to pay the employee terminates if the 
employer offers a COVID-19 test at least five days after the exposure 
and the employee refuses to take it. Employers may also require 
employees who are removed from the workplace under this paragraph to 
work remotely or in isolation when suitable work is available. These 
employees would be paid as usual for their work. Employers with 10 or 
fewer employees are required to remove employees from the workplace 
under this paragraph but are not required to pay them during the time 
they are removed.
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    \48\ Recent legislation, the American Rescue Plan Act, Public 
Law 117-2, section 9641, extends tax credits to many employers for 
paid leave provided to employees through September 30, 2021 for 
COVID-19 related reasons. These tax credits will cover leave 
provided to employees removed from work under this ETS. This reduces 
costs to employers by shifting those costs to taxpayers.
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    The ETS does not require notification or removal of employees who 
were wearing respirators, along with other required PPE, at the time 
they had close contact with a person with COVID-19. In addition, an 
employee's close contact with a patient with COVID-19 does not trigger 
the notification requirements (and therefore does not trigger removal 
requirements) if the patient with COVID-19 was in an area where such 
patients are normally expected, such as an emergency room or COVID-19 
clinic (as opposed to a maternity unit of a hospital, a physician's 
office that screens out COVID-19 patients, a physical therapist's 
office, etc.).
Cost Analysis Assumptions
    The health screening activities could include instructing employees 
to perform a self-assessment for symptoms before they arrive to work. 
The training on the elements of this self-assessment are included under 
the cost of training and there is no cost to the employer for this 
activity because it can be completed by the employee concurrent with 
other

daily activities without taking time from those activities. Although 
employers are not required to use temperature screening for employee 
screening, OSHA assumes for purposes of this analysis that this may be 
done as part of screening and estimates that it will take an average of 
15 seconds per employee per day. OSHA also estimates that 
establishments will purchase no-touch thermometers at a rate of 1 per 
100 employees, on average, with a minimum of 1 per establishment and 
unit cost of $29.50 per thermometer (Rice et al., December 18, 2020).
    OSHA also includes 5 minutes of General and Operations Manager (OES 
11-1020) labor per case (i.e., each employee required to notify their 
employer) to make arrangements for the employee per above, and an 
additional 40 minutes per case to notify other potentially exposed 
employees. This includes the time to identify which of the exposed 
employees would be excluded from the notification and removal 
requirements because they were wearing respirators and required PPE at 
the time of the exposure.
Cost per Establishment, Health Screening and Notification
    In order to estimate the feasibility of the ETS and due to the 
highly uncertain path of the pandemic over the period this ETS will be 
in effect, OSHA examined feasibility based on historic numbers of cases 
and fatalities from two periods: March 19, 2021 through April 19, 2021, 
inclusive of the cases on the start and end dates (designated as the 
``primary'' scenario) and a monthly average over April 1, 2020 through 
April 1, 2021, inclusive of the start and end dates (called the 
``alternative'' scenario). Using these scenarios, OSHA estimated cost 
per establishment for the screening and notification requirements of 
this provision under both scenarios. Costs per establishment are shown 
below in Table VI.B.25 by setting and size. They incorporate the 
baseline compliance rates of 50 percent for very small entities and 75 
percent for all other entities.
[GRAPHIC] [TIFF OMITTED] TR21JN21.034

Medical Removal Protection and Medical Removal Protection Benefits
    There are two types of costs that employers can incur to comply 
with the ETS requirements for medical removal: Payments to employees 
who are removed from work and payment for testing to determine whether 
those employees can return to work. OSHA developed cost estimates for 
medical removal protection (MRP) benefits for the two scenarios 
described above in section VI.B.III.k, Health Screening and 
Notification. The estimates for each scenario (primary and alternative) 
follow the same procedure.\49\ In order to estimate the cost to 
employers of providing MRP benefits to their workers, OSHA needed to 
make the following estimates:
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    \49\ The provisions for MRP have an exemption for all 
establishments with 10 or fewer employees, so these establishments 
are not included in calculating the cost of MRP benefits.
---------------------------------------------------------------------------

     The number of workers who would need to be removed \50\ 
from the workplace;
---------------------------------------------------------------------------

    \50\ Includes workers who have or are suspected to have COVID-19 
illness, those diagnosed to have COVID-19 by a licensed healthcare 
provider, those who have specified symptoms, and those who have had 
close contact at work with someone who is COVID-19 positive (unless 
they have no symptoms and have either been fully vaccinated or 
recently recovered from COVID-19).
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     The number of removed workers who would be COVID-19 
positive;
     The number of workers who would receive a COVID-19 test, 
the number of workers who would test negative for COVID-19, and the 
cost to the employer of those tests;
     The number of days COVID-19 positive employees and 
employees who receive a negative COVID-19 test would be paid MRP 
benefits;
     The daily wage paid to removed workers;
     The number of days that can be offset by other paid leave 
benefits; and
     The impact of the tax credit for paid sick leave included 
in the American Rescue Plan Act (ARP), Public Law 117-2, assuming 100 
percent take-up for all

qualifying firms (i.e., those with fewer than 500 
employees).51 52
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    \51\ In estimating the costs and feasibility of an OSHA 
standard, OSHA assumes that employers behave rationally to minimize 
their costs and thus assumes all eligible employers would take the 
tax credit. The agency examines the impact of less than 100 percent 
take-up of the tax credit in the sensitivity analysis in section 
VI.C.XVII.
    \52\ Note that certain government employers (mainly state and 
local governments) are qualified for the tax credit regardless of 
size.
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Number of Workers Removed
    The base number of COVID-19 cases among workers is determined based 
on historic infection data. OSHA's calculations of the number of COVID-
19 cases among workers affected by this ETS, based on the two 
scenarios, are shown in the benefits section of this analysis (see 
section VI.B.VIII.d for details of those estimates).
    As shown in Row A of of the Benefits section, OSHA identified 
2,041,229 COVID-19 cases during the period of March 19, 2021 through 
April 19, 2021, which serves as the basis for the ``primary'' scenario, 
and 2,507,290 cases as the monthly average over the year beginning 
April 1, 2020 and ending April 1, 2021, which serves as the 
``alternative'' scenario.
    As explained in the Benefits analysis, OSHA then adjusted that 
number of cases by removing cases that were outside of the range of 
working age adults (18-64 years) and then including a further reduction 
to account for a percentage of that population that is not employed 
(See Benefits, Rows B and C). Using the primary scenario as an example, 
there were 1,047,145 remaining cases (See Benefits, Row C). OSHA then 
removed an additional 228,797 cases to account for teleworkers, who in 
this analysis do not receive any benefit from the ETS nor incur any 
costs for the employer. The remaining number of cases (818,348, as 
shown on Row E of Benefits) is one month of cases among workers 
expected to be in the physical workplace. While OSHA begins its 
analysis with the same data as presented in Benefits, the Benefits and 
Cost analysis diverge at this point because the Benefits remove 
additional cases to account for community spread (see, Row F), while 
those cases are not removed for costs because employers will incur 
removal costs for those workers regardless of whether they were 
infected at work or elsewhere.
    Because this analysis is examining the effect of six months of the 
ETS, OSHA multiplied that 818,348 by six months to produce a product of 
4,910,088 total cases of workers in the workplace over 6 months. Based 
on OSHA's industry analysis, 13 percent of all employees in the 
workforce are covered by 29 CFR 1910.502 (see the Benefits analysis). 
OSHA assumes that the number of cases would be allocated according to 
those percentages, so during the entire period of the ETS the number of 
workers under the ETS who have COVID-19 are, respectively, 625,933 
(primary), and 768,848 (alternative).53 54 In Table VI.B.26, 
for convenience, OSHA presents the cases discussed in the following 
text.
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    \53\ Primary = 13% (rounded) of 625,933 cases in the workplace 
over 6 months; Alternative = 13% (rounded) of 768,848 cases in the 
workplace over 6 months.
    \54\ The products are accurate--13 percent is a rounded number. 
These numbers do not include teleworkers since they are not in the 
workplace and hence do not qualify for MRP, but they do include 
workers at the physical workplace who actually become infected 
through community spread rather than at work.
[GRAPHIC] [TIFF OMITTED] TR21JN21.035

    Like the benefits analysis, the cost analysis further reduces the 
number of cases to account for vaccinations. Due to the prioritization 
of healthcare workers for vaccinations, OSHA assumes a vaccination rate 
of 75 percent for the healthcare sector.\55\ Since the original CDC 
data reflect cases that occurred during periods with a reduced but 
positive vaccination rate, the calculation to adjust the data for the 
increase to a 75 percent vaccination rate is slightly complicated. It 
is explained later in the Benefits section. The final result is that 
for the primary scenario OSHA estimates that 62.9 percent of the cases 
remain after all adjustments are incorporated, and for the alternative 
scenario, 40.4 percent of cases remain. The reduction in the number of 
cases prevented through vaccination ultimately means that fewer 
employees will need to be temporarily removed from the workplace per 
the requirements of the ETS (with a corresponding reduction in 
benefits). OSHA thus estimates that under the primary scenario there is 
an adjusted total of 393,662 COVID-19 cases (those cases remaining 
after the additional number of cases are reduced to reflect cases 
prevented by vaccination--75 percent) are removed: (625,933 *

0.629)). The adjusted number of cases under the alternative scenario is 
310,637 (768,848 * 0.404).
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    \55\ OSHA had no direct estimates of healthcare workers who have 
been vaccinated but based this estimate on the following sources. 
Workforce COVID-19 vaccination rates among 8 top U.S. hospitals 
(Masson, February 22, 2021) found vaccination rates of about 60 to 
85% among hospital personnel in February 2021. Early COVID-19 First-
Dose Vaccination Coverage Among Residents and Staff Members of 
Skilled Nursing Facilities Participating in the Pharmacy Partnership 
for Long-Term Care Program--United States, December 2020-January 
2021 (Gharpure et al., February 5, 2021) found vaccination rates of 
about 37.5% among nursing home staff. Given the time that has passed 
since these studies and the fact that, in the benefits analysis, 
there is no way to determine job category or industry, OSHA believes 
an overall rate of 75 percent for healthcare workers is a reasonable 
average for the job categories and industries being considered here.
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    Finally, the agency adjusts MRP cases to account for a gradual 
reduction in the need for MRP as the comprehensive protections of the 
standard lower the number of transmissions at the workplace (e.g., 
working with distance or barriers, etc.). Most other costs of the ETS 
do not include this type of adjustment because they are not dependent 
on reductions in workplace transmission (e.g., barriers would still be 
required regardless of whether some workplace transmissions are 
prevented). As in the Benefits analysis, OSHA assumes that the 
effectiveness rate in the workplace will be an overall 75 percent, 
meaning that 75 percent of the infections would be prevented over the 
6-month course of the ETS. The final number of cases for the primary 
scenario is therefore reduced to 98,445 (393,662 * (1-0.75)), and for 
the alternative scenario it is reduced to 77,659 (310,637 * (1-0.75)). 
Note that the effectiveness would be higher except that OSHA assumes, 
as it does in Benefits, that 20 percent of the cases will be worker 
infections resulting from community transmission outside the workplace 
and therefore not reduced by the provisions of the ETS. However, unlike 
Benefits, those community spread cases are not subtracted from the 
total number of remaining cases because the employers will still bear 
the same cost for addressing them as if the worker had been infected at 
the workplace. For example, whether the employee was infected in the 
workplace or outside the workplace, once the employer learns that the 
employee has tested positive for COVID-19 the employer must still 
remove that employee from the workplace in order to protect its other 
employees and must provide MRP benefits to the removed employee.
    OSHA estimates that in half of these cases (49,208 for the primary 
scenario) workers will know they are COVID-19 positive through a COVID-
19 test or via diagnosis by a licensed healthcare provider of suspected 
or confirmed COVID-19 (OSHA assumes this group diagnosed by a 
healthcare provider is then confirmed by a positive test). The other 
half will have symptoms as described in the ETS (before being tested 
and confirmed positive).
    Beyond the positive cases, other workers will need to be removed 
from the workplace because they are exposed to someone at the workplace 
who has COVID-19, or develop the symptoms specified in Sec.  
1910.501(i)(2)(iii) or (iv), even though they are not actually infected 
with COVID-19 and ultimately test negative (but must still be 
temporarily removed from the workplace pending the testing results). To 
estimate this number of removed workers, OSHA assumes that for every 
worker who has symptoms and who will eventually test positive for 
COVID-19 there will be an equal number (49,208 for the primary 
scenario) of workers who will have symptoms but who will test negative 
and not be infected (Kim et al., Jan 25, 2021, Tostmann et al., April 
23, 2020). OSHA further assumes that for every potential COVID-19 case 
reported to an employer (based on a test, diagnosis, or symptoms) there 
will be 1.5 workers who will have close contact at work with a person 
with COVID-19.\56\ The ETS exempts workers who are wearing respirators 
and other required PPE from being removed due to close contact with a 
person with COVID-19. OSHA assumes 25 percent of the workers are 
wearing N95 respirators and the other required PPE (section VI.B.III.e 
of this analysis) and therefore would not need to be notified of such 
contact nor removed from work as a result of it. This is support for 
the assumption that on average 1.5 people covered by the ETS will need 
to be removed because they have close contact with an infected person 
at work. Thus, focusing just on the primary scenario from above for the 
purposes of illustration, with 98,415 COVID-19 cases there will be an 
additional 147,263 workers (98,415*1.5) who would need to be removed 
from work because they had close contact at work with someone who has 
COVID-19.
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    \56\ OSHA examines the effects of varying this assumption in a 
sensitivity analysis (see section VI.B.III.q).
---------------------------------------------------------------------------

Number of Workers Who Would Receive a COVID-19 Test
    When testing is an option, OSHA expects employers to have employees 
tested so that the employees can return to their work as quickly as 
possible. For workers with suspected COVID-19 illness with symptoms, 
which includes cases diagnosed by a licensed healthcare provider that 
are then tested and found to be negative, the employer can offer the 
test immediately. If the test is negative, the worker can immediately 
return to work upon receipt of the test results. If the test is 
positive, the employee would continue removal according to either 
guidance from a licensed healthcare provider or CDC's isolation 
guidance.
    For workers who are removed due to close contact, OSHA has made 
several assumptions. Workers removed due to close contact with a 
primary worker who is COVID-19 positive will either be removed for 14 
calendar days or the employer can provide a COVID-19 test 5 days after 
the workplace exposure. If the results of the test are negative, the 
worker removed due to close contact can return to work 7 calendar days 
after exposure. If the results of the test are positive, the worker 
will continue for the full removal of 14 days. The cost of the test is 
estimated to be a $10 administrative fee plus $5 in travel costs (this 
is an average--some employees will not require any travel 
reimbursement, while others may have higher travel costs); all other 
costs of testing are assumed to be borne by insurance or other third-
party payers. Note that for testing after an employee is removed there 
is no need to factor in lost work time because the employee is not 
working and is already compensated for that time.
Number of Days of MRP Benefits
    If a worker is COVID-19 positive, OSHA assumes they will be removed 
from the workplace on average for 10 working days,\57\ based on 
following CDC guidelines on isolation days and accounting for the 
severity of the cases.\58\ The CDC guidelines recommend 10 calendar 
days minimum for isolation absent a continued fever.
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    \57\ OSHA acknowledges that some workers do not work a standard 
5-day work week but, for the purposes of this analysis, the agency 
assumes all employees who will be removed under MRP do so.
    \58\ See CDC (February 18, 2021).
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    Workers who are removed from work before they know if they have 
COVID-19 fall into two groups: Workers who are removed because they 
have specific symptoms, and workers removed because they have been in 
close contact with someone at work who is COVID positive. For workers 
in this first group (with symptoms) who are provided tests by their 
employers but test negative, OSHA estimates they will be tested on the 
first day they are removed and will be removed from work for an average 
of two days. For workers in the second group, who are removed due to 
close contact with a COVID-19 case in the workplace, the employer may 
provide the employee with a test at least five days after the exposure 
to the COVID positive employee. The regulatory text (paragraph 
(i)(4)(iii)(2)(i) also states that an employee removed due to close 
contact who tests negative can return to work after 7 calendar days 
from exposure. OSHA therefore estimates that employees in the second 
group (removed due to having close contact) will be tested five days 
after exposure and, if their test comes back negative, they will return 
to work after 7 calendar

days (which translates to 5 working days of paid removal).
    If their test comes back positive, OSHA assumes employees in both 
groups (symptoms and close contact) will on average complete the 
remainder of a 10-working day (14 calendar days) period of removal 
before returning to work.\59\
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    \59\ As support for an average of 14 calendar days for isolation 
OSHA drew on several studies to estimate this average based on a 
breakdown of cases to asymptomatic, mild/moderate, severe without 
hospitalization, and severe with hospitalization. First is the 
equation, showing shares of various cases multiplied by their 
expected days out, and then an explanation of each term:
    (17% * 10) + (66.4% * 12) + (7% * 20) + (9.6% * 35.5) [ap] 14 
calendar days.
    Where broken down term by term: The first term is asymptomatic 
cases where CDC guidelines have a minimum of 10 calendar days for 
isolation (CDC, March 12, 2021). The seventeen percent is from 
Byambasuren et al., (December 11, 2020). The second term is for mild 
to moderate cases which may need a couple of extra days above the 
minimum of 10 days (CDC, March 12, 2021). The 66.4 percent comes 
from a study finding that approximately 80 percent of symptomatic 
COVID-19 cases are mild to moderate (Wu and McGoogan, April 7, 
2020). That 80 percent was multiplied by the remaining cases after 
removing the asymptomatic cases: (0.8 * (1-0.17) = 0.664). The last 
term is for hospitalizations, where the total of 35.5 days is from 
both a study by Emory University that found second surge 
hospitalization cases had an average length of stay as 8.2 days 
(Meena et al., March 1, 2021) and another study that found that the 
median number of days to return to work after hospitalization was 27 
days (Chopra et al., November 11, 2020). The 9.6 percent is from 
Grave Danger (Section IV.A. of this preamble). Finally, the third 
term is for severe, but without hospitalization, cases, where the 
maximum number of days CDC expects is 20 days (CDC, March 12, 2021). 
The 7 percent is the percentage left for severe without 
hospitalization after subtracting out the percentages for other 
types of cases.
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Daily MRP Benefits Paid to Removed Workers
    The ETS includes a $1,400 weekly cap on MRP payments, except that 
employers with fewer than 500 workers need not pay more than $200 per 
day (\2/3\ of the worker's regular pay, up to $200 per day) after the 
first two weeks. Since OSHA uses average wage rates in this analysis, 
this analysis necessitated the calculation of a truncated average wage 
with a weekly limit of $1,400 as prescribed in paragraph 
(i)(5)(iii)(A). The wage data used for this analysis do not have the 
kind of detail needed to calculate an exact truncated average wage, so 
the agency employed a relatively rough estimate using the median, 
rather than the average, wage (since with right-tailed data like wage 
distributions the median is below the mean) and then truncating the 
median wage at $1,400 for a full-time, 40-hour work week, if needed. 
This maximum wage is therefore $35 an hour ($1400/40). Note that this 
may overestimate the costs given that wages are capped at \2/3\ of 
regular pay (up to $200/day) after the first two weeks for employers 
with fewer than 500 workers.
Other Paid Leave Offsetting MRP Benefits
    OSHA also considered how much of the MRP payments can be offset by 
other payment sources. For this analysis, OSHA only considered the 
availability and cost offset due to sick leave and payroll tax credits 
for qualifying leave payments made for removal that are part of the 
recently enacted ARP (see Pub. L. 117-2, section 9641).
    For this analysis, OSHA assumed a 100 percent take-up of the tax 
credit for sick leave paid under provisions in the ARP for all eligible 
employers (i.e., establishments with fewer than 500 employees) while 
these provisions are in effect. Hence, for firms with fewer than 500 
employees, all the wage costs associated with providing MRP benefits 
are assumed to be zero while the credits are available. These tax 
credits will generally be claimed on employers' tax returns, which in 
most cases are filed quarterly, although employers may be able to 
access funds early in anticipation of claiming the credits. The agency 
estimates that approximately three months of the ETS will be in place 
while the ARP tax credit will not be unless the tax credit is extended 
(these ARP provisions are currently slated to cover leave provided 
through September 30, 2021) and so OSHA includes \3/6\ of MRP costs to 
account for the three months of costs that would not be reimbursed 
through the tax credit.
    For cases where the employer applies an employee's sick leave to 
days where the employee is both removed from work and is unable to work 
at home, OSHA calculated the average number of sick days the employee 
will have at the time of the removal and deducted those days in 
calculating the wage payments the employer makes. BLS data show that, 
overall, 78 percent of workers have access to paid sick leave with an 
average length of available leave of 8 days.60 61 Assuming 
workers have used, on average, 50 percent of their available paid sick 
leave for other reasons by the time the leave is needed during the ETS, 
the average employee would have 3.12 days of paid sick leave available 
(0.78 * 0.5 * 8). Because there is the possibility of multiple removal 
periods for a single individual (in which case the worker would likely 
have no sick leave available the second time), OSHA adjusted the 
available paid sick leave days per worker down from 3.12 to 3 days. 
Hence, for workers who are removed for symptoms or close contact and 
tested but ultimately found to not be infected, employers will not have 
to pay any quarantine wage costs if the employees are out 3 work days 
or fewer. If they are out longer, the employer would have to pay for 
each of the days the employee is out after the first 3 work days. For 
example, if an employee who was removed for a total of 7 days and 
tested negative, the cost to the employer would be for 4 days of 
removal following the 3 days of sick leave. For employees who are 
COVID-19 positive and must be removed from the workplace for 10 work 
days (14 calendar days), the em