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Federal Register / Vol. 86, No. 116 / Monday, June 21, 2021 / Rules and Regulations 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 COVID19 remains high.
The pneumonia associated with the SARSCoV2 virus can become severe, resulting in respiratory failure and ARDS, a life-threatening lung injury. In a U.S. study of 35,302 COVID19
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 COVID19 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 COVID19 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 COVID19, 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 COVID19
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 COVID19 patients developed AKI
that requires renal replacement therapy Gupta et al., 2021.
COVID19 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 COVID19 inpatients developed sepsis. A study of 1849 year olds in the COVIDNET surveillance system found that 16.6% of patients in that age range developed sepsis Owusu
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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.
COVID19 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 COVID19 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
COVID19 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 studys 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, COVID19 may cause patients to develop a hypercoagulable state, a condition in which blood clots can develop in someones legs and embolize to their lungs, further worsening oxygenation. Blood clots in COVID19 patients have also been reported in arteries, resulting in strokeseven in young peopleas 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 COVID19
patients on prophylactic-dose anticoagulation. A systematic review of more than 28,000 COVID19 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. COVID19
poses such a threat of blood clots that NIH guidelines now recommend that hospitalized non-pregnant adults with COVID19 should receive prophylactic dose anticoagulation NIH, April 21, 2021a.

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These health effects are particularly relevant to healthcare workers because there is evidence that healthcare workers are more likely to develop more severe COVID19 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 COVID19
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 COVID19 disease following infection i.e., disease requiring hospitalization than infected non-essential workers Mutambudzi et al., 2020.
Mild to Moderate Cases of COVID19
Even the less severe health effects of COVID19 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 COVID19 cases are mild to moderate Wu and McGoogan, April 7, 2020, which is defined as having any symptom of COVID19 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 OSHAs finding that COVID19 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 commonlyreported symptoms in people who are
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