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Federal Register / Vol. 86, No. 116 / Monday, June 21, 2021 / Rules and Regulations
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potential for employee transmission by cautioning that, in contrast to the recognized risk associated with patient care, healthcare employees might have failed to recognize the risk associated with interacting with co-workers in areas such as breakrooms and nursing stations. Physical distancing and PPE
may therefore not have been used as consistently in those situations.
The authors of a different study concluded that nurses and EMTs were, respectively, 26% and 33% more likely to contract COVID19 than attending physicians. Nurses and EMTs job duties require more intense, close contact with patients compared to physicians, as well as higher frequency and duration of patient contact. Firew et al., October 21, 2020 conducted a cross-sectional survey of healthcare employees in May of 2020 across 48 states, the District of Columbia, and U.S. territories. The 2,040 respondents who completed at least 80% of the survey were included in the study. Among included participants, 31.1% were attending physicians, 26.8% were nurses, 13%
were EMTs, 8.82% were resident physicians or fellows, 3.97% were physician assistants, and 16.32% were other healthcare employees. A total of 598 respondents 29.3% reported SARSCoV2 infections.
In a prospective study of over 2
million community members and 99,795 frontline healthcare workers that was performed in the U.S. and UK from March through April 2020, healthcare workers were 3.4 times as likely to selfreport a positive COVID19 test as the general public, after adjusting for the increased likelihood of healthcare personnel receiving a COVID19 test Nguyen et al., 2020. In the U.S. alone, healthcare workers were almost two times more likely to report a positive test after adjusting for greater likelihood of testing.
Detection of SARSCoV2 in Healthcare Employees OSHA reviewed a number of studies that included hospital employees. Many hospitals provide short-term and/or long-term care for COVID19 patients who have symptoms that are severe enough to require hospitalization.
Therefore, close contact with COVID19
patients is expected in hospital settings, putting hospital employees at risk of developing COVID19. Examples of employees who work in hospitals include healthcare practitioners, who generally have either licensure or credentialing requirements e.g., doctors, nurses, pharmacists, physical therapists, massage therapists for the purpose of promoting, maintaining,
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monitoring, or restoring health.
Individuals who provide healthcare support services also work at hospitals.
Examples of employees who provide healthcare support services and may have close contact with COVID19
patients in some circumstances include patient intake/admission, patient food services, chaplain services, equipment and facility maintenance, housekeeping services, healthcare laundry services, and medical waste handling services. As noted above, hospital employees are at risk from close contact with patients.
Some of the studies reviewed below were done in employees of healthcare systems that included both hospitals and ambulatory care centers such as physician offices, medical clinics including urgent care and retail-based clinics, outpatient surgical centers, and outpatient cancer treatment centers.
Although this ETS does not cover nonhospital ambulatory care settings where all non-employees are screened prior to entry and people with suspected or confirmed COVID19 are not permitted to enter, it was not possible to separate out results for hospital versus ambulatory care employees. Also it is not known to what extent those ambulatory care centers in the studies reviewed by OSHA performed screening to identify suspected or confirmed COVID19. Risk of exposure and transmission of SARSCoV2 is expected to be lower in ambulatory healthcare settings that perform screening to exclude persons with suspected or confirmed COVID19.
However some types of ambulatory medical facilities e.g., family practice;
pediatrics clinic; urgent care may choose to test patients for COVID19 or examine and treat COVID19 patients on site. Therefore, healthcare employees and healthcare support employees in some ambulatory care centers who do not conduct health screening to identify and exclude suspected or confirmed COVID19 patients are at risk of infection due to close contact with patients who could potentially have COVID19.
Barrett et al., 2020 conducted a prospective cohort study of healthcare employees and non-healthcare employees with no known previous SARSCoV2 infection who were recruited and tested for SARSCoV2
from March 24 through April 7, 2020 at Rutgers University and two of its affiliated university hospitals in New Jersey. As of July 2020, New Jersey was one of the hardest hit areas, with less than 3% of the U.S. population but 8.5% of all known U.S. cases.
Healthcare employees were defined as individuals who worked at least 20

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hours per week in a hospital, had occupations with regular patient contact, and were expected to have contact with at least three patients per shift over the following three months.
Occupations included residents, fellows, attending physicians, dentists, nurse practitioners, physician assistants, registered nurses, technicians, respiratory therapists, and physical therapists. Non-healthcare employees included faculty, staff, trainees, or students working at Rutgers for at least 20 hours a week and who had no patient contact. The study reported that 7.3% of healthcare employees 40 of 546 and 0.4% of non-healthcare employees 1 of 283 tested positive for SARSCoV2
infection. Even after the authors conducted sensitivity analyses to exclude individuals with symptoms at baseline and those who had exposure to someone with COVID19 or COVID19
symptoms outside of work, differences between infection rates in healthcare employees and non-healthcare employees continued to be observed.
OSHA finds this suggests that healthcare employees were more likely than non-healthcare employees to have developed COVID19 from a workplace exposure during the early months of the pandemic in the United States. The study authors concluded that the potential for workplace exposure is further supported by the fact that only 8% of infected study subjects reported contact with someone having COVID19
symptoms outside of work. In addition, higher rates of infection were observed in healthcare employees who worked in the hospital that had more COVID19
patients and was located in the community that had higher rates of SARSCoV2 infections. The study authors noted that because that hospital was overwhelmed, it was not always possible to separate COVID19 vs. nonCOVID19 patients, which may have led to additional exposures among staff.
Among healthcare employees, nurses had the highest rate of observed infections 11.1% tested positive, and attending physicians had the lowest rate of observed infection 1.8% positive.
Resident and fellow physicians had a 3.1% positivity rate and other groups of healthcare employees had a 9%
positivity rate. Increased risk of infection was associated with spending greater proportions of work time in patients rooms and higher reported exposures to patients with suspected or diagnosed COVID19.
Mani et al., November 15, 2020
reported results from SARSCoV2
testing of 3,477 symptomatic employees in the University of Washington
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