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Federal Register / Vol. 86, No. 116 / Monday, June 21, 2021 / Rules and Regulations that a layered approach would be expected to reduce infections by 84%.
Several similar studies evaluated the importance of layering controls during the 2002/2003 SARS outbreak caused by SARSCoV1, which is a different strain of the same species of virus as the virus that causes COVID19 SARSCoV2
and has some similar characteristics;
importantly, both viruses are strains of the same viral species and exhibit the same modes of transmission.
Researchers assessed five Hong Kong hospitals on how the utilization of interventions affected SARS
transmission Seto et al., May 3, 2003.
In total, the study evaluated 244
workers on their compliance with wearing masks, gowns, and gloves as well as adhering to hand hygiene protocols. Among the 69 workers who fully complied with the layered controls, there were no infections.
However, 13 of 185 workers who used only some of the interventions were infected. The researchers concluded that the combined practice of droplet and contact precautions together significantly reduced the risk of infection from exposures to SARSinfected individuals.
Another study investigated the approaches taken to reduce SARSCoV
1 transmission in hospitals in Taiwan during the 2003 portion of the outbreak Yen et al., February 12, 2010.
Researchers surveyed forty-eight Taiwanese hospitals that provided care for 664 SARSCoV1 patients, including 119 healthcare workers, to determine which controls each hospital implemented. Control measures included isolation of fever patients in the Emergency Department ED, installation of handwashing stations in the ED, routing patients from the ED to an isolation ward, installation of fever screen stations in the ED, and installation of handwashing stations throughout the hospital. Analysis showed that while early SARSCoV1
case identification at fever screening stations outside the hospital could reduce transmission inside the hospital by half, combining that intervention with other interventions could almost double that reduction.
A modeling effort to simulate an epidemic of seasonal influenza at a hypothetical hospital in Ann Arbor, Michigan, found that different interventions used in a layered approach would result in a greater predicted reduction in nosocomial cases i.e., healthcare-associated infections Blanco et al., June 1, 2016. The study evaluated six different intervention techniques thought to be effective against influenza, including hand
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hygiene, employee vaccination, patient pre-vaccination, patient isolation, therapies e.g., antibody treatments, steroids, and face coverings. The researchers found, based on the model, that while no individual intervention exceeded a 27% percent reduction in cases, utilizing all controls would prevent half of all cases. While this model employed influenza as the vehicle to examine the effectiveness of layered protections, it gives no reason to believe that this approach would not be equally effective for other viruses such as SARSCoV2.
In 2016, the World Health Organization, a specialized agency of the United Nations that is focused on international public health WHO, 2016, addressed the use of layering interventions to reduce infections in performed systematic reviews in its Guidelines on Core Components of Infection Prevention and Control Programmes at the National and Acute Health Care Facility Level. OSHAs perspective of layered interventions e.g., engineering controls, work practice controls, personal protective equipment, training is consistent with what the WHO Guidelines define as multimodality. WHO defines multimodality as follows:
A layered strategy comprises several elements or components three or more;
usually five, http www.ihi.org/topics/
bundles/Pages/default.aspx implemented in an integrated way with the aim of improving an outcome and changing behavior. It includes tools, such as bundles and checklists, developed by multidisciplinary teams that take into account local conditions.
The five most common components include:
i System change availability of the appropriate infrastructure and supplies to enable infection prevention and control good practices; ii education and training of health care workers and key players for example, managers; iii monitoring infrastructures, practices, processes, outcomes and providing data feedback; iv reminders in the workplace/communications;
and v culture change within the establishment or the strengthening of a safety climate.

The WHO guidelines strongly recommend practicing multimodality/
layered interventions to reduce infections based on WHOs systematic review of implementation efforts at facility-level and national scales. Based on a systematic review of 44 studies on implementing infection control practices at the facility level, and another systematic review of 14 studies on the success of National rollout programs using layered strategies, WHO
concluded that using layered strategies was effective in improving infection prevention and control practices and
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reducing hospital-acquired illnesses WHO, 2016.
Vaccination does not eliminate the need for layered controls for healthcare workers exposed to COVID19 patients, which can result in exposures that are more frequent and potentially carrying higher viral loads than those faced in workplaces not engaged in COVID19
patient care. The Director of the CDCs National Institute for Occupational Health NIOSH recently wrote to OSHA
that layers of control are still needed for vaccinated healthcare workers who remain at particularly elevated risk of being infected while treating COVID
19 patients: The available evidence shows that healthcare workers are continuing to become infected with SARSCoV2, the virus that causes COVID19, including both vaccinated and unvaccinated workers . . .
Regardless of vaccination status, healthcare workers need additional protections such as respirators and other personal protective equipment PPE
during care of patients with suspected or confirmed COVID19. Howard, May 22, 2021. Further, a recent CDC
study found that despite the positive impact on the roll-out of large-scale vaccination programs on reducing the transmission of COVID19, a decline in non-pharmaceutical interventions NPIs;
e.g., physical distancing, face covering use may result in a resurgence of cases Borchering, May 5, 2021. The authors concluded that vaccination coverage in addition to compliance with mitigation strategies are essential to minimize COVID19 transmission and prevent surges in hospitalizations and deaths.
Thus, to effectively control COVID19
transmission to those who are not vaccinated or immune, an increase in vaccination coverage in addition to NPIs, such as physical distancing, are crucial.
Based on the above evidence, OSHA
is requiring in the ETS that healthcare employers must not only implement the individual infection prevention measures discussed in the following sections, but also layer their controls to protect workers from the COVID19
hazard due to the additional protection provided to workers when multiple control measures are combined.
References Blanco, N et al., 2016, June 1. What Transmission Precautions Best Control Influenza Spread in a Hospital.
American Journal of Epidemiology 183
11: 10451054. https doi.org/10.1093/
aje/kwv293. Blanco et al., June 1, 2016.
Borchering, RK et al., 2021, May 5.
Modeling of Future COVID19 Cases, Hospitalizations, and Deaths, by Vaccination Rates and
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