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Federal Register / Vol. 86, No. 116 / Monday, June 21, 2021 / Rules and Regulations
From the Chinese Center for Disease Control and Prevention. JAMA. 32313:
12391242. doi: 10.1001/
jama.2020.2648. Wu and McGoogan, April 7, 2020.
Zhang, P et al., 2020, February 14. Longterm bone and lung consequences associated with hospital-acquired severe acute respiratory syndrome: a 15-year follow-up from a prospective cohort study. Bone Research. 88. https
doi.org/10.1038/s41413-020-0084-5.
Zhang et al., February 14, 2020.

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b. Transmission of SARSCoV2
SARSCoV2 is a highly transmissible virus. Since the first case was detected in the U.S., there have been over 32 million reported cases of COVID19, affecting every state and territory, with thousands more infected each day. According to the CDC, the primary way the SARSCoV2 virus spreads from an infected person to others is through the respiratory droplets that are produced when an infected person coughs, sneezes, sings, talks, or breathes CDC, May 7, 2021.8
Infection could then occur when another person breathes in the virus.
Most commonly this occurs when people are in close contact with one another in indoor spaces within approximately six feet for at least fifteen minutes CDC, May, 2021.
The best available current scientific evidence demonstrates that the farther a person is away from the source of the respiratory droplets, the fewer infectious viral particles will reach that persons eyes, nose, or mouth because gravity pulls the droplets to the ground see the Need for Specific Provisions, Section V of the preamble, on Physical Distancing. For example, a systematic review of SARSCoV2 up to early May 2020 and similar coronaviruses i.e., SARSCoV1 a virus related to SARS
CoV2 and Middle Eastern Respiratory Syndrome MERS a disease caused by a virus that is similar to SARSCoV2
and spreads through droplet transmission found 38 studies, containing 18,518 individuals, to use in a meta-analysis that found that the risk of viral infection decreased significantly as distance increased Chu et al., June 27, 2020. A second COVID19 study from Thailand reviewed physical 8 On May 7, 2021, the CDC updated its guidance regarding airborne transmission CDC, May 7, 2021;
https www.cdc.gov/coronavirus/2019-ncov/
science/science-briefs/sars-cov-2transmission.html. OSHA notes that this change does not alleviate the need for any of the controls in this ETS. Because OSHA has determined that the controls in this ETS are necessary to address a grave danger as quickly as possible, the agency determined that it was appropriate to issue the ETS
while it continues to evaluate the new evidence to determine whether additional controls may be necessary at a later date.

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distancing information collected from 1,006 individuals who had an exposure to infected individuals Doung-ngern et al., September 14, 2020. The study revealed that the group with direct physical contact and the group within one meter but without physical contact were equally likely to become infected with SARSCoV2. However, the group that remained more than one meter away had an 85% lower infection risk than the other two groups. The studies findings on physical distancing combined with expert opinion firmly establish the importance of droplet transmission as a driver of SARSCoV
2 infections and COVID19 disease.
COVID19 may also be spread through airborne particles under certain conditions Schoen, May 2020; CDC, May 7, 2020; Honein et al., December 11, 2020. That airborne transmission can occur during aerosol-generating procedures AGPs in healthcare such as when intubating an infected patient is a reasonable concern see CDC, March 12, 2020. CDC provides recommendations for infection prevention and control practices when caring for a patient with suspected or confirmed SARSCoV2 infection that include the use of a respirator CDC, February 23, 2021. There are several studies examining the risks associated with AGPs. For example, a publication detailing one of the first known SARS
CoV2 occupational transmission events in U.S. healthcare providers reported a statistically significant increased risk from AGPs Heinzerling et al., April 17, 2020. However, the currently available information specifically related to SARSCoV2 exposure during AGPs is limited Harding et al., June 1, 2020.
Data from the Respiratory Protection Effectiveness Trial ResPECT, designed to assess effectiveness of PPE to prevent respiratory infections, were analyzed to identify risk factors for endemic coronavirus infections among healthcare personnel Cummings et al., July 9, 2020. This study found that AGPs may double the risk of infection among healthcare providers. Although the infectious agents studied were surrogate coronaviruses and not the SARSCoV
2 virus, the study indicates increased risk from such procedures for infections from the coronavirus family, and thus the study is relevant. In addition, a systematic review of research on transmission of acute respiratory infections from patients to healthcare employees focused on publications from the first SARS virus outbreak Tran et al., April 26, 2012. Risks of SARS
CoV1 infection in those performing AGPs were several times higher than in healthcare workers not exposed to
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AGPs. Workers may also be exposed to the SARSCoV2 virus during AGPs conducted outside of the hospital setting, including certain dental surgical procedures Leong et al., December 2020, cardiopulmonary resuscitation CPR provided by homecare workers Payne and Peache, February 4, 2021, and endoscopy Teng et al., September 16, 2020; Sagami et al., January 2021.
Risk from AGPs during autopsies is evident from reports of staff infections during autopsies on decedents infected with tuberculosis, which is a wellknown airborne infectious agent Nolte et al., December 14, 2020. Additionally, research that measured airborne particles released during the use of an oscillating saw with variable saw blade frequencies and different saw blade contact loads concluded that, even in the best-case scenario tested on dry bone, the number of aerosol particles produced was still high enough to provide a potential health risk to forensic practitioners Pluim et al., June 6, 2018. Other reports from healthcare settings have raised the possibility of spread of airborne particles from suspected or confirmed COVID19
patients, absent AGPs. For example, infectious viral particles were collected from in the room of a COVID19 patient from distances as far as 4.8 meters away in non-AGP hospital settings Lednicky et al., September 11, 2020, and transmission via aerosol was suspected in a Massachusetts hospital Klompas et al., February 9, 2021. For more discussion of this subject, see the Need for Specific Provisions Section V of the preamble on Respirators.
The extent to which COVID19 may spread through airborne particles in other contexts is less clear. CDC has noted that in some circumstances airborne particles can remain suspended in the air and be breathed in by others, and travel distances beyond 6 feet for example, during choir practice, in restaurants, or in fitness classes in situations that would not be defined as involving close contact:
With increasing distance from the source, the role of inhalation likewise increases.
Although infections through inhalation at distances greater than six feet from an infectious source are less likely than at closer distances, the phenomenon has been repeatedly documented under certain preventable circumstances. These transmission events have involved the presence of an infectious person exhaling virus indoors for an extended time more than 15 minutes and in some cases hours leading to virus concentrations in the air space sufficient to transmit infections to people more than 6 feet away, and in some cases to people who have passed through that space soon after the infectious person left.

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