This post is the sixth in an ongoing series on pandemic preparedness and response planning. It builds on the previous post, Pandemic Preparedness and Response Planning – Pandemic Preparedness and Response Committee, Working Groups, and Roles and Responsibilities. If you haven’t already read that, take a few minutes to do so before diving into this post.
In the last post we described why identifying key decision makers, defining roles and responsibilities, and assigning accountability is crucial to a facility being prepared and able to effectively respond once a pandemic is upon us. The next phase of pandemic preparedness planning is putting in controls designed to minimize initial exposure, contain spread, and provide for safe operations during a pandemic. These traditional concepts have been used to protect employees against workplace hazards for decades – although we have had limited experience in applying to pandemics or epidemics. This post will describe the hierarchy of workplace hazard controls and explain their applicability during a pandemic.
Hierarchy of Workplace Control
Typically, there are four or five levels of controls used to protect employees from various physical and health hazards in the workplace, although the first two are often combined.
The idea is that the control methods at the top of the hierarchy are more effective and protective than those at the bottom if and when they can be implemented to control a specific hazard. Because the most effective control sometimes does not apply, a facility then evaluates the next most effective control until the workplace and job function can be done safely. Following this hierarchy normally leads to the implementation of inherently safer systems. Both the National Institute for Occupational Safety and Health (NIOSH) and the Occupational Safety and Health Administration (OSHA) have provided guidance and established standards and rules based on this hierarchy.
Elimination and substitution physically remove or replace the hazard. In some cases, there is no substitute, the hazard is integral to the facility or business, or there is no way to eliminate the hazard entirely. A mandatory reverse use of this control arguably was employed in response to COVID-19. Because the threat of the COVID-19 hazard could not be effectively removed from the workplace, federal and state governments removed the workers from the hazard at non-essential businesses by ordering the businesses to close temporarily. Because individual facilities cannot eliminate the risk of COVID-19 entering the workplace as it is foreign to the entity and the operation, there are no elimination or substitution controls available short of shutting down operations.
EPA has effectively used this strategy with respect to banning and/or severely restricting the manufacture or use of certain chemicals over time (e.g., asbestos, PCBs, etc.), but this usually does not occur until the hazards of a chemical are well known and there have been significant adverse impacts. Institutions and industries have been very effective over the last several decades at eliminating many workplace hazards by voluntarily substituting less hazardous chemicals for more hazardous chemicals or changing processes to use less volume of chemicals. While this strategy is very effective with chemicals and processes that are well understood, it is not easily applied in a pandemic scenario.
Engineering controls isolate people from the hazard, typically through process changes or physical separation. They are designed to remove the hazard at the source before an employee whose job requires interaction with the hazard encounters it. Well-designed engineering controls can be highly effective and typically do not require any significant behavior change on the part of the employee.
We are getting accustomed to seeing some of the engineering controls that are being implemented in response to COVID-19 and are starting to learn more about the effectiveness of applying different engineering controls in our attempt to contain its spread. Examples of engineering controls include:
- Installation of physical barriers such as plastic guards in grocery stores, post offices, busses, etc.
- Installation of high-efficiency air filters and/or increasing ventilation rates in manufacturing facilities, office buildings, research labs.
- Specialized negative pressure ventilation in some settings such as healthcare and autopsy.
- Limiting customer interactions to a drive through window or front door pickup at restaurants, retail establishments, etc.
- Non-touch temperature readers at workplace entryways.
- Designating separate up and down staircases and mandating specific traffic flow patterns within a building to avoid face-to-face interactions.
- Limits on volume of people in a space at offices, grocery stores, retail stores, gatherings, etc.
- Designating specific seats that can be used in movie theatres, conference rooms, auditoriums, etc.
- Locking or taping of restroom stalls and urinals.
Administrative Controls/Safe Work Practices
Administrative controls require changes in the way people do their work and are typically implemented with existing processes where hazards are not particularly well controlled. We are getting accustomed to numerous administrative controls through the response to COVID-19 including, in part:
- Postponing/cancelling large social gatherings like professional/collegiate sports, concerts, and parades.
- Closing schools, colleges, vocational centers, certification programs, etc.
- Temporarily shutting down “non-essential” workplaces (as identified by federal and state governments).
- Encouraging or requiring sick employees to stay home/self- isolate.
- Establishing alternating days or extra shifts that reduce the total number of employees in a facility at a given time.
- Requiring social/physical distancing.
- Limiting/discontinuing nonessential travel.
- Imposing or voluntarily implementing work-from-home policies.
- Requiring self-isolation or quarantining once arriving in certain states.
- Replacing face-to-face meetings with remote meeting platforms.
- Enhanced promotion of personal hygiene, increased cleaning of hard surfaces, readily available hand sanitizers, increased signage, etc.
- Mandatory use of face coverings in public.
- Restricting entrance into hospitals by non-patients.
- Providing alternative transportation to essential employees that rely on public transportation.
- Preparing protective procedures for travel when it is essential.
Administrative controls require behavioral changes and are usually more effective with at least some basic training or increased awareness of why they are being imposed. Based on initial data, some of these controls in isolation and in combination have shown to be effective in some settings and significantly less effective in others.
Personal Protective Equipment (PPE)
While engineering and administrative controls are considered more effective in minimizing exposure, PPE is needed to prevent certain exposures. There are some jobs that cannot be done with 6 feet of separation and the use of face coverings would not protect the worker (face coverings and masks are for the protection of others, not the wearer, which is why they are not PPE). For example, healthcare workers treating COVID-19 patients cannot do it safely without using enhanced respiratory protection, body protection, eye protection, etc. While correctly using PPE can help prevent some exposures, it should not take the place of other prevention strategies.
Examples of PPE include: gloves, goggles, face shields, and respiratory protection, when appropriate. During an outbreak of an infectious disease such as COVID-19, recommendations for PPE specific to occupations or job tasks may change depending on geographic location, updated risk assessments for workers, and information on PPE effectiveness.
All types of PPE must be:
- Selected based upon the hazard to the worker.
- Properly fitted and periodically refitted, as applicable (e.g., respirators).
- Consistently and properly worn when required.
- Regularly inspected, maintained, and replaced, as necessary.
- Properly removed, cleaned, and stored or disposed of, as applicable, to avoid contamination of self, others, or the environment.
Employers are obligated to provide their workers with PPE needed to keep them safe while performing their jobs, as well as training on the proper use of PPE. The types of PPE required during a pandemic are based on the risk of being infected while working and job tasks that may lead to exposure. For example, workers, including those who work within 6 feet of individuals known to be, or suspected of being, infected with COVID-19 and those performing aerosol-generating procedures, need to use NIOSH-approved, N95 filtering facepiece respirators or more protective respiratory protection. A comprehensive, written respiratory protection program that includes fit-testing, training, and medical exams should be implemented.
When disposable N95 filtering facepiece respirators are not available, alternative respirators may include: a R/P95, N/R/P99, or N/R/P100 filtering facepiece respirator; an air-purifying elastomeric (e.g., half-face or full-face) respirator with appropriate filters or cartridges; powered air purifying respirator (PAPR) with high efficiency particulate air (HEPA) filter; or supplied air respirator (SAR). Use of a surgical N95 respirator is effective when both respiratory protection and resistance to blood and body fluids is needed.
Respirator training should address selection, use (including donning and doffing), proper disposal or disinfection, inspection for damage, maintenance, and the limitations of respiratory protection equipment. The appropriate form of respirator will depend on the type of exposure and on the transmission pattern of COVID-19.
Hazard Control Program
Every facility’s pandemic preparedness and response plan should include a workplace or hazard control section that addresses each of the hierarchy of controls and includes.
- Written procedures to control the known and identified hazards.
- Procuring equipment needed to control hazards.
- Assigning responsibilities for implementing the controls.
- Overseeing compliance with the written controls, at least until it becomes part of “normal operations.”
- Conducting employee training.
- Developing written Standard Operating Procedures (SOPs), Standard Maintenance Procedures (SMPs), and protocols for the controls that will be implemented.
- Conducting emergency drills to ensure that procedures and equipment provide adequate protection during emergency situations.
Once hazard prevention and control measures have been identified (during the risk identification and management directives discussed in an earlier post, Pandemic Preparedness & Response Planning – Assessing Risks to Enhance Decision-Making), they should be implemented according to the hazard control components of the plan. If control measures cannot be implemented simultaneously, then organizations should start on the highest priorities or “worst-first” basis, according to the hazard ranking priorities (risk) established during hazard identification and assessment. It is essential to then follow up to confirm that controls are effective. Employers should track progress in implementing controls, inspect and evaluate controls once they are installed, and follow routine preventive maintenance practices. This includes confirming that engineering controls are properly installed and tested, and that employees are trained on their use and are in fact using them consistently and correctly. It also includes conducting regular inspections to confirm controls are operating as designed.
Follow up is also required to determine if implemented controls are effective or need to be modified. It is important to involve workers in the evaluation of the controls, and if controls are not effective, identify, select, and implement further control measures that will provide adequate protection. Consistent, thorough, and ongoing evaluations of the effectiveness of all implemented controls is fundamental to their effectiveness, and organizations should never assume that controls are working without confirming.
The next post will discuss employee training, drills and exercises.