Dear Safety and Health Code Board,

The American Federation of State, County and Municipal Employees (AFSCME) strongly supports adopting an Emergency Temporary Standard for Infectious Disease Prevention: SARS-CoV-2 Virus that Causes COVID-19 and urges the incorporation of the following recommendations to the final standard.  

AFSCME’s 1.4 million members serve in hundreds of occupations across the nation—from nurses to corrections officers, childcare providers to bus operators—providing the vital services that make America happen. AFSCME advocates for fairness in the workplace, excellence in public services, and freedom and opportunity for all working families. An important part of AFSCME’s mission is to advocate for the workplace health and safety of working people, including AFSCME members who work in Virginia.

SARS-CoV-2, the virus that causes the Coronavirus Disease 2019 (COVID-19) and source of the COVID-19 pandemic, has spread to 188 countries. As of June 17, 2020, the United States continued to be the epicenter of this pandemic with 2,137,604 confirmed cases and 117,030 deaths¹. Confirmed COVID-19 cases in Virginia totaled 55,331 and were responsible for a total of 1,570 deaths². The number of cases is likely underestimated because testing capacity in the United States continues to be limited and some individuals infected with the virus never exhibit symptoms.

Importance of a Mandatory Standard

Given the continuing widespread transmission of COVID-19, it is critical that the Board and VOSHA immediately adopt and implement an emergency temporary standard. Only a mandate, such as a standard that requires employers to establish an infection control plan, can ensure the safety of workers. Voluntary guidelines and recommendations focusing on COVID-19 will not protect workers sufficiently, as evidenced by the fact that many employers currently are not taking the appropriate and necessary steps to protect workers from COVID-19 exposure. This failure of voluntary guidelines has had and will continue to have tragic consequences, as is readily apparent in the number of confirmed cases and deaths among essential workers. In adopting a final standard, we urge the Board and VOSHA not to defer to voluntary guidelines. In particular, we urge elimination of the proposed standard’s safe harbor that deems an employer’s compliance with CDC recommendations for mitigating SARS-CoV-2 and COVID-19 related hazards or job tasks addressed by this standard as constituting compliance with the standard. The standard must be a mandatory requirement that supersedes any recommendations or guidelines.

Potential Vaccine.

Although there is no vaccine currently available to prevent COVID-19, the FDA is working with vaccine developers, researchers, and manufacturers to expedite the development and availability of medical products like vaccines and treatments. If a COVID-19 vaccine were to become available in the future, AFSCME supports voluntary vaccination programs that make a safe vaccine available at no cost to the employee and at a reasonable time and place. However, no worker should face any form of retaliation for refusing to be vaccinated. The employer should ensure that employees who decline to accept a recommended and offered vaccination sign the statement for each declined vaccine. The federal Occupational Safety and Health Administration (OSHA) adopted this position in the Bloodborne Pathogens Standard, and we urge the Board to follow this approach³. Without a vaccine or effective medical treatment, the resurgence of COVID-19 cases is a possibility as reopening begins.

Antibody Testing

We urge you to eliminate the serological test section (in §40 A.3) in the proposed standard because of the significant uncertainties and shortcomings of antibody testing and the potential for misuse. In addition to the potential for generally producing false-positive results, tests for antibodies could be affected by cross-reactivity. That is, the test may identify antibodies for other coronaviruses, such as the common cold, not necessarily antibodies for SARS-CoV-2. Further, little is known about immunity or protection after infection by the virus, including the effectiveness and duration of any immunity. For example, research suggests that the immune response may not be long-lasting, especially for individuals who were asymptomatic⁴. In addition, it would allow employers to misuse the test against workers. Given these concerns, we strongly urge the Board to eliminate this section completely.

Universal Precautions

A deficiency in the proposed standard is that it focuses too heavily on respiratory droplet precautions. While transmission occurs mainly through respiratory droplets, it also happens through aerosols and contact from the droplets and aerosols that settle on surfaces, where they can remain viable for as long as several days. Universal precautions need to be implemented, including transmission-based precautions for aerosol, contact and droplets for workers who come into direct or indirect contact with suspected or confirmed COVID-19 cases.

Exposure Risk Level

While all workers are at risk of becoming exposed to SARS-CoV-2 in the workplace, the proposed standard requires employers to classify each employee according to the hazards they are potentially exposed to and the job tasks they undertake and then to implement controls and protections based on whether the hazards or job tasks classified have a very high, high, medium or lower level of exposure risk. We are concerned that the proposed exposure risk level classifications do not accurately reflect current workplace infections and may not provide for movement between categories as conditions in the workplace change.

Further, some hazards and job tasks are incorrectly categorized and should be reclassified to address the high risk of exposure in certain settings, especially during periods of community transmission. For example, the proposed standard incorrectly classifies some nursing home worker tasks as medium risk when the residents with whom a worker comes into contact may be infected with SARS-CoV-2 but are not known or suspected to have COVID-19. Given the disastrous impact COVID-19 has had in nursing homes — with nursing home workers and residents accounting for one-third of all COVID-19 deaths nationwide and, as of May 11, three-fifths of deaths in Virginia⁵— we urge you to categorize nursing homes as high risk.

Occupational Exposure Definition

Occupational exposure should be defined as the state of being actually or potentially exposed to contact with SARS-CoV-2 virus disease-related hazards during the course of employment and not job tasks. Workers can be exposed to the virus while on paid break time, in a worksite cafeteria room and in other circumstances beyond the performance of specific job tasks.

Infectious Disease Preparedness and Responses Plan Recommendations

An Infectious Disease Preparedness and Responses Plan is an essential element of a prevention program. The plan determines which workers are at risk and the activities and operations that put them at risk. All employers should develop a plan with the involvement of management, employees and employee representatives. The proposed standard does not require the involvement of employees and employee representatives. Therefore, we urge you to revise this in the final standard. The plan should incorporate the following:

• The employer and employees should conduct a job-exposure determination by occupation and activities. Management and employee involvement are crucial to identify workplace hazards in the assessment. The hazard assessment must be continuous as job activities and operations may change rapidly.
• All employers should use engineering and administrative controls to mitigate the hazard. Following the hierarchy of controls, where engineering and administrative controls do not provide sufficient protection, the employer must provide and ensure that employees use personal protective equipment (PPE).
• Training.
• Health screenings.
• Reporting of exposure or incident.
• Recordkeeping.
• Anti-discrimination and anti-retaliation provisions.
• Plan evaluation.

Engineering Controls

In addition to the recommend engineering controls in the proposed standard, employers should modify the ventilation rate to be 12 or more air changes per hour (ACH). The required ventilation rate may be achieved in part by using in-room high-efficiency particulate air (HEPA) filtration or other air cleaning technologies. In healthcare settings ventilation headboards can be used when an airborne infection isolation room (AIIR) room is in use or not available. Personnel who transport a COVID-19 case or suspected case in a vehicle need a solid partition that separates the passenger area from the area where employees are located.

Administrative Controls

In addition to the proposed administrative controls, we urge an additional requirement that employers implement adequate staffing levels to work safely. Employers must also incorporate rests and shift breaks to avoid worker fatigue during the pandemic. Wearing PPE can be extremely physically taxing; workers who need to wear PPE ensembles for long periods of time should be given breaks and relief when needed. Additional staff may be necessary to assist workers in donning and doffing PPE safely. PPE stock and supplies need to be available for workers to use for possible surges. Stockpile plans need to be in place to ensure PPE and supplies are readily available and accessible. Front-line public service workers are critical to fighting this pandemic and re-opening our economy; in the past several months, many have lacked adequate PPE because of shortages and unpreparedness by some employers.

Health screenings are used to monitor at-risk workers for illness and to manage those who develop symptoms. The daily health screening should be on paid time completed at each shift for each worker before they enter the facility. The health screening should include temperature checks and a respiratory health questionnaire.  The best practice is for workers to avoid forming lines to complete a temperature check and employers to use a communication system to notify workers when to approach the testing area while they possibly wait in their personal vehicles. Workers who are symptomatic should be sent home until they test negative for the disease or have ceased exhibiting symptoms for a long enough period.

The proposed standard is not consistent in how each category in the exposure risk level (very high, high, medium, low) is controlled and makes egregious exclusions. For example, in health care settings which are considered very high/high risk, the proposed standard requires employers to provide alcohol-based hand sanitizers containing at least 60% ethanol or 70% isopropanol to employees at fixed worksites and to emergency responders and other personnel for decontamination in the field when working away from fixed work sites. However, this is not required for workers in the medium exposure risk level.

Personal Protective Equipment   

PPE is the last line of defense and should only be considered after exhausting engineering and administrative controls. The equivalency of surgical masks and respirators must be avoided in the proposed standard text. The listing of PPE selection in the proposed standard needs to be corrected to only list PPE such as gloves, gowns, goggles and respirators (N95 are the minimum). Surgical masks, procedure masks, dust masks and face masks are not considered respirators and therefore are not respiratory protection. Surgical masks and face coverings are not designed to filter particles or provide a seal against the wearer’s face to prevent leakage. Respirators should be certified by NIOSH. Under the NIOSH classification system, an N95 respirator is the minimum level of protection⁶. A P100 filter/respirator can be used in place of an N respirator and offers a higher level of protection.

Half-face elastomeric respirators are reusable and offer a better seal on the wearer’s face. During the pandemic, elastomeric respirators have been a beneficial choice for a hospital in Maryland⁷. California’s Aerosol Transmissible Disease standard mandates powered air-purifying respirators (PAPR) with High-Efficiency Particulate Air (HEPA) filters, or a respirator providing equivalent or greater protection, to employees who perform high hazard procedures on confirmed COVID-19 cases or suspected cases. The final standard should require a PAPR with a HEPA filter to be used whenever a worker performs a high-hazard procedure on a known or suspected COVID-19 case such as intubation, airway suction and caring for patients on positive pressure ventilation. The use of anything less than the listed PPE would be dangerous.

Training

Employers should ensure that all workers regardless of occupational exposure participate in a training program. The employers should provide training at the time of initial assignment and at least annually thereafter, not to exceed 12 months from the previous training or when changes (such as the introduction of new engineering or work practice controls, modification of tasks or procedures or institution of new tasks or procedures) affect the employee's occupational exposure or control measures. When workers are trained, the training material must be appropriate in content and vocabulary to the education level, literacy and language of employees being trained. Every training program should include an opportunity for interactive questions and answers with a person who is knowledgeable in the subject matter of the training as it relates to the workplace that the training addresses and who is also knowledgeable about the employer's plan.

The training program should contain at a minimum the following elements:

A. The requirements of this standard.

B. Explanation of the employer's plan; the means by which the employee can obtain a copy of the written plan; and how employees can provide input as to its effectiveness.

C. COVID-19 symptoms, including the signs and symptoms that require urgent medical attention.

D. Awareness that transmission can occur when infected individuals are pre-symptomatic and asymptomatic.

E. An explanation of the modes of transmission and applicable source control procedures.

F. An explanation of the appropriate methods for recognizing tasks and other activities that may expose the employee to COVID-19.

G. An explanation of the use and limitations of methods that will prevent or minimize exposure to COVID-19, including appropriate engineering and work practice controls, decontamination and disinfection procedures and personal and respiratory protective equipment.

H. An explanation of the basis for selection of PPE; its uses and limitations; and the types, proper use and fit, location, removal, handling, cleaning, decontamination and disposal of the PPE items employees will use. Training should meet the requirements for workers whose assignment includes the use of a respirator.

I. An explanation of the procedure to follow if exposure or incident occurs, including the method of reporting the incident, the medical follow-up that will be made available and post-exposure evaluation.

J. The anti-discrimination and anti-retaliation provisions of the standard.

Recordkeeping

Recordkeeping is an important component of a standard as it provides opportunities for program improvements. The proposed standard is missing any form of recordkeeping and should require employers to maintain the following records:

(1) Medical records and COVID-19 Exposure Logs.

(2) Training records. Training records should include the following information:

A. The date(s) of the training session(s).

B. The contents or a summary of the training session(s).

C. The names and qualifications of persons conducting the training or who are designated to respond to interactive questions.

D. The names and job titles of all persons attending the training sessions.

(3) Records of implementation of the Infectious Disease Preparedness and Responses Plan.

A. Records of an annual review of the Plan should include the name(s) of the person conducting the review, the dates the review was conducted and completed, the name(s) and work area(s) of workers involved and a summary of the conclusions.

B.  Records of exposure incidents should be retained. These records should include: the date of the exposure incident; the names, and any other employee identifiers used in the workplace, of employees who were included in the exposure evaluation; the disease or pathogen to which employees may have been exposed; the name and job title of the person performing the evaluation; the date of the evaluation; and the date of contact and contact information for any other employee who either notified the employer or was notified by the employer regarding potential employee exposure.

C. Records of inspection, testing and maintenance of non-disposable engineering controls, including ventilation and other air handling systems, air filtration systems, containment equipment, biological safety cabinets and waste treatment systems. The records should include the name(s) and affiliation(s) of the person(s) performing the test, inspection or maintenance, the date and any significant findings and actions that were taken.

D. Records of the respiratory protection program should be established and maintained in accordance with OSHA’s Respiratory Protection standard. Records of stockpile (inventory) and availability of PPE should also be maintained.

Last, we strongly support the anti-discrimination/anti-retaliation language in the proposed standard.

Workers are stepping up to the plate by continuing to serve their communities during this pandemic. In the past, Virginia adopted state standards that go beyond the federal OSHA standards when it recognized hazards for confined spaces in the telecommunications industry and tree trimming operations. We applaud Virginia for recognizing COVID-19 as a health hazard to all workers. We urge the Board to continue to make strides for worker protections and take immediate action to protect workers from COVID-19 by issuing and enforcing the Infectious Disease Prevention Standard. AFSCME appreciates the opportunity to provide these comments. If you have any questions, please feel free to contact me.

Sincerely, 

           Eunice Salcedo

           Health and Safety Specialist

           Department of Research and Collective Bargaining Services

           AFSCME