The Occupational Medicine Forum is a JOEM Forum Editor reviewed opinion piece and does not necessarily represent an official ACOEM position. The Forum is intended for health professionals and is not intended to provide medical or legal advice, including illness prevention, diagnosis or treatment, or regulatory compliance. Such advice should be obtained directly from a physician and/or attorney.
Answered by Chinyere Omeogu, MD, MPH, Director Occupational Employee Health, Durham Veterans Healthcare System, Durham, North Carolina; Judith Green-McKenzie, MD, MPH, Professor & Chief, Residency Program Director, Division of Occupational Medicine, Department of Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.
The 2019 Novel Coronavirus (COVID-19) is the first new occupational disease to be described in this decade.1 COVID-19 is an acute and severe respiratory infectious disease spread by aerosolized droplets and caused by the severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2). COVID-19 shares symptoms with SARS-CoV and MERS-CoV2 and presents with generalized symptoms like fever and malaise and also has respiratory,3,4 cardiovascular,3,5–7 neurological,8–10 dermatological,11–14 and gastrointestinal3,4,15,16 manifestations.
Since the first report of cases from Wuhan, Hubei Province of China, at the end of 2019, COVID-19 cases have been reported in all continents, except for Antarctica.17 COVID-19 was declared a pandemic by the World Health Organization (WHO) on March 11th, 2020.18 As of May 13th, 2020, there have been 4,179,479 confirmed cases of COVID-19, including 287,525 deaths, reported to WHO. With increasing numbers of COVID-19 cases and people requiring health care, it became obvious that healthcare personnel (HCP) providing care in any capacity to these patients were at risk of contracting the virus. In a case series of 138 patients treated in a Wuhan Hospital, 40 patients (29% of cases) were healthcare workers.3
Like in other pandemics, the healthcare system was at the core of the COVID-19 response. A health system consists of all organizations, people, and actions whose primary intent is to promote, restore, or maintain health.19 COVID-19 presented a formidable challenge to systems first in Asia and then in Europe. The United States followed. By February 2020, 3 of 121 exposed health care personnel in Solano County, California tested COVID positive. These individuals were among the first known cases of probable occupational transmission of COVID-19 to HCP in the United States.20
In order to face this challenge, health systems in the US had to react quickly and strategize as to how best to mobilize resources to effectively approach this virus and the challenge it brought. Health systems had to innovate, think outside the box, and institute new mechanisms for accomplishing tasks, while ensuring quality care was given efficiently, safely, and equitably. These solutions needed a public health approach as the bedrock. Public health solutions would ensure the greater good of employees while achieving optimal health outcomes. Occupational & Employee Health (O&EH) professionals, who are trained in public health and population management, were called upon to help lead the effort. The solution to this crisis, in order to be efficient and effective, could not be individualized. In addition, the ability to scale up was also essential in order to reach the numerous employees involved in various health systems. O&EH providers were well positioned and poised to accept this leadership role.
In order to maintain a healthy workforce, with needs that were several and varied, an organized and resourced institutional infrastructure was needed. This infrastructure included the provision of timely information regarding the number of infected patients, the evolving science regarding the virus, its manifestations and treatment, access to PPE, ability to evaluate those exposed and potentially exposed, training contact tracers, and HCPs to make decisions regarding quarantine and maintain astute record keeping. Given the respiratory spread of the COVID-19 virus, new workflows had to be designed to meet the increased need for respiratory fit testing to be carried out safely and efficiently, for example. All this had to happen in the midst of continuing to care for other workplace injuries and illnesses and keeping up with the surveillance needs of the workforce. Frontline HCPs range from nurses and physicians, to environmental service workers and food services workers. O&EH HCPs were their support. The need for collaboration within healthcare institutions in order to protect employees from infection at work as well as in the community was critical—as the community may eventually affect the workforce. The risk of employees becoming ill and unable to work or becoming potential sources of infection to other employees was at an all-time high. Human capital within the institution was amassed and all had a role to play in approaching this pandemic to ensure success—strong leadership and coordination from the executive leadership, IT, infection control, safety, industrial hygiene, and O&EH. Staff deployment to other areas and institutions to meet existing needs was common.
Information was highly valued, as more questions than answers were the norm. There was uncertainty regarding treating a new disease whose manifestations were only slowly becoming clearer, based on collective experience of patients and HCPs. There were questions regarding parameters for who should be quarantined as well as the length of time for quarantine and this changed over time. The answers to these and several other questions are still evolving. Rapid dissemination of evidence-based information was and continues to be essential. This has mandated that health care systems be even more agile and flexible. Updating policies as soon as they had been written was common. Close collaboration with stakeholders ranging from institutions such as governments, and employers to the general population and individuals became crucial.
Historically, when health systems are challenged, like with COVID—“strengthening” the system is the way to success. The WHO has a framework for health systems strengthening, which consists of essential “building blocks.” Broadly, the areas are service delivery; health workforce; information; medical products, vaccines, and technologies; financing; and leadership/governance.21 WHO defines health systems strengthening as being based on improving these six health system building blocks and managing their interactions in ways that achieve more equitable and sustained improvements across health services and health outcomes. O&EH strengthened its health system along these six WHO building blocks. We will describe in-depth, some of the changes made by O&EH services to meet the COVID challenge along these 6 building blocks, which adapted specifically for O&EH services are:
- 1. Occupational Health Service delivery: Core packages of services provided by OH including preplacement exams, workplace injuries, surveillance exams, immunizations, administrative exams, employee exposures like Blood Borne Pathogen Exposure (BBPE), employee wellness programs, others like medical clearance for respiratory fit testing; health delivery models like face to face care provision versus telehealth; management and organization of quality OH programs; promote safety at the work place; demand for care and services from employees including workplace injuries.
- 2. Health work force addresses maintain adequate staff: O&EH workforce policies including policies/Standard Operating Procedures/algorithms; advocacy for OH support and resources; standards including guidance from organizations like CDC and OSHA and how organization adapted it for implementation. Other departments that work closely with OH to maintain adequate staff like industrial hygiene, workers compensation and pension, human resources and safety.
- 3. Occupational Health Information: Facility and population-based information and surveillance systems; screening tools and forms; innovations like text messages and Apps; evolving information; daily or weekly reporting and metrics.
- 4. Medical products, lack of vaccines, and technologies: Reliable procurement; equitable access; quality of products like PPE; test kit and testing availability; thermometers availability.
- 5. Financing and others: Occupational health financing and costing; privacy; information security; and support for families of Health Care personnel.
- 6. Leadership and governance: Oversight of OH services; regular communication with employees; collaborating with health department; meeting with incident command and top management.
Thus far the success of the approach of health systems to the pandemic has relied on rapid scaling of solutions, innovation and organization and mobilizing forces, invariably the specialty of Occupational Medicine that provides O&EH services has played an integral and leadership role in this work. The foundation of this tiny specialty is indeed population health with a focus on ensuring the health, wellness, and safety of employees and citizens. This field, where medicine and public health meet, emphasizes work as a social determinant of health and O&EH professionals employ a multidisciplinary approach to recognize, diagnose, treat, and prevent injury, illness, and other hazardous health conditions that arise from adverse exposures at work, home, and the environment. The toolkit accumulated over time by O&EH professionals through training and experience have been deployed to face this greater threat. O&EH services were ready to collaborate with other entities in their respective health systems to work together to meet the challenge.
This is the first of a series of articles that will discuss the experience of O&EH services around the country coping with COVID along the six essential “building blocks” for health systems strengthening. It will discuss the approach to the issues faced by US health systems and during the COVID-19 pandemic and the innovations introduced and scaled to this formidable challenge.
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