Since it was first identified and described in China in December 2019, COVID-19 has spread to over 197 countries and territories around the world with over 400,000 cases and 18,000 deaths. The case fatality rate may be as high as 3-4% and, although indications are that it is a mild, self-limiting disease for the majority of those who are infected, it undoubtedly has the potential to cause significant global disruption. Several countries are moving from “containment” to “delay” phase in controlling the COVID-19 outbreak, with a recent UK model suggesting a possible peak in June 2020.
The COVID-19 pandemic has led to considerable concern among workers who understandably worry about becoming infected and/or infecting co-workers, customers, and family members. Questions from workers tend to center around three main themes:
- How does COVID-19 occur? Is it primarily by inhalation or getting droplets from spittle and cough on my hands? What type and degree of contact with an infectious person is likely to put me at risk.
- How effective are personal protective equipment (PPE)? Are masks effective in protecting me from the virus and/or protecting others from me if I am infectious?
- What other measures can I take to change my working behavior to reduce the risk of catching COVID-19?
This article aims to address each of these questions, consider current public health advice, and to identify knowledge gaps relating to workplace transmission.
Health Care Workers and COVID-19
Healthcare workers have always had a recognized increase in risk of developing infections and diseases present in the community where their patients are drawn. Healthcare workers are usually on the front line dealing with those who are ill and at the most infectious period of a disease, as in the case of Ebola, MERS, and SARS. Therefore, healthcare facilities can act as a focus for infection spreading, giving rise to disease clusters linked to clinics, hospitals, and other health locations. For instance, during the SARS and MERS outbreaks in 2003 and 2015, around 44 and 100% of cases were linked to healthcare settings. Moreover, healthcare workers made up about a quarter of those who were infected.
Other workers involved in providing services to the public may also be particularly vulnerable during particularly outbreaks where transmission is through close contact, as in the case of COVID-19.
Beyond healthcare professionals, there is a broad range of service-economy workers who may be at risk of a respiratory infection like COVID-19. Jeepney drivers, taxi drivers, bus drivers, cleaners, cashiers, shop workers, hospitality staff, and bank workers are among the many service-sector employees who will have frequent and close interaction with numerous people over the course of a shift. Many of these workers will either have direct physical contact with the public or indirect contact through exchange of goods or money. There are also complex societal issues around workers who may be feeling ill but feel that they have to work for economic or other reasons, and thus increase the risk of infection for their colleagues and the public.
How Does Infection Occur?
Public health advice focuses on four main health measures: thorough and frequent hand washing; avoiding touching your eyes, nose, and mouth; covering your nose and mouth when sneezing or coughing; and maintaining social distancing (at least 6 feet). These health measures are based on the fact that the SARS-CoV-2 virus is transmitted through large airborne droplets and/or from dermal and surface contamination of those droplets. The relative importance of ocular exposure routes, surface-to-hand to peri-oral zone and surface-to-hand to peri-oral zone, and direct inhalation has not been determined.
Over the past two decades, research on understanding dermal and inadvertent ingestion exposure to hazardous substances has been extensive, with much of it publish in various journals. Many of these studies can help us to consider the frequency of hand-to-mouth contact at work, what influences such behavior, and also the features of liquids that affect transmission from surfaces to skin and from hand to mouth. While most studies look at chemical liquids and dust rather than body fluids containing biological agents, they can provide a crucial framework to conceptualize exposure pathways and look at ways to change how work is performed to help minimize the risk of infection and exposure.
How Useful is Personal Protective Equipment (PPE)?
Personal Protective Equipment (PPE) is often the control measure of last resort provided the many challenges in getting workers to wear PPE correctly throughout all of the time it is required. However, the relative role of hand-to-mouth and inhalation is still unclear. While powered air purifying respirators may be a solution for protecting healthcare workers, these are unlikely to be practical in several lower-risk work settings. Wearing masks is likely to lessen inhalation of very small droplets, whereas a disposable respiratory certified to an appropriate standard can (on average) decrease the concentration by about 95%.
Furthermore, there is the potential that wearing masks may discourage people from touching their face; on the other hand, it may increase such activity due to frequent moving of the mask, fidgeting unconsciously, or from irritation of the area around the nose and mouth.
Health Measures: Changing Working Behavior to Reduce the Risk of Becoming Infected
Educating workers about tasks and processes that generate high concentrations of aerosol and demonstrating this through feedback using real-time measurement and/or video can be an effective tool to control exposure. Visualization of hand contamination and the impact of thorough hand washing is important as well.
Developing and recommending changes to workspaces or how tasks are performed can be an effective way to control the spread of the virus. These changes may be structural or behavioral.
Structural workplace changes may include using barriers and screens, particularly in customer-facing roles such as for bankers who face customers daily. These structural changes may offer some degree of protection from COVID-19. It may be worth considering which roles could benefit from distancing measures like this: primary care reception staff, pharmacists, and hospital staff may be protected in this way.
Behavioral workplace changes can also be simple. Already, we are seeing changes to traditional greeting practices with handshakes and cheek kisses being replaced by elbow bumps or other non-contact methods. Maintaining social distance (of at least 6 feet) from others can be effective in protecting workers as well. Reducing the time required at the workplace, delivering services through telephone or video, or working remotely may be an option for some workers and may be effective in containing the spread of the virus.
The Bottom Line
Currently, there are still uncertainties around how transmission of respiratory infections like COVID-19 occur within workplace settings, and there is a crucial need for research on what health measures are likely to be most effective both to protect workers and to prevent workers from spreading disease in the communities that they serve. Researchers should seek to address the following questions:
- In the transmission of COVID-19, what is the relevant importance of inhaled exposure compared to hand-to-peri oral routes and surface contamination?
- How effective are the different types of personal protective equipment (PPE) in reducing both inhaled and surface virus transmission?
- What structural and behavioral changes in the workplace can be encouraged to reduce the risk of spreading the virus?