Information contained in this publication is intended for informational purposes only and does not constitute legal advice or opinion, nor is it a substitute for the professional judgment of an attorney.
On May 1, as part of Littler’s Virtual Executive Employer, attorney Alka Ramchandani-Raj was fortunate to interview Dr. John Howard, the Director of the National Institute for Occupational Safety and Health (NIOSH), to discuss NIOSH’s role in the response to COVID-19 and key safety and health issues facing employers as the economy reopens. We are publishing the interview as part of our “Next Normal” series.
Alka Ramchandani-Raj: Dr. Howard thank you so much for your willingness to join us during these challenging times. We appreciate the hard work that you and your team at NIOSH have been performing over the last several months. Before we look ahead to the world over the next three months, we wanted to ask a few questions about NIOSH's role in the federal government's response to COVID-19. In early 2020 as the virus started to spread around the world and eventually in the United States, how did NIOSH mobilize direct resources to the outbreak and could you explain the coordination between NIOSH's activities and the formulation of CDC's public health recommendations?
Dr. John Howard: The National Institute for Occupational Safety and Health or “NIOSH” is a component of the Centers for Disease Control and Prevention and the first step that CDC does whenever there is an epic outbreak, an epidemiological outbreak or a natural disaster for instance – whether it's Ebola or polio, COVID-19, or a natural disaster like the Deepwater Horizon – is to open up an emergency operations center in Atlanta at CDC's headquarters.
And what that does is bring together all the CDC assets that you would need, all the expertise that you would need, the specialization that you would need in order to respond to that particular disaster or infectious disease epidemic. In this case, a worldwide pandemic. So, what happened very early in late January and early February, as you know, the Health and Human Services Secretary Alex Azar declared a public health emergency on February 4th, actually mobilizing the nation's entire health care community and responding to COVID-19.
CDC began working then very closely with state health departments on tracking the cases of COVID-19, screening travelers from China, as some people remember in the early days where we had airport quarantine stations, and providing interim guidance, immediate guidance, for doctors in terms of this new disease.
NIOSH joined that effort in the CDC emergency operations center. We have special expertise in certain aspects of any disaster and for the COVID-19 pandemic our special contribution is in respiratory protection. NIOSH has what is called the National Personal Protective Technology Laboratory located in Pittsburgh. That is the laboratory that tests new respirators for certification and use in the workplace. And so, that's a special expertise that we at NIOSH have that's often called upon when CDC responds to these large infectious disease outbreaks or disasters. So we then start developing interim guidance to help respond.
In the case of COVID-19 as we all know there was the immediate apparent shortage of filtering face piece respirators like N95s. And so we began developing guidance early on about how the country could cope with that shortage of guidance. Our experts worked in tandem with others at CDC to develop those early public health recommendations regarding respiratory protection. And we continue to work on guidance related to that area.
Alka Ramchandani-Raj: One interesting aspect of the virus and a challenge for employers has been the novel nature of it and the maturation of CDC guidance. What is the process and the standards used by the CDC and NIOSH to update or change the guidance and recommendations made as the outbreak has continued to develop? Is there an established protocol that is used?
Dr. John Howard: Well the protocol is a pretty “here and now” protocol based on prioritization of public health need. It's very stakeholder-triggered. So, for example, NIOSH very early on identified a stakeholder need for information that employers could use to respond to the pandemic in terms of their businesses and operations of the businesses. So we worked with other experts in the CDC emergency operations center and we developed interim guidance which is on our website.
And actually right now as of yesterday [April 30, 2020], I found out, that is the second-most downloaded guidance from the CDC coronavirus website. It's entitled Interim Guidance for Businesses and Employers to Plan and Respond to Coronavirus Disease 2019. So that is one way that we develop guidance is based immediately on the stakeholder need.
And then we gather our experts together. So not so much sure that it's a formal protocol as it is a quick responsive process that we use when we recognize the need. Recently we've gotten interest from employers to add more specificity to our guidance and to have it more industry sector and subsector specific. So we're hoping to be able to do that in the coming revisions to that guidance as well as a number of fact sheets that we have on the NIOSH website.
You know one of the things I'd like to note is some people always ask, “well, why is that word ‘interim’ there before ‘guidance’?” And a lot of times given the rapidity with which we've all had to respond to COVID-19, sometimes we're not yet there in terms of the science having been worked out but because of the pressing need we feel that guidance has to be gotten out. We always are trying to improve it as we go through time.
Alka Ramchandani-Raj: As we work with employers, the first thing that we are asked is what specifically do we need to do to protect our employees? From NIOSH's perspective, what industries are having the greatest difficulty in managing the outbreak and why and how is NIOSH working with them to address their issues?
Dr. John Howard: Well right now, today, May 1 2020, I'd say the industry that's having the greatest challenge in ensuring a safe workplace for their employees is the meat and poultry processing industry. And we're working with them very closely on ensuring a safe workplace. A lot of challenges there in that industry, but other industries in which there are congregate living arrangements like nursing homes or prisons and jails, they're also facing challenges because you've got people living and working in very close quarters.
And, that's an issue. And if I can extrapolate it to other industries between the production industries in which you only have employees within the workplace. And then contrast that with industries on the consumption side, service industries where you have both employees and customers. I think the challenge is for the consumption service-based industries, it's a little harder because you're seeing customers coming in, the production side a little easier, but still in meat packing due to the fact that they're very close to, having to work very close together, they have a very large challenge. We in NIOSH and CDC personnel have provided onsite assistance to meatpacking and poultry processing plants in so far – 18 states.
And as a result of that assistance we've published on the CDC website guidance for meat and poultry processing. We also published just today a MMWR article, which is Morbidity and Mortality Weekly Report, which is CDC's major scientific communication publication. We published an article today summarizing those investigations and the various recommendations we have to ensure that those workplaces are safe.
Alka Ramchandani-Raj: As you know, there has been widespread reporting about shortages of personal protective equipment, otherwise known as PPE, and specifically respiratory protection. What has NIOSH done if anything to help with the shortage of N95 respirators or other types of PPE? And how would you advise an employer that's attempting to acquire PPE but is unable to do so due to supply chain issues?
Dr. John Howard: Well this is a big question. You know one of the first things that I would say is that we have streamlined and shortened the approval process for N95 respirators also called a type of filtering face piece respirator. Normally the approval process can take up to six months. We've added staff, we used overtime, lots of different methods that we've been able to reduce the approval of a new unit down to seven to ten days.
So we've been working overtime, 24/7, to get those approvals out because we're well aware of the constrained supply of filtering face piece respirators, especially as you mentioned before in the health care industry. We also recently issued a new rule, an interim final rule that created a new standard for a particular type of respirator, an alternative to a filtering face piece respirator called a powered air purifying respirator, or “PAPR” for short, and tailored for the health care and hospital environment.
We're hoping that given the shortage in that industry, they can utilize alternatives such as the PAPR and we have a number of manufacturers who are very interested in producing PAPRs for the health care industry, especially for use when health care workers are engaged in aerosolized procedures or procedures in which small aerosols can form, like intubating a patient and putting them on mechanical ventilation.
We've also continued to work closely with our federal partners at the U.S. Food and Drug Administration and OSHA to provide guidance for health care providers on how to remain safe during this public health emergency given that constrained supply of respirators. Now our goal is to provide science-based infection and control recommendations, but we're also having to balance that for the current reality of a limited supply of N95 respirators in health care settings.
So to summarize, we've done I think five things that address your question. First, we've put out guidance about optimizing the supply of N95s by utilizing all the steps in the hierarchy of controls. A lot of employers jump right to the bottom, you know to the PPE, and they don't go through the other steps of engineering controls, administrative controls and other steps in the hierarchy.
The second thing we've done is to emphasize that there are NIOSH-approved alternatives to the filtering face piece respirator and especially to the N95, where it's feasible a P100 for instance can be used, an elastomeric, a half face or a full faced elastomeric, or as I said before, a powered air purifying respirator.
The third thing we've done is to look at the issue of a respirator that a hospital might get from the stockpile, the national stockpile, those respirators may have exceeded their designated shelf life. And we've given guidance about how those respirators can be evaluated by the user and use, looking carefully at the elastic bands that attach the respirator to the head for instance as an example.
We've also given advice about respirators that are comparable to the N95, but are made in other countries like China and we have advice and recommendations for purchasers of the N95s based on whether or not they conform to international standards like European Union standards.
And then lastly, we've put out guidance about decontamination of N95 respirators and their reuse, chiefly by three methods: vaporous hydrogen peroxide; germicidal radiation; and heat and humidity. So a number are beginning to use vaporous hydrogen peroxide to decontaminate tens of thousands of N95s that then go back into use in health care where the constraints of supply are significant.
Alka Ramchandani-Raj: As companies return to work, they may require N95s to perform other types of work safely, such as in construction. Or in California, we see this with the wildfire smoke prevention regulation. What should employers do with the shortage if they cannot obtain these masks?
Dr. John Howard: We realize that N95s are prioritized for health care, where doctors and nurses and others in the hospital environment are exposed to significant dosages of SARS Coronavirus 2. So, we're trying to make sure that the N95s that are available, given the constraint supplies are utilized in health care and then, as you mention, that can leave other industry sectors like construction, wildland firefighting, etc., without. We believe that those alternatives that I mentioned before – the elastomeric and the PAPR should be looked at by those employers. In construction, it's more acceptable by workers and employers to use some of those alternatives than it would be in health care.
Certainly in firefighting, firefighters use SCBAs that are trained in using these highly advanced respirators. So the answer to the question is we realize there is a constraint. We want to save N95s and other filtering face piece respirators for the health care industry. So we hope that other industries that are experiencing that shortage will switch to a higher level, an alternative respirator.
Alka Ramchandani-Raj: Over the next two days, we will be exploring a number of return to work issues as the economy begins to reopen. From NIOSH's perspective, what are the biggest challenges facing employers in reopening safely?
Dr. John Howard: Well you know there are a lot of challenges. And again, I refer all of our listeners to the interim guidance for businesses on the CDC website. But certainly you know there's a number of steps I think that are challenges for employers based on whether they're operating a production-type workplace in which there are only employees present or even more challenging where they're operating a workplace in which consumption is the issue, a service-type sector.
So preparing the workplace I think is a big challenge, responding to varying levels of transmission in the community that the workplace is in and applying trigger breaks for instance. I think it's extremely important that employers check in with their local public health department to see where cases are going up, down, flat, whatever, in their workplace. I think it's very important to identify a workplace infection control coordinator or officer. One person has to be responsible for all the various steps that an employer has to take and it's extremely important I think to do that.
I think then that coordinator, with the employer, has to decide whether they're going to use any kind of viral testing for their employees. Clearly, when you want to reduce transmission among employees in the workplace, preventing the virus from coming into the workplace for instance, making sure that people who are sick can stay home.
We have to de-dense-ify a lot of workplaces using the mitigation principle that you hear about every day, physical distancing. But we also have to look at whether staggered shifts can work, whether telework can continue to work, virtual meetings instead of in-person meetings, and in some workplaces we have to actually put partitions between the employees and a customer as we see now in grocery stores and pharmacies and other areas.
I think it's important for employers to make sure that they have a plan when they see absenteeism spiking in their workplace perhaps due to a spike in the cases in their particular area. What's the plan for that? I think the environment of the workplace also and how to make it safe. That's a big challenge too. What's the ventilation rate in an indoor workplace? What's the percentage of outdoor air that we're doing to recirculate?
What's the procedure that we use for routine and regular environmental disinfection of touch surfaces and objects? And what's our plan when a suspected case is reported to us for environmental cleaning and disinfection? So all of those I think are the challenges that an employer faces and no one is bigger than the other. I think the point I would make is they all have to be done. Otherwise there may be a gap in your protection strategy for your workplace.
Alka Ramchandani-Raj: From an engineering and administrative control perspective, how can employers know what measures to implement in the worksite? For example, if an employer cleans frequently and does some sort of symptom screen, does the employer also need to implement social distancing or create barriers between desks? Many employers are struggling with how much is enough as they open their work environment.
Dr. John Howard: I understand it's really a significant issue of what, when enough is enough. And the only advice I can say is to go through the hierarchy of controls looking at the workplace from the perspective of the virus. If you were the virus how can you get from an infected individual who happens to be in your workplace that you have not been able to catch coming into your workplace by thermometer checks or asking them if they're sick or if they've been in contact with a suspected or confirmed case in their family and you're in the workplace.
The virus is now in the workplace. How can you prevent it from jumping from one person, an infected person, to the other? Because remember, this virus has no feet, it doesn't have wings, it needs people to be together in order to get from one person to the other.
So I always say look at it from the virus's perspective. Where's the advantage to the virus in getting from an infected person to another infected person? Where is the advantage of the virus that's laying on a table that an infected person has just touched that another uninfected person may come along within a number of hours or a couple days, not, not two weeks later, that you have not cleaned that day, because as you know a contaminated workplace with your fingers on it is only a touch away from your eyes or your nose or your mouth and that's how the virus gets in.
So I realize that knowing when enough is enough is a very difficult question. But I think clearly if you're in a community in which there is a lot of person-to-person spread and there are a lot of cases reported and you have a workplace in which physical distancing is a real challenge, you have to work harder at it, and you have to employ other parts of the hierarchy of controls.
Alka Ramchandani-Raj: Finally we want to close on a couple of hot topics—the use of face coverings and symptom checks. Do you recommend that all employers regardless of industry mandate the use the face coverings? And can you explain the difference between a face covering and an N95 respirator?
Dr. John Howard: Well the first question is very easy to answer. Yes. CDC recommends wearing a cloth face covering in public settings and that's a workplace unless you work entirely by yourself. Where, especially where other social distancing measures are difficult to maintain. And again we go back to those service-type workplaces, grocery stores and pharmacies, especially important that everybody wear a cloth facemask, customers and the employees in that because we want to interrupt significant person-to-person spread.
The assumption is currently that a lot of us are asymptomatic and certain surveys have shown up to 25 percent of folks sampled can be asymptomatic. They could be shedding the virus from their nose. You want to keep those orifices covered especially when you're interacting close to other people. We always suggest a six-foot minimum. But, remember you know passing somebody on the street or the sidewalk. It's not just distance, it's duration that you should take into consideration, that kind of passing somebody for a very short period of time a matter of seconds. That's a very very low risk interaction. But when you're together as a clerk in a grocery store with tens of people coming in it's important that we use a cloth facial covering for that. They can be fashioned from household items and materials at home. There's lots of information on various websites about how to sew such a low-cost facial covering.
Now the second question is, is an important one too. They're not PPE. They are not the same as a respirator. What they are is a type of source control. In other words, you are assumed to be the one who may be asymptomatic but harboring the virus. And we want to put a cloth face, facial covering over you because we want to control the source, meaning you have been shedding the viruses, especially from coughing, sneezing, strong forcible speaking even.
And we've had certain situations where we've had outbreaks in church choirs because they've all been singing close together, not separated. The cloth facial covering protects others from the covered person. The N95, it protects the wearer in a health care setting where you have patients with COVID-19, they cannot keep on any kind of facial covering because of their coughing and other things. A filtering face piece respirator like an N95 protects the wearer especially from aerosolized hazards that we see in hospitals. As I mentioned, from intubation. So that's the difference between a cloth facial covering as a source control and a respirator as an N95 protecting the wearer.
Alka Ramchandani-Raj: Thank you again Dr. Howard, this has been extremely helpful to our viewers. Are there any closing notes you would like to make to the employers listening to this?
Dr. John Howard: Well the last thing I'd like to say is first of all thank you for inviting me to speak with you all today and for the listeners who are interested in all the guidance that is available on CDC website. All they have to do is go to the main page. They'll see a big coronavirus there. They click on that and then go to “What's New.” And every day we update that with the new guidance that came out that day. So, I encourage people if they want more information to go to What's New on the Coronavirus Web site at www.CDC.gov.
Alka Ramchandani-Raj: Thank you again for joining us Dr. Howard. This has been extremely helpful. We will continue to closely monitor the great work that you and your team at NIOSH are performing.