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Federal Register / Vol. 86, No. 116 / Monday, June 21, 2021 / Rules and Regulations
CDC still recommends source controls for vaccinated healthcare workers to protect unvaccinated people, it has relaxed several NPIs for health care providers HCP in some circumstances.
CDC has stated that fully vaccinated HCP could dine and socialize together in break rooms and conduct in-person meetings without source control or physical distancing CDC, April 27, 2021a. The CDC also recommends that fully vaccinated HCP no longer need to be restricted from work after a high-risk exposure, as long as they remain symptom-free CDC, April 27, 2021a.
Perhaps more significantly, while acknowledging the growing body of evidence against SARSCoV2
transmission from vaccinated people to unvaccinated people, the CDC has not identified evidence of a substantial risk of such transmission even in healthcare settings. Therefore, pending additional evidence of such transmission, the risk of transmission from vaccinated healthcare workers to unvaccinated coworkers does not appear to be high enough to warrant OSHAs imposition of mandatory controls through an ETS
to protect unvaccinated workers from exposure to vaccinated workers.
On the other hand, HCP treating suspected and confirmed COVID19
patients are expected to have higher exposures to the SARSCoV2 virus than others in the workforce, because such work involves repeated instances of close contact with infected patients Howard, May 22, 2021. Exposure can be even higher in aerosol generating activities. Indeed, one study reported higher infection rates among vaccinated HCWs during a regional COVID19
surge Keehner et al., Mar. 23, 2021.
Thus, the CDC has not relaxed infection control practices or PPE intended to protect HCP, including respirator use.
CDC, April 27, 2021a. NIOSH has stated that the available evidence shows that healthcare workers are continuing to become infected with SARSCoV2 . . . including both vaccinated and unvaccinated workers, and the conditions for the transmission of the virus exist at healthcare workplaces Howard, May 22, 2021.
The CDC has also indicated that it will continue to evaluate the impact of vaccination; the duration of protection, including in older adults; and the emergence of novel SARSCoV2
variants on healthcare infection prevention and control recommendations CDC, April 27, 2021a. OSHA, too, will continue to monitor this issue and revise the ETS as appropriate.

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Grave Danger Exists in Healthcare Workplaces Where Unvaccinated Workers Are Present The evidence shows that the advent of vaccines does not eliminate the grave danger from exposure to SARSCoV2
in healthcare workplaces where less than 100% of the workforce is fully vaccinated. Unvaccinated workers can transmit the virus to each other and can become infected as a result of exposure to persons with COVID19 who enter the healthcare facility. An outbreak of COVID19 due to an unvaccinated, symptomatic HCP was recently reported in a skilled nursing facility in which 90.4% of residents had been vaccinated Cavanaugh, April 30, 2021. The outbreak, due to the R.1 variant, caused attack rates that were three to four times higher in unvaccinated residents and HCPs as among those who were vaccinated. Additionally, unvaccinated persons were significantly more likely to experience symptoms or require hospitalization. Therefore, unvaccinated employees at these workplaces remain at grave danger of infection, along with the serious health consequences of COVID19, as discussed in the remainder of this section.
Although the risk appears to be lower, breakthrough infections of vaccinated individuals do occur, but the potential for secondary transmission remains not fully substantiated. For instance, a small yet significant portion of the population does not respond well to vaccinations Agha et al., April 7, 2021; Boyarsky et al., May 5, 2021; Deepak et al., April 9, 2021; ACI, April 28, 2021 and may be as vulnerable as unvaccinated individuals. These individuals could potentially transmit the SARSCoV2
infection to unvaccinated employees. In a California study, seven out of 4,167
fully vaccinated health care workers experienced breakthrough infections Keehner et al., May 6, 2021. A similar study from the Mayo Clinic, included 44,011 fully vaccinated individuals with 30 breakthrough infections being recorded Swift et al., April 26, 2021.
Of those breakthrough cases, 73% were symptomatic. Secondary transmission was not evaluated in the study. A
nursing facility in Chicago found 22
possible breakthrough cases of SARS
COV2 infection among fully vaccinated staff and residents Teran et al., April 30, 2021. Of those cases, 36% were symptomatic. However, no secondary transmission was observed in the facility. The lack of secondary transmission was likely due to the facilitys implementation of nonpharmaceutical interventions and high vaccination rates. The authors
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concluded that to ensure outbreaks do not occur from breakthrough infections in workplaces with vaccinated and unvaccinated workers that the facilities need to maintain high vaccine coverage and non-pharmaceutical interventions.
While these breakthrough events appear to be uncommon, it is important to remember how quickly a few cases can result in an outbreak in unvaccinated populations.
Moreover, even though the U.S. is approaching the time where there is sufficient vaccine supply for the entire U.S. population, administering the vaccine throughout the country will still take more time. As of May 24, 2021, CDC statistics show that 43% of the population between 18 and 65 has been fully vaccinated CDC, May 24, 2021a.
To this end, there is still a need to strengthen confidence in the safety and effectiveness of the vaccines for significant portions of the population, including workers, to reduce vaccine hesitancy. Even in the healthcare industry, where distribution has enabled entire worker populations to be completely vaccinated by now, some workers exhibited reluctance to getting vaccinated. On January 4, 2021, a study of 1,398 U.S. emergency department health care personnel found that 95%
were offered the vaccine, with 14%
declining Schrading et al., February 19, 2021. In February of 2021, the CDC
released a study of initial vaccine efforts at skilled nursing facilities offering longterm care Gharpure et al., February 5, 2021. The study found that only 37.5%
of eligible staff were vaccinated, leaving a potentially significant population vulnerable to SARSCoV2 infections and capable of transmission.
An anonymous survey of employees across the Yale Medicine and Yale New Haven Health system was used to estimate the prevalence of and underlying reasons for COVID19
vaccine hesitancy. The survey was sent to about 33,000 employees and medical staff across the Yale healthcare system and included clinical staff and those who support the critical infrastructure without direct patient contact e.g., food service staff. Out of 3,523 responses an 11% response rate, 85% of respondents stated they were extremely likely or somewhat likely to receive the COVID19 vaccine. Of that 85%, 12%
expressed mild hesitancy by stating they would get it within the next 6 months.
But 14.7% of overall respondents expressed reluctance by responding neither likely nor unlikely, somewhat unlikely, or extremely unlikely to receive the COVID19
vaccine. Overall, 1 in 6 personnel in this health system survey expressed at least
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