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Federal Register / Vol. 86, No. 116 / Monday, June 21, 2021 / Rules and Regulations
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to the general population. Carter et al., May 2021 found that healthcare worker infection rates varied from region to region, noting the importance of community transmission as a factor in infection rates. In Jacob et al., March 10, 2021, health care workers serology results were compared to residence location, job designation, and other characteristics to identify risk factors.
The study authors found that community transmission was a significant factor in acquiring infections, but were not able to tie in any specific job designation resulting in increases in infection risk. The authors note, however, that the study did not show that workplace exposures did not increase risk; rather it showed that the levels of community transmission observed may be a greater driver of transmission. It should also be noted that the non-pharmaceutical interventions for each job classification are different, so a direct comparison of non-clinical and clinical personnel may result in conclusions with limited application.
One might expect that a full shift with fully and properly implemented nonpharmaceutical interventions should result in lower infection rates. This appeared evident in a study comparing infection rates between first and second COVID19 outbreak surges in Norway Magnusson et al., January 6, 2021. For instance, during the first wave from February 26, 2020 to July 17, 2020, nurses were almost three times more likely to be infected than those in a similar age range 20 to 70 years old.
However, during the second wave from July 18, 2020 to December 18, 2020, infection rates for nurses were largely indistinguishable from the population at large of a similar age. The authors suggested that the decrease in the odds ratio was potentially due to the implementation of appropriate infection control practices that were previously lacking.
Studies Examining Risks After Known Exposures Heinzerling et al., April 17, 2020
examined the development of COVID
19 in 120 healthcare employees who were unknowingly exposed to a patient with COVID19. The patient was later identified as one of the first U.S.
community cases of COVID19, and Heinzerling et al., April 17, 2020
concluded that the investigation presented a unique opportunity to analyze exposures associated with SARSCoV2 transmission in a healthcare setting without recognized community exposures. Of the 120
healthcare employees who were
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exposed, 43 developed symptoms within 14 days of exposure and were tested for COVID19. Three of those employees 7% of those tested were positive for COVID19. Although those three employees represent 2.5% of the total exposed, it is possible that more employees might have developed COVID19 because asymptomatic employees were not tested. The healthcare employees who became infected, when compared to those who were not infected, were more commonly present during two aerosol-generating procedures nebulizer treatment 67%
vs. 9% and non-invasive ventilation 67% vs. 12%; more commonly performed physical examinations of the patient 100% vs. 24%; and were exposed to the patient for longer durations of time median 120 minutes vs. 25 minutes. None of the exposed healthcare employees had been wearing the complete set of PPE recommended for contact with COVID19 patients.
Long-Term Care Facilities Long-term care facilities include nursing homes, skilled nursing facilities, and assisted living facilities.
They provide both medical and personal care services to people unable to live independently. Because long-term care facilities are a congregate living situation, infections such as COVID19
can spread rapidly between patients or residents and the healthcare staff who care for them. Therefore, employees who work at these facilities have an elevated risk of exposure and infection.
Like employees who work at hospitals, employees who work at long-term care facilities include both healthcare practitioners, who may have direct and close contact with patients and residents, as well as healthcare support staff who could also be exposed to patients and residents. See the section on Detection of SARSCoV2 in Healthcare Employees above for a description of the types of employees who may work at these facilities.
McMichael et al., March 27, 2020
investigated a COVID19 outbreak affecting patients, employees, and visitors at a long-term care facility in King County, Washington in February of 2020. SARSCoV2 infections were identified in 129 persons, including 81
residents, 34 of 170 staff 20%, and 14
visitors. None of the employees died, but 2 of the 34 infected employees 5.9% had symptoms severe enough to require hospitalization. The median age of the employees was 42.5 years range 2279 years. Job titles reported for the employees that were infected included physical therapist, occupational therapist assistant, environmental care
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worker, nurse, certified nursing assistant, health information officer, physician, and case manager. The study authors noted that infection prevention procedures at the facility were insufficient, and they concluded that introduction of SARSCoV2 into longterm care facilities will result in high attack rates among residents, staff, and visitors.
Weil et al., September 1, 2020
reported a cross-sectional study of skilled nursing facilities in the Seattle area between March 29 and May 13, 2020. Testing was performed by Public Health of Seattle and King County testing of both residents and staff or the Seattle Flu Study testing of only employees. The authors described the period of the study to be at the peak of the pandemic, but the skilled nursing facilities were not experiencing outbreaks at the time of the study.
Testing of employees for SARSCoV2
was voluntary, and 1,583 employees at 16 skilled nursing facilities were tested.
Eleven of the 16 skilled nursing facilities had at least one resident or employee who tested positive. Forty-six 2.9% employees had positive or inconclusive testing for SARSCoV2.
Of 1208 residents tested, 110 9.1%
were positive. Study authors noted shortages in PPE.
Yi et al., September 7, 2020
evaluated surveillance data on COVID
19 for assisted living facilities in 39
states representing 44% of the total long-term care facilities in the U.S.. The states began reporting data at various periods ranging from February 27 to April 30, 2020. As of October 15, 2020, 6,440 of 28,623 22% assisted living facilities had at least one COVID19
case among residents or staff ranging from 1.3% of assisted living facilities in Iowa to 92.8% of assisted living facilities in Connecticut. In 22 states, 17,799 cases of COVID19 were reported in staff total number of staff not specified. In 9 states, 46 of 7,128
0.6% employees with COVID19 died.
Bagchi et al., 2021 reported on the CDCs National Healthcare Safety Network NHSN surveillance of nursing homes, which began on April 26, 2020.
As of May 25, 2020, the Centers for Medicare & Medicaid Services CMS
began requiring nursing homes to report COVID19 cases in residents and staff.
The authors analyzed data in residents, nursing home staff, and facility personnel that was reported from May 25 through November 22, 2020 in all 50
states, the District of Columbia, Guam, and Puerto Rico. Staff members and facility personnel were defined as all persons working or volunteering in the facility, including contractors,
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