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Federal Register / Vol. 86, No. 116 / Monday, June 21, 2021 / Rules and Regulations
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explains how those controls must be implemented in the workplace. Not all of the requirements of the ETS are examined in this Need for Specific Provisions section. Some are addressed fully in the Summary and Explanation sections.
A. IntroductionEffective Infection Prevention Utilizes Overlapping Controls An effective infection prevention program utilizing a suite of overlapping controls in a layered approach better ensures that no inherent weakness in any one approach results in an infection incident. OSHA emphasizes that each of the infection prevention practices required by the ETS provide some protection from COVID19 by themselves, but work best when used together, layering their protective impact to boost overall effectiveness. A
common depiction of this approach in use is Reasons model of accident causation dynamics, more commonly referred to as the Swiss Cheese Model of Accident Causation Reason, April 12, 1990. Reason combined concepts of pathogen transmission and airplane accidents to present a model that illustrated that accidents are the result of the interrelatedness of imperfect defenses and unsafe actions that are largely unobservable until an adverse outcome becomes apparent. Using the Swiss cheese analogy, each control has certain weaknesses or holes. The holes differ between different controls. By stacking several controls together with different weaknesses, the holes are blocked by the strengths of the other controls. In other words, if controls with different weaknesses are layered, then any unexpected failure of a single control is protected against by the strengths of other controls. The model provides a guiding approach to reduce incidents across many sectors Reason et al., October 30, 2006 and that perspective is reflected in widely accepted approaches to controlling infectious diseases HICPAC, January 1, 1996; Rusnak et al., July 31, 2004; CDC, 2012; WHO, 2016.
The CDC Healthcare Infection Control Practices Advisory Committees HICPAC Isolation Guidelines, which apply to healthcare settings, are an example of established national guidelines that illustrate layered controls to prevent the transmission of infectious diseases Siegel et al., 2007.
The Isolation Guidelines recommend two tiers of precautions: Standard Precautions and Transmission-Based Precautions e.g., airborne, droplet, contact. Standard Precautions, under the Isolation Guidelines, are the
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minimum infection prevention practices that apply to patient care, regardless of the suspected or confirmed infection status of the patient, in any setting where health care is practiced. They are based on the principle that there is a possible risk of disease transmission from any patient, patient sample, or interaction with infectious material. For Standard Precautions, guidance follows that a certain set of controls should be implemented to reduce infectious disease transmission regardless of the diagnosis of the patient, in part because there is always baseline risk that is not necessarily either obvious or detectable.
These precautions include controls such as improved hand hygiene, use of personal protective equipment, cleaning of equipment, environmental controls, handling of bed linens, changing work practices, and patient placement. When used in concert, these approaches protect workers from potential exposure to infectious agents.
The Isolation Guidelines second tier of precautions, Transmission-Based Precautions, takes into consideration the transmission mechanism of specific diseases and complements Standard Precautions to better protect workers from the presence of known or suspected infectious agents. For instance, SARSCoV2, the infectious agent that causes COVID19, is considered to be mainly transmissible through the droplet route in most settings though there is evidence for airborne transmission as noted throughout this preamble. Droplet transmission occurs by the direct spray of large droplets onto conjunctiva or mucous membranes e.g., the lining of the nose or mouth of a susceptible host when an infected person sneezes, talks, or coughs. Droplet precautions are a suite of layered controls that are designed to prevent the direct spray of infectious material and supplement the suite of layered controls used for Standard Precautions. They are designed to protect workers from infectious agents that can be expelled in large respiratory droplets from infected individuals. These added interventions are implemented when infection is known or suspected and include placing patients in single rooms or physically distant within the same room, increased mask usage, and limiting patient movement. COVID19 is considered capable of spreading through multiple routes of transmission, including airborne. Thus, the CDC recommends respiratory protection, isolation gowns, and gloves in healthcare settings to protect workers in those settings.
While a suite of layered controls is appropriate for controlling infectious
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diseases, it is important to use the hierarchy of controls when choosing which controls to include and the order in which to implement them. Briefly, the hierarchy of controls refers to the concept that the best way to control for hazards is to preferentially utilize the most effective before complementing with less effective controls.19 Ideally, the hazard is eliminated, which would likely mean using an option such as conducting a telehealth visit outside of a patient care setting with respect to COVID19 to ensure that there is no shared workspace and thus no potential for employee exposure to COVID19.
When a telehealth visit is not possible, workers must be protected through the implementation of controls. Outside the realm of infection control, the utilization of an engineering control or a change in on-site work practices could alone effectively minimize a hazard in many cases. However, infection prevention failures often are not apparent until an outbreak occurs, resulting in many infected workers.
Therefore, it is important for employers to not only adhere to the hierarchy of controls when identifying controls to implement, but also to augment layers of feasible engineering controls e.g., adequate ventilation, barriers with administrative and work practice controls e.g., physical distancing, cleaning, disinfection, telework, schedule modification, health screening. Personal protective equipment e.g., gloves, respirators, and facemasks can provide the final layer of control. This approach is consistent with both OSHA and CDC guidance for protecting workers and the public from COVID19.
In addition to the broad recognition and implementation of layered controls to protect against infectious diseases, a recent study elucidated the effectiveness of isolated and layered controls, with respect to close contacts amidst several community COVID19 outbreaks in Thailand Doung-ngern et al., September 14, 2020. While individual controls, such as wearing a face covering or maintaining at least a minimum distance from others, significantly reduced cases 28% and 40%, respectively, the researchers concluded 19 The hierarchy of controls is a longstanding occupational safety practice and OSHA policy.
Under its hierarchy of controls policy reflected in a number of standards, OSHA typically only allows employers to rely on respirators or other PPE to the extent that engineering controls to eliminate the hazard are not feasible. See, e.g., 1910.134a respiratory protection and 1926.103 respiratory protection; 1910.1000e air contaminants;
1910.95b occupational noise exposure and 1926.101 hearing protection.

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