Infectious disease transmission

• Primary routes of infectious disease transmission are direct and indirect contact, droplet, and airborne.

The primary routes of infectious disease transmission in U.S. workplace settings are contact, droplet, and airborne. Contact transmission can be sub-divided into direct and indirect contact. Direct contact transmission involves the transfer of infectious agents to a susceptible individual through physical contact with an infected individual (e.g., direct skin-to-skin contact). Indirect contact transmission occurs when infectious agents are transferred to a susceptible individual when the individual makes physical contact with contaminated items and surfaces (e.g., doorknobs, patient-care instruments or equipment, bed rails, examination tables). Two examples of contact transmissible infectious agents include Methicillin-resistant Staphylococcus aureus (MRSA) and Vancomycin-resistant enterococcus (VRE).

Droplets containing infectious agents are generated when an infected person coughs, sneezes, or talks, or during certain medical procedures, such as suctioning or endotracheal intubation. Transmission occurs when droplets generated in this way come into direct contact with the mucosal surfaces of the eyes, nose, or mouth of a susceptible individual. Droplets are too large to be airborne for long periods of time, and droplet transmission does not occur through the air over long distances. Two examples of droplet transmissible infectious agents are the influenza virus which causes the seasonal flu and Bordetella pertussis which causes pertussis (whooping cough).

Airborne transmission occurs through very small particles or droplet nuclei that contain infectious agents and can remain suspended in the air for extended periods of time. When these particles are inhaled by a susceptible individual, they enter the respiratory tract and can cause infection. Since air currents can disperse these particles or droplet nuclei over long distances, airborne transmission does not require face-to-face contact with an infected individual. Airborne transmission only occurs with infectious agents that are capable of surviving and retaining infectivity for relatively long periods of time in airborne particles or droplet nuclei. Only a limited number of diseases are transmissible via the airborne route. Two examples of agents that can be spread through the airborne route include Mycobacterium tuberculosis which causes tuberculosis (TB) and the measles virus (Measles morbillivirus), which causes measles (sometimes called “rubeola,” among other names).

Bloodborne pathogens

• The Bloodborne Pathogens standard requires employers to establish a control plan, implement universal precautions, use engineering and work practice controls, provide PPE when needed, train workers, offer post-exposure evaluation and follow-up, and more.

In general, the Occupational Safety and Health Administration (OSHA)’s Bloodborne Pathogens Standard at 1910.1030 requires covered employers to:

• Establish an exposure control plan. This is a written plan to eliminate or minimize occupational exposures to bloodborne pathogens. The employer must prepare an exposure determination that contains a list of job classifications in which all workers have occupational exposure and a list of job classifications in which some workers have occupational exposure, along with a list of the tasks and procedures performed by those workers that result in their exposure.
• Update the plan annually to reflect changes in tasks, procedures, and positions that affect occupational exposure, and also technological changes that eliminate or reduce occupational exposure. In addition, employers must annually document in the plan that they have considered and begun using appropriate, commercially available effective safer medical devices designed to eliminate or minimize occupational exposure. Employers must also document that they have solicited input from front-line workers in identifying, evaluating, and selecting effective engineering and work practice controls.
• Implement the use of universal precautions, treating all human blood and other potentially infectious material (OPIM) as if known to be infectious for bloodborne pathogens.
• Identify and use engineering controls. These are devices that isolate or remove the bloodborne pathogens hazard from the workplace. They include sharps disposal containers, self-sheathing needles, and safer medical devices, such as sharps with engineered sharps-injury protection and needleless systems.
• Identify and ensure the use of work practice controls. These are practices that reduce the possibility of exposure by changing the way a task is performed, such as appropriate practices for handling and disposing of contaminated sharps, handling specimens, handling laundry, and cleaning contaminated surfaces and items.
• Provide personal protective equipment (PPE) such as gloves, gowns, eye protection, and masks. Employers must clean, repair, and replace this equipment as needed. Provision, maintenance, repair and replacement are at no cost to the worker.
• Make available hepatitis B vaccinations to all workers with occupational exposure. This vaccination must be offered after the worker has received the required bloodborne pathogens training and within 10 days of initial assignment to a job with occupational exposure, unless exempted.
• Make available post-exposure evaluation and follow-up to any occupationally exposed worker who experiences an exposure incident. An exposure incident is a specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood or OPIM. This evaluation and follow-up must be at no cost to the worker and includes documenting the route(s) of exposure and the circumstances under which the exposure incident occurred; identifying and testing the source individual for HBV and HIV infectivity, if the source individual consents or the law does not require consent; collecting and testing the exposed worker’s blood, if the worker consents; offering post-exposure prophylaxis; offering counseling; and evaluating reported illnesses. The healthcare professional will provide a limited written opinion to the employer and all diagnoses must remain confidential.
• Use labels and signs to communicate hazards. Warning labels must be affixed to containers of regulated waste; containers of contaminated reusable sharps; refrigerators and freezers containing blood or OPIM; other containers used to store, transport, or ship blood or OPIM; contaminated equipment that is being shipped or serviced; and bags or containers of contaminated laundry, except as provided in the standard. Facilities may use red bags or red containers instead of labels. In HIV and HBV research laboratories and production facilities, signs must be posted at all access doors when OPIM or infected animals are present in the work area or containment module.
• Provide information and training to workers. Employers must ensure that their workers receive regular training that covers all elements of the standard including, but not limited to information on bloodborne pathogens and diseases, methods used to control occupational exposure, hepatitis B vaccine, and medical evaluation and post-exposure follow-up procedures. Employers must offer this training on initial assignment, at least annually thereafter, and when new or modified tasks or procedures affect a worker’s occupational exposure. Also, HIV and HBV laboratory and production facility workers must receive specialized initial training, in addition to the training provided to all workers with occupational exposure. Workers must have the opportunity to ask the trainer questions. Also, training must be presented at an educational level and in a language that workers understand.
• Maintain worker medical and training records. The employer also must maintain a sharps injury log, unless it is exempt under Part 1904, the Recording and Reporting Occupational Injuries and Illnesses Standards.

COVID-19

• SARS-CoV-2 is highly infectious and commonly spread through person-to-person contact (within six feet), primarily through inhalation of respiratory particles (droplets and aerosols).

Coronavirus Disease 2019 (COVID-19) is a respiratory disease caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) virus. People with COVID-19 have had a wide range of symptoms reported – ranging from mild symptoms to severe illness. Symptoms may appear two to fourteen days after exposure to the virus. Anyone can have mild to severe symptoms. Possible symptoms include:

• Fever or chills,
• Cough,
• Shortness of breath or difficulty breathing,
• Fatigue,
• Muscle or body aches,
• Headache,
• New loss of taste or smell,
• Sore throat,
• Congestion or runny nose,
• Nausea or vomiting, and/or
• Diarrhea.

SARS-CoV-2 is highly infectious and commonly spread through person-to-person contact (within six feet), primarily through inhalation of respiratory particles (droplets and aerosols). These particles are produced when an infected person exhales, talks, sings, shouts, coughs, or sneezes. Note that the virus that causes COVID-19 can also be spread by people who have no symptoms and individuals who do not know they are infected.

Less commonly, this virus is spread through airborne transmission over longer distances when smaller droplets and particles linger in air, particularly in enclosed spaces with inadequate ventilation. Another less typical way that the virus spreads is when someone touches a contaminated surface, and then touches the nose, mouth, or eyes. Current evidence suggests that SARS-CoV-2 may remain viable for hours to days on a variety of surfaces.

Measles

• Measles is a highly contagious illness that usually includes symptoms such as a high fever, runny nose, cough, and a rash.
• The MMR (measles, mumps, rubella) vaccine protects against the spread of measles.

Measles is a highly contagious illness that primarily spreads via:

• Droplets or airborne particles from the noses, mouths, or throats of infected people.
• Contact with an infected person’s respiratory droplets or saliva.
• Contact with surfaces contaminated with respiratory secretions or saliva.

Despite a great reduction in the number of cases and near eradication of the disease in the United States at the start of the 21st century, measles continues to occur domestically. Measles is usually a childhood disease but can affect individuals of any age. Outbreaks are most common in the winter and spring.

The first sign of measles is usually a high fever, which begins about 10-12 days after exposure to the virus and lasts four to seven days. A runny nose, cough, red and watery eyes, and white spots inside the cheeks can develop in the initial stage. After several days, a rash erupts, usually beginning on the face and upper neck. Over about three days, the rash spreads, eventually reaching the hands and feet. The rash lasts for five to six days. On average, the rash occurs 14 days after exposure to the virus (within a range of 7-21 days).

Infected people, including children and adults, can spread the measles virus for several days before they develop a rash. People are most infectious while they have symptoms such as fever and cough, and most people remain infectious for several days once the rash appears. However, some immunocompromised people (i.e., those with weakened immune systems) may be able to spread the virus until they fully recover. People who develop measles-like symptoms after vaccination are not typically able to spread measles to others.

Workers may be exposed to measles whenever the virus is circulating in the community. Some workers also may be exposed to infected individuals who arrive in the U.S. from abroad. Workers who perform services or other activities in homes in affected communities also may be exposed. Workers who have not received the measles vaccine or who have not had the disease can get measles if they are exposed.

The measles, mumps, and rubella (MMR) vaccine can prevent measles. For the vast majority of recipients, the vaccine is safe and effective. As with almost any vaccine, however, a small number of recipients may experience allergic reactions, side effects, or other adverse events. The benefits of vaccination typically far outweigh these risks.

Address developing infection control plans and other infection prevention measures for workers in general and for those who may be at higher risk, including:

• Healthcare and dental workers.
• Childcare and school workers.
• Laboratory workers.
• Environmental services workers.
• Workers who are pregnant.
• Workers who travel abroad.

MERS

• MERS is a respiratory disease caused by the coronavirus MERS-CoV. Symptoms include cough, shortness of breath, and fever, and is fatal in approximately 35 percent of cases.
• Most workers in the U.S. are unlikely to encounter the virus that causes MERS, except through travel-related cases. There is no vaccine or treatment for MERS.

Middle East Respiratory Syndrome (MERS) is a viral respiratory disease that primarily affects the lungs and breathing passages. It is caused by the coronavirus MERS-CoV. MERS was first reported in Saudi Arabia in 2012. At least 25 other countries have reported confirmed cases of MERS. So far, all cases of MERS link to countries in and near the Arabian Peninsula. The disease has spread to other regions, including the United States, Europe, and South Korea through travel-associated cases. Only two patients in the U.S. have tested positive for MERS-CoV infection out of more than 500 suspected cases of MERS. Both positive cases occurred in May 2014 in individuals visiting the U.S. from Saudi Arabia.

The most recent MERS-CoV outbreak — primarily affecting South Korea — is the largest outside the Middle East. The World Health Organization (WHO) stays up-to-date with information on the outbreaks of MERS.

MERS-CoV does not generally spread among the general population in areas affected by an outbreak, but it is thought to spread from person to person through close contact, such as healthcare workers caring for infected patients, or people living with an infected person. There is no evidence to date of MERS-CoV spread in a sustained pattern in communities.

MERS symptoms usually include cough, shortness of breath, and fever. Some people may also experience gastrointestinal symptoms, such as nausea, vomiting, and diarrhea. More severe complications such as pneumonia and kidney failure can also occur. Approximately 35 percent of patients infected with MERS-CoV die from the illness. Treatment for this viral infection is supportive based on the medical condition of the patient. No vaccine or chemoprophylaxis (e.g., an effective antiviral medicine) currently exists for MERS.

Most workers in the U.S. are unlikely to encounter MERS-CoV or individuals with MERS. People who may be at increased risk for MERS include travelers returning from the Arabian Peninsula, close contacts with an ill traveler from the Arabian Peninsula, close contacts with a confirmed case of MERS, and healthcare personnel not following recommended infection-control practices. The majority of cases in the South Korean outbreak resulted from human-to-human transmission in healthcare settings, including some cases attributable to suboptimal infection prevention and control in such facilities. In addition to healthcare, other sectors with some risk for exposure include laboratories, mortuaries, medical transportation and airlines.

MRSA

• MRSA is a type of staph infection that is resistant to many antibiotics, including some commonly used ones.
• MRSA occurs most frequently in healthcare settings but can also be community acquired.

Methicillin-resistant Staphylococcus aureus, or MRSA, is a type of staph that is resistant to some antibiotics such as methicillin and other more common antibiotics such as oxacillin, penicillin, and amoxicillin. MRSA infections occur most frequently among persons in hospitals and other healthcare facilities (such as nursing homes and dialysis centers) who have weakened immune systems. These healthcare-associated MRSA infections include infections of surgical wounds, the urinary tract, bloodstream and lungs (pneumonia). HA-MRSA can also cause illness in persons outside of hospitals and healthcare facilities. MRSA infections that are acquired by persons who have not been recently (within the past year) hospitalized or had a medical procedure (such as dialysis, surgery, the insertion of a catheter) are known as community-associated MRSA infections. CA-MRSA infections are usually manifested as skin infections, such as pimples and boils, and occur in otherwise healthy people. However, some severe CA-MRSA infections have also occurred in healthy individuals.

Anyone can get a MRSA infection. People are more likely to get a MRSA infection if they have:

• Skin-to-skin contact with someone who has a MRSA infection
• Contact with items and surfaces that have MRSA on them
• Openings in their skin such as cuts or scrapes
• Crowded living conditions
• Poor personal hygiene or a lack of cleanliness

Norovirus

• Noroviruses cause acute gastroenteritis in humans and animals.
• Noroviruses can spread rapidly in healthcare settings, cruise ships, hotels, schools and more. The CDC estimates that 23 million infections per year in the U.S. are caused by NoVs.

Noroviruses (NoVs) caused the first sudden major diarrhea and vomiting outbreak (referred to as acute gastroenteritis or AGE). In addition to causing disease in humans, some NoV strains have caused disease in cows, pigs and mice. There have been no documented cases of animal NoVs being transmissible to humans or vice versa.

The Centers for Disease Control and Prevention (CDC) estimates that each year in the U.S. NoVs are responsible for approximately 23 million infections resulting in 50,000 hospitalizations. In addition, NoVs are the leading cause of AGE in the U.S.; NoV episodes have taken place on cruise ships and in healthcare settings (hospitals and nursing homes), hotels, retirement centers, and schools.

Although NoVs are currently more of a concern to the general public than to employees, the increasing incidence of NoV outbreaks exposes many different employee groups, especially healthcare workers (HCWs). For example, in a Maryland hospital in 2004, 265 HCWs developed AGE during a NoV outbreak. The percentage of HCWs affected was three times higher than the percentage of patients affected. Similarly, in an Oregon long-term care facility in April 2006 a relatively large number of employees (25) became ill with AGE.

Because of high levels of contact and vulnerable patient populations, healthcare settings can be particularly susceptible to outbreaks of norovirus.

According to the CDC, the usual time from exposure to onset of symptoms is 24 to 48 hours but can be as short as 12 hours. This illness is characterized by:

• Sudden-onset vomiting,
• Watery, non-bloody diarrhea with abdominal cramps, and
• Nausea.

SARS

• SARS is a sometimes-fatal respiratory illness that is spread primarily through close contact with a symptomatic person.

Severe acute respiratory syndrome (SARS) is a sometimes fatal, respiratory illness. The first identified cases occurred in China in late 2002, and the disease has now spread throughout the world. SARS is caused by a coronavirus known as SARS-associated coronavirus (SARS-CoV). Suspected SARS cases in the United States have involved individuals returning from travel to Asia and healthcare workers and other contacts of those patients. SARS does not appear to be caused by casual contact; transmission appears to be primarily through close contact with a symptomatic patient. The Centers for Disease Control and Prevention (CDC) has defined a suspect case of SARS as an illness of unknown cause that began in February 2003 or later and meets the following criteria:

• Fever of at least 100.5 degrees F;
• One or more clinical findings of respiratory illness, such as cough, shortness of breath, difficulty breathing, hypoxia, or X-ray evidence of either pneumonia or acute respiratory distress syndrome; and
• The onset of symptoms occurs within 10 days of either (1) travel to an area with documented or suspected community transmission of SARS; or (2) close contact with either a person with a respiratory illness who traveled to a SARS area or a known suspect SARS case. Close contact means having cared for, lived with, or had direct contact with respiratory secretions and/or body fluids.

Tuberculosis (TB)

• Tuberculosis is a respiratory infection spread by airborne droplets from an infected person.
• Multidrug-resistant forms of TB present additional hazard, as they are more difficult and take longer to cure.

Tuberculosis (TB) is caused by the bacteria Mycobacterium tuberculosis and is spread by airborne droplets generated when a person with TB disease coughs, speaks, sings, sneezes, etc. Infection occurs when a susceptible person inhales droplets containing the bacteria, which then become established in the body.

Additional hazard is now present because of multidrug-resistant (MDR) TB. MDR organisms are resistant to the drugs that are normally used to treat TB, such as Isoniazid and Rifampin. The course of treatment when treating MDR TB increases from six months to 18–24 months, and the cure rate decreases from nearly 100 percent to less than 60 percent. Mortality among patients with MDR-TB can be high.

An effective TB infection control program includes the following elements:

• Early identification, isolation, and treatment of persons with TB (e.g., provide and practice early patient screening in the Emergency Department to identify potentially infectious patients and prevent employee exposures).
• The use of engineering and administrative procedures to reduce the risk of exposure.
• The use of respiratory protection.
• Exposure Control Plan.
• Risk assessments.
• Medical surveillance of employees.
• Case management.

Zika

• Zika virus is primarily transmitted through mosquito bite. It is found in Mexico, Central America, South America, the Caribbean, tropical areas of Southeast Asia, Oceania, and parts of Africa.
• All travelers may be at risk, as are aid workers and missionary workers. It is particularly dangerous for pregnant women.

Zika virus infection is caused by the Zika virus (ZIKV), which belongs to the Flaviviridae family. The virus is primarily transmitted by infected daytime biting female Aedes aegypti and Aedes albopictus mosquitoes which are typically active from dawn to dusk. There is evidence that Zika virus is also transmitted by other mosquitoes belonging to the Aedes genus. The virus can be transmitted from a pregnant woman to her fetus.

Zika virus is present in Mexico, Central America, South America, the Caribbean, tropical areas of Southeast Asia, Oceania, and parts of Africa. All travelers are at risk. Long-term travelers and aid or missionary workers going to areas where Zika virus is endemic are at greater risk.

Zika virus is associated with neurological complications: Guillain-Barré syndrome (progressive muscle weakness that can lead to temporary paralysis) and microcephaly (decreased head size which may lead to developmental delays) in infants born to pregnant women infected with the virus.

Real-time data on Zika virus outbreaks and transmission is often not available. This is because most people who become infected with Zika virus do not show signs or symptoms. In some countries, reliable reporting and monitoring systems that track virus transmission may not be available. As a result, it is not always possible to convey a country’s current level of risk, but travelers should take precautions wherever risk exists.

All travelers going to areas with Zika virus risk are advised to take mosquito bite precautions, particularly during the daytime. Pregnant women or couples considering pregnancy should consult a healthcare practitioner prior to travel.

Hazard recognition

• In assessing potential hazards, employers should consider if and when their workers may be in close contact (within six feet) with someone who could have the virus and be able to spread it without knowing it.
• OSHA has divided job tasks into four potential risk exposure levels for COVID-19: very high, high, medium, and lower risk.

The Occupational Safety and Health Administration (OSHA) requires employers to provide a workplace free from recognized hazards that are causing or are likely to cause death or serious physical harm (see 29 U.S.C. 654(a)(1)). To meet this obligation, it is important for employers to assess occupational hazards to which their workers may be exposed to the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) virus.

In assessing potential hazards, employers should consider if and when their workers may be in close contact (within six feet) with someone who could have the virus and be able to spread it without knowing it. The extent of community spread, if any, is a key consideration in hazard assessment. Employers should also determine if workers could be exposed to environments (e.g., worksites) or materials (e.g., laboratory samples and waste) contaminated with the virus.

Employers may rely on the identification of infected individuals who have signs and/or symptoms of Coronavirus Disease 2019 (COVID-19) to help identify exposure risks for workers and implement appropriate control measures. It is possible that someone may have been in close contact (within about six feet) with someone with SARS-CoV-2 in their community and, thus, may have had exposure that should prompt employer action (e.g., excluding the worker from the workplace during an appropriate self-monitoring quarantine period).

Four risk levels

OSHA has divided job tasks into four potential risk exposure levels for COVID-19: very high, high, medium, and lower risk, as listed in the table below. As workers’ job duties change or they perform different tasks in the course of their duties, they may move from one exposure risk level to another. Employers should always rely on current hazard assessments to identify workers’ initial exposure risk to the virus on the job and changes to exposure risk if and when job duties change.

Control and prevention

• All employers should remain alert to and informed about changing outbreak conditions as they relate to community spread of the virus and testing availability. They should implement infection prevention and control measures accordingly.

• Employers should develop and implement a COVID-19 response plan that uses the hierarchy of controls and other tools to address worker protection during an outbreak.

Measures for protecting workers from exposure to and infection with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) virus, the virus that causes Coronavirus Disease 2019 (COVID-19), depends on exposure risk. That risk varies based on:

• The type of work being performed,
• The potential for interaction (prolonged or otherwise) with people, and
• Contamination of the work environment.

According to the Occupational Safety and Health Administration (OSHA), employers should adopt infection prevention and control strategies based on a thorough workplace hazard assessment. Those strategies include using appropriate combinations of engineering and administrative controls, safe work practices, and personal protective equipment (PPE) to prevent worker exposures. Some OSHA standards that involve the prevention of occupational exposure to SARS-CoV-2 also require employers to train workers on elements of infection prevention and control like PPE.

All employers should remain alert to and informed about changing outbreak conditions as they relate to community spread of the virus and testing availability. They should implement infection prevention and control measures accordingly.

General guidance for all workers and employers

For all workers, regardless of specific exposure risks to Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) virus, it is always a good practice to:

• Wear cloth face coverings, at a minimum, at all times when around coworkers or the general public. If a respirator, such as an N95 respirator or better, is needed for conducting work activities, then that respirator should be used, and the worker should use a cloth face covering when the worker is not using the respirator (such as during breaks or while commuting).
• Frequently wash hands with soap and water for at least 20 seconds. When soap and running water are not immediately available, use an alcohol-based hand sanitizer with at least 60 percent ethanol or 70 percent isopropanol as active ingredients and rub the hands together until they are dry. Always wash hands that are visibly soiled.
• Avoid touching the eyes, nose, or mouth with unwashed hands.
• Practice good respiratory etiquette, including covering coughs and sneezes or coughing/sneezing into your elbow/upper sleeve.
• Avoid close contact (within six feet for a total of 15 minutes or more over a 24-hour period) with people who are visibly sick, and practice physical distancing with coworkers and the public.
• Stay home if sick.
• Recognize personal risk factors. According to the Centers for Disease Control and Prevention (CDC), certain people, including older adults and those with underlying conditions such as heart or lung disease, chronic kidney disease requiring dialysis, liver disease, diabetes, immune deficiencies, or obesity, are at higher risk for developing more serious complications from Coronavirus Disease 2019 (COVID-19).

Additional guidance from the Equal Employment Opportunity Commission (EEOC) and other federal agencies may be relevant to both workers and employers.

Recording and reporting COVID-19 infections and deaths

• Employers should record employee COVID-19 cases in the OSHA 300 Log if the cases are: 1) confirmed; 2) work related; and 3) involve one or more recording criteria (such as medical treatment, days away from work, etc.).

Under mandatory Occupational Safety and Health Administration (OSHA) rules in 1904, employers are responsible for recording work-related cases of COVID-19 illness on OSHA’s Form 300 logs if the following requirements are met: (1) the case is a confirmed case of COVID-19; (2) the case is work-related (as defined by 1904.5); and (3) the case involves one or more relevant recording criteria (set forth in 1904.7) (e.g., medical treatment, days away from work). Employers must follow the requirements in 1904.39 when reporting COVID-19 fatalities and hospitalizations to OSHA. Employers should also report outbreaks to health departments as required and support their contact tracing efforts.

In addition, employers should be aware that Section 11(c) of the OSH Act prohibits reprisal or discrimination against an employee for speaking out about unsafe working conditions or reporting an infection or exposure to COVID-19 to an employer. In addition, mandatory OSHA standard 1904.35(b) also prohibits discrimination against an employee for reporting a work-related illness.

Note on recording adverse reactions to vaccines: The Department of Labor and OSHA, as well as other federal agencies, are working diligently to encourage COVID-19 vaccinations. OSHA does not want to give any appearance of discouraging workers from receiving COVID-19 vaccination or to disincentivize employers’ vaccination efforts. As a result, OSHA will not enforce 1904’s recording requirements to require any employers to record worker side effects from COVID-19 vaccination through May 2024. OSHA will reevaluate the agency’s position at that time to determine the best course of action moving forward. Individuals may choose to submit adverse reactions to the federal Vaccine Adverse Event Reporting System.

If an employee has been hospitalized with a work-related, confirmed case of COVID-19, does the employer need to report this in-patient hospitalization to OSHA?

Under 1904.39(b)(6), employers are only required to report in-patient hospitalizations to OSHA if the hospitalization “occurs within twenty-four (24) hours of the work-related incident.” For cases of COVID-19, the term “incident” means an exposure to SARS-CoV-2 in the workplace. Therefore, in order to be reportable, an in-patient hospitalization due to COVID-19 must occur within 24 hours of an exposure to SARS-CoV-2 at work.

The employer must report such hospitalization within 24 hours of knowing both that the employee has been in-patient hospitalized and that the reason for the hospitalization was a work-related case of COVID-19. Thus, if an employer learns that an employee was in-patient hospitalized within 24 hours of a work-related incident, and determines afterward that the cause of the in-patient hospitalization was a work-related case of COVID-19, the case must be reported within 24 hours of that determination. See 1904.39(a)(2), (b)(7)-(b)(8).

Employers should note that 1904.39(b)(6)’s limitation only applies to reporting; employers who are required to keep OSHA injury and illness records must still record work-related confirmed cases of COVID-19, as required by 1904.4(a).

How should an employer report the fatality or in-patient hospitalization of an employee with a confirmed, work-related case of COVID-19?

Employers may report a fatality or in-patient hospitalization using any one of the following:

• Call the nearest OSHA office;
• Call the OSHA 24-hour hotline at 1-800-321-OSHA (6742); or
• By electronic submission, report online (see https://www.osha.gov/report).

Employers should be prepared to supply:

• Business name;
• Name(s) of employee(s) affected;
• Location and time of the incident;
• Brief description of the incident; and
• Contact person and phone number so that OSHA may follow up.

If an employee has died of a work-related, confirmed case of COVID-19, must the employer report this fatality to OSHA?

Under 1904.39(b)(6), an employer must “report a fatality to OSHA if the fatality occurs within thirty (30) days of the work-related incident.” For cases of COVID-19, the term “incident" means an exposure to SARS-CoV-2 in the workplace. Therefore, in order to be reportable, a fatality due to COVID-19 must occur within 30 days of an exposure to SARS-CoV-2 at work.

The employer must report the fatality within eight hours of knowing both that the employee has died, and that the cause of death was a work-related case of COVID-19. Thus, if an employer learns that an employee died within 30 days of a work-related incident and determines afterward that the cause of the death was a work-related case of COVID-19, the case must be reported within eight hours of that determination.

Employers should note that 1904.39(b)(6)’s limitation only applies to reporting; employers who are required to keep OSHA injury and illness records must still record work-related fatalities, as required by 1904.4(a).

COVID-19 federal OSHA rulemakings

• OSHA has issued two rulemakings for COVID-19 in 2021 but withdrew one of them and withdrew most of the provisions from the other. Only certain recording and reporting provisions remain in place.
• OSHA hopes to issue two more rulemakings — one on COVID-19 for healthcare and the other on infectious diseases.

On June 21, 2021, the Occupational Safety and Health Administration (OSHA) adopted a Healthcare Emergency Temporary Standard (Healthcare ETS) to protect workers from Coronavirus Disease 2019 (COVID-19) in settings where they provide healthcare or healthcare support services. By law, under 29 U.S.C. 655(c), an ETS is effective until superseded by a permanent standard — a process contemplated by the Occupational Safety and Health Act to occur within 6 months of the ETS’s promulgation. Therefore, on December 27, 2021, OSHA announced that the agency:

• Will continue to work to issue a final standard that will protect healthcare workers from COVID-19 hazards;
• Will work on its broader Infectious Diseases rulemaking;
• Withdrew the non-recordkeeping portions of the healthcare ETS; but
• Is keeping in effect the COVID-19 log and reporting provisions at 29 CFR 1910.502(q)(2)(ii), (q)(3)(ii)-(iv), and (r).

The Occupational Exposure to COVID-19 in Healthcare Settings final rule reached the Office of Management and Budget on December 7, 2022. Once or if approved by the budget office, that rulemaking may be published in the Federal Register. In addition, OSHA hopes to publish the proposed Infectious Diseases rule in the Federal Register by June 2024.

It is noteworthy that, on November 5, 2021, OSHA issued a separate rulemaking, the Vaccination and Testing ETS, with the intent to protect unvaccinated workers of large employers with 100 or more workers from workplace exposure to COVID-19. However, after the Supreme Court stayed the Vaccination and Testing ETS on January 13, 2022, OSHA withdrew it effective January 26, 2022. OSHA did not withdraw the Vaccination and Testing ETS as a proposed rule, however, and the agency strongly encourages vaccination of workers.

Related laws and regulations

• Even without a comprehensive COVID-19 standard, OSHA has requirements related to preventing occupational exposure to SARS-CoV-2 and to hazardous chemicals used for cleaning and disinfection.

Several Occupational Safety and Health Administration (OSHA) requirements apply to preventing occupational exposure to Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) virus, the virus that causes Coronavirus Disease 2019 (COVID-19). Among the most relevant are:

• 29 USC 654(a)(1), General duty clause, Section 5(a)(1) of the Occupational Safety and Health Act of 1970, which requires employers to furnish to each worker "employment and a place of employment, which are free from recognized hazards that are causing or are likely to cause death or serious physical harm;”
• 29 CFR 1904, Recording and reporting occupational injuries and illnesses;
• 1910.132, General requirements (for personal protective equipment);
• 1910.133, Eye and face protection;
• 1910.134, Respiratory protection;
• 1910.138, Hand protection;
• 1910.141, Sanitation;
• 1910.142, Temporary labor camps;
• 1910.145, Specifications for accident prevention signs and tags;
• 1910.502(q)(2)(ii), (q)(3)(ii)-(iv), and (r), Healthcare;
• 1910.1020, Access to employee exposure and medical records;
• 1910.1450, Occupational exposure to hazardous chemicals in laboratories;
• 1915.88, Sanitation;
• 1915.91, Accident prevention signs and tags;
• 1915.152, General requirements (for personal protective equipment);
• 1915.154, Respiratory protection;
• 1915.157, Hand and body protection;
• 1915.1020, Access to employee exposure and medical records;
• 1917.1, Scope and applicability (regarding employee exposure/medical records and respiratory protection);
• 1917.127, Sanitation;
• 1918.1, Scope and application (regarding employee exposure/medical records and respiratory protection);
• 1918.95, Sanitation;
• 1926.33, Access to employee exposure and medical records;
• 1926.51, Sanitation;
• 1926.95, Criteria for personal protective equipment;
• 1926.102, Eye and face protection;
• 1926.103, Respiratory protection;
• 1928.21, Applicable standards in 29 CFR part 1910 (regarding temporary labor camps);
• 1928.110, Field sanitation; and
• 29 CFR 1960, Basic program elements for federal employee occupational safety and health programs and related matters.

OSHA's Bloodborne Pathogens Standard (29 CFR 1910.1030) applies to occupational exposure to human blood and other potentially infectious materials (OPIM) that typically do not include respiratory secretions that may contain SARS-CoV-2 (unless visible blood is present). However, the provisions of the standard offer a framework that may help control some sources of the virus, including exposures to body fluids (e.g., respiratory secretions) not covered by the standard.

Employers must also protect their workers from exposure to hazardous chemicals used for cleaning and disinfection. Employers should be aware that common sanitizers and sterilizers could contain hazardous chemicals. Where workers are exposed to hazardous chemicals, employers must comply with OSHA's Hazard Communication Standard (29 CFR 1910.1200), Personal Protective Equipment standards, and other applicable OSHA chemical standards.

Codified at 29 USC 660(c), employers will find that section 11(c) of the Occupational Safety and Health Act of 1970 prohibits employers from retaliating against workers for exercising a variety of rights guaranteed under the OSH Act, such as filing a safety or health complaint with OSHA, raising a health and safety concern with their employers, participating in an OSHA inspection, or reporting a work-related injury or illness.

Guidance for job tasks associated with certain risk levels

• Workers whose jobs do not require contact with people known to have or suspected of having COVID-19, nor frequent close contact with the general public or other workers, are at lower risk of occupational exposure.
• Employers with workers that perform job duties that involve medium, high, or very high occupational exposure risks should develop and implement a COVID-19 response plan that uses the hierarchy of controls and other tools to address worker protection during an outbreak.

Guidance for job tasks associated with lower exposure risk

Workers whose jobs do not require contact with people known to have or suspected of having Coronavirus Disease 2019 (COVID-19), nor frequent close contact with the general public or other workers, are at lower risk of occupational exposure. Close contact means within six feet for a total of 15 minutes or more over a 24-hour period. Employers and workers in operations associated with a lower risk of exposure should:

• Remain aware of evolving trends in community transmission. Changes in community transmission, or work activities that move workers into higher risk categories, may warrant additional precautions in some workplaces or for some workers.
• Monitor public health communications about COVID-19 recommendations.
• Ensure that workers have access to that information.
• Collaborate with workers to designate effective means of communicating important COVID-19 information.
• Frequently check the Occupational Safety and Health Administration (OSHA) and Centers for Disease Control and Prevention (CDC) COVID-19 websites for updates.

Guidance for job tasks associated with increased risk

Certain workers are likely to perform job duties that involve medium, high, or very high occupational exposure risks in areas with community transmission of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) virus, the virus that causes COVID-19. These workers and their employers should remain aware of the evolving community transmission risk. According to OSHA, employers should:

• Assess the hazards to which their workers may be exposed;
• Evaluate the risk of exposure;
• Develop and implement a COVID-19 response plan that uses the hierarchy of controls and other tools to address worker protection during an outbreak; and
• Select, implement, and ensure workers use controls to prevent exposure.

Possible elements of a COVID-19 response plan include:

• Worker screening — This is screening workers for COVID-19 signs and/or symptoms (such as through temperature checks). The complexity of screening will depend on the type of worksite and the risk of a COVID-19 outbreak among workers. If implemented, worker screening should include screening protocols, criteria for exclusion of sick workers, and criteria for returning to work. Because people infected with SARS-CoV-2 can spread the virus even if they do not have signs/symptoms of infection, screening may play a part in monitoring worker health but may have limited utility on its own. Employers' temperature screening programs may rely on workers self-monitoring, rather than employers directly measuring, temperatures. Protocols for worker screening must be applied equally, without discrimination based on race, national origin, sex, age, disability, or other protected characteristics. Note that 29 CFR 1910.1020 may apply to temperature records. However, if employers do not record workers' temperatures, or if workers' temperatures are recorded but not made or maintained by a physician, nurse, or other healthcare personnel or technician, the mere taking of a temperature would not amount to a record that must be retained.
• Identify and isolate suspected cases— This is the prompt identification and isolation of potentially infectious individuals. Wherever feasible, keep infectious people out of the workplace, including through the use of a system for workers to report if they are sick or have symptoms of COVID-19 or through the use of screening measures. If a worker develops signs or symptoms of COVID-19 at the workplace, send the person home or to seek medical care. If the person cannot immediately leave the workplace, isolate the individual in a location away from workers, customers, and other visitors and with a closed door (e.g., in a single occupancy restroom), if possible, until they can go home or leave to seek medical care.
• Engineering controls — These are physical changes to the workplace to isolate workers from a hazard. Examples of engineering controls include:
  • Installing plexiglass, stainless steel, or other barriers between workers, such as on assembly lines, or between workers and customers, such as at points of sale.
  • Using rope and stanchion systems to keep customers/visitors from queueing within six feet of work areas.
  • Adjusting ventilation systems to introduce additional outside air and/or increase air exchange to introduce fresh air. Consult a qualified technician if necessary.
  • Modifying physical workspaces to increase the distance between workers.
• Administrative controls and safe work practices — These are changes in policies and procedures for how workers perform job duties to ensure work activities are conducted safely. Examples include:
  • Limiting the number of workers assigned to a particular shift in a facility.
  • Ensuring workstations are spaced at least six feet apart.
  • Posting signage, in languages the workers understand, to remind workers, customers, and visitors to maintain a distance of at least six feet between one another and to practice regular hand hygiene.
  • Providing training and information in languages the workers understand.
  • Increasing the frequency of cleaning and disinfection within the worksite.
  • Encouraging or permitting workers to wear cloth face coverings, if appropriate, to help contain potentially infectious respiratory droplets.
• PPE — This is equipment that protects workers from hazards when engineering and administrative controls are insufficient on their own. PPE should be selected based on the results of an employer's hazard assessment and workers' specific job duties. Consider accommodations for religious exercise for those workers who, for instance, have or cannot trim facial hair due to religious belief, or provide reasonable modifications for persons with disabilities. Other considerations include the following:
  • When disposable gloves are used, workers should typically use a single pair of nitrile exam gloves (unless other gloving protocols are necessary for the work setting or task). Change gloves if they become torn or visibly contaminated with blood or body fluids.
  • When both face and eye protection are needed, use surgical masks and either goggles or face shields. Personal eyeglasses are not considered adequate eye protection.
  • Cloth face coverings are not acceptable substitutes for PPE intended to prevent worker exposure to droplets or other splashes or sprays of liquids. If workers need respirators, they must be used in the context of a comprehensive program that meets the requirements of OSHA's Respiratory Protection Standard (29 CFR 1910.134).
  • Surgical masks are not respirators and do not provide the same level of protection to workers as properly fitted respirators. Cloth face coverings are also not acceptable substitutes for respirators.
  • If there are shortages of PPE items, such as respirators or gowns, they should be prioritized for high-hazard activities.
  • After removing PPE, always wash hands with soap and water, if available, for at least 20 seconds. Ensure that hand hygiene facilities (e.g., sink or alcohol-based hand sanitizer) are readily available at the point of use (e.g., at or adjacent to the PPE removal area).
  • Employers should establish, and ensure workers follow, standard operating procedures for cleaning (including laundering) PPE and items such as uniforms or laboratory coats, as well as for maintaining, storing, and disposing of PPE.
• Cleaning and disinfection — The CDC provides instructions for environmental cleaning and disinfection. Employers operating workplaces during a COVID-19 pandemic should continue routine cleaning and other housekeeping practices in any facilities that remain open to workers or others. Use EPA-registered disinfectants with label claims to be effective against SARS-CoV-2. Routine cleaning and disinfection procedures (e.g., using cleaners and water to pre-clean surfaces before applying an EPA-registered disinfectant to frequently touched surfaces or objects for appropriate contact times as indicated on the product's label) are appropriate for SARS-CoV-2. Workers who conduct cleaning tasks must be protected from exposure to hazardous chemicals used in these tasks. Do not use compressed air or water sprays to clean potentially contaminated surfaces, as these techniques may aerosolize infectious material.
• Adequate ventilation will protect all people in a closed space — Key measures include:
  • Ensuring the heating, ventilation, and air conditioning (HVAC) system is operating in accordance with the manufacturer’s instructions and design specifications,
  • Conducting all regularly scheduled inspections and maintenance procedures,
  • Maximizing the amount of outside air supplied,
  • Installing air filters with a minimum efficiency reporting value (MERV) 13 or higher where feasible,
  • Maximizing natural ventilation in buildings without HVAC systems by opening windows or doors, when conditions allow (if that does not pose a safety risk), and
  • Considering the use of portable air cleaners with high efficiency particulate air (HEPA) filters in spaces with high occupancy or limited ventilation.
• Worker training — This involves the training of all workers with occupational exposure to SARS-CoV-2 about the sources of exposure to the virus, the hazards associated with that exposure, and appropriate workplace protocols in place to prevent or reduce the likelihood of exposure. Training should include information about how to isolate individuals with suspected or confirmed COVID-19 or other infectious diseases, and how to report possible cases. Training must be offered during scheduled work times and at no cost to the worker. Workers required to use PPE must be trained.
• Anti-retaliation — Workers may not be discriminated against for raising concerns about COVID-19 infection control in their workplaces. Section 11(c) of the Occupational Safety and Health (OSH) Act prohibits discharging or in any other way discriminating against a worker for engaging in various occupational safety and health activities. Workers have a right to raise a reasonable concern about infection controls or voluntarily provide and safely wear PPE, such as a respirator, face shield, gloves, or surgical mask. Employers should ensure that workers know who to contact with questions or concerns about workplace safety and health, and that there are prohibitions against retaliation for raising workplace safety and health concerns or engaging in other protected occupational safety and health activities. Also, consider using a hotline or other method for workers to voice concerns anonymously.

Additional considerations for workers with increased susceptibility

If workers may be at increased susceptibility for SARS-CoV-2 infection or complications from COVID-19, consider offering adjustments to their work responsibilities or locations to minimize exposure. Other flexibilities, if feasible, can help prevent potential exposures among workers who have heart or lung disease, chronic kidney disease requiring dialysis, liver disease, diabetes, severe obesity, or immunocompromising health conditions. Employers should be cognizant of the requirements of the Americans with Disabilities Act, the Rehabilitation Act, and the Age Discrimination in Employment Act. The Equal Employment Opportunity Commission (EEOC) has guidance about COVID-19 and equal employment opportunity laws.

Vaccination, testing, and treatment

• OSHA strongly encourages employers to provide paid time off to workers for the time it takes for them to get vaccinated and recover from any side effects.
• If an employer implements screening protocols that include COVID-19 viral testing, the ADA requires that any mandatory medical test of employees be “job-related and consistent with business necessity.”
• Most people with COVID-19 have mild illness and can recover at home.

Vaccination

OSHA emphasizes that vaccination is the most effective way to protect against severe illness or death from Coronavirus Disease 2019 (COVID-19). OSHA strongly encourages employers to provide paid time off to workers for the time it takes for them to get vaccinated and recover from any side effects. Employers should also consider working with local public health authorities to provide vaccinations for unvaccinated workers in the workplace.

OSHA suggests that employers consider adopting policies that require workers to get vaccinated or to undergo regular COVID-19 testing – in addition to mask wearing and physical distancing – if they remain unvaccinated. People are considered fully vaccinated for COVID-19 two weeks or more after they have completed their final dose of a COVID-19 vaccine authorized by the U.S. Food and Drug Administration (FDA) in the U.S. Even with the vaccine, evidence suggests that fully vaccinated people who do become infected with certain variants can be infectious and can spread the virus to others.

Additionally, employers must focus extra attention on workers who are at high-risk for serious complications from the virus. Some conditions, such as a prior transplant, as well as prolonged use of corticosteroids or other immune-weakening medications, may affect workers’ ability to have a full immune response to vaccination.

Notes:

• The federal Equal Employment Opportunity (EEO) laws do not prevent an employer from requiring all employees to be vaccinated against COVID-19, subject to the reasonable accommodation provisions of Title VII of the Civil Rights Act, the Americans with Disabilities Act (ADA), and other EEO considerations.
• Under the ADA, workers with disabilities may be legally entitled to reasonable accommodations that protect them from the risk of contracting COVID-19 if, for example, they cannot be protected through vaccination, cannot be vaccinated, or cannot use face coverings. Employers should consider taking steps to protect these at-risk workers as they would unvaccinated workers, regardless of their vaccination status.
• The Equal Employment Opportunity Commission (EEOC) enforces Title VII of the Civil Rights Act, which prohibits employment discrimination based on religion. This includes a right for job applicants and workers to request an exception, called a religious or reasonable accommodation, from an employer requirement that conflicts with their sincerely held religious beliefs, practices, or observances. If an employer shows that it cannot reasonably accommodate an employee’s religious beliefs, practices, or observances without undue hardship on its operations, the employer is not required to grant the accommodation.

Testing

Viral tests look for a current infection with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) virus, the virus that causes COVID-19, by testing specimens from the nose or mouth. All tests should be performed following FDA requirements. Any positive COVID-19 viral test means the virus was detected, and the person has or recently had an infection. A negative COVID-19 viral test means the test did not detect the virus, but this doesn’t rule out that the person could have an infection.

In addition, a COVID-19 viral test is a medical examination within the meaning of the ADA. Therefore, if an employer implements screening protocols that include COVID-19 viral testing, the ADA requires that any mandatory medical test of employees be “job-related and consistent with business necessity.” Employer use of a COVID-19 viral test to screen workers who are or will be in the workplace will meet the “business necessity” standard only when it is consistent with guidance from Centers for Disease Control and Prevention (CDC), FDA, and/or state/local public health authorities that is current at the time of testing.

Antibody tests, on the other hand, detect antibodies that the body makes to fight the virus that causes COVID-19. Antibody tests should never be used to diagnose a current infection with the virus that causes COVID-19. An antibody test may not show if the person has a current infection, because it can take one to three weeks after the infection for the body to make antibodies. Antibody tests can be used for public health surveillance or to test for conditions associated with COVID-19, however.

An antibody test, as a medical examination under the ADA, must be job-related and consistent with business necessity. Based on this CDC guidance, antibody testing does not meet the ADA’s “business necessity” standard for medical examinations or inquiries for employees. Therefore, requiring antibody testing before allowing workers to re-enter the workplace is not allowed under the ADA.

Treatment

Most people with COVID-19 have mild illness and can recover at home. The CDC says that a person can treat symptoms with over-the-counter medicines to help feel better. If, however, a person has COVID-19 and is more likely to get very sick from COVID-19, treatments are available that can reduce their chances of being hospitalized or dying from the disease. Medications to treat COVID-19 must be prescribed by a healthcare provider or pharmacist and started within five to seven days after symptoms appear. A healthcare provider will help decide which treatment, if any, is right for the person.

The FDA has authorized or approved several antiviral medications used to treat mild to moderate COVID-19 in people who are more likely to get very sick. Antiviral treatments target specific parts of the virus to stop it from multiplying in the body, helping to prevent severe illness and death. The National Institutes of Health (NIH) provides COVID-19 treatment guidelines for healthcare providers to help them work with their patients and determine the best treatment options for them. Several options are available for treating COVID-19. Some treatments might have side effects or interact with other medications a person is taking.

Measles hazard recognition

• Measles is highly contagious to anyone who does not have immunity through vaccine or previous infection.
• Healthcare workers are among those at highest risk for contracting measles.

Measles is readily transmissible to anyone who does not have immunity through effective vaccination or from having had measles already. Workers who may be near infected individuals, including members of the public or infected coworkers, are at risk of exposure regardless of their jobs. The measles virus spreads primarily through infectious droplets or airborne particles when an infected person breathes, coughs, or sneezes and through contact with respiratory secretions or saliva from an infected person. Measles can remain in the air for up to about two hours after a person with the disease has occupied an area. Environmental surfaces, such as tables or desks, also may be contaminated with infectious respiratory secretions or saliva that can spread the virus for up to about two hours.

Susceptible (i.e., non-immune) healthcare workers (HCWs) are among those at the highest risk for contracting measles. Because measles frequently affects children, workers in childcare facilities and schools are also at an increased risk for exposure to measles. Occupational exposure risk may be highest when measles outbreaks are occurring-especially outbreaks affecting the community in which employees work. Occupational exposure risk is much lower, but not necessarily eliminated, when there is no ongoing measles transmission.

Measles vaccines and treatment

• The CDC says the MMR vaccine for measles is very safe and effective. Adults who did not receive the vaccine as children may still receive it.
• The MMR vaccine is also effective at preventing measles when administered within 72 hours of an exposure.

Most people born in the United States since the early 1970s have been vaccinated for measles, as the Centers for Disease Control and Prevention (CDC) recommends children get two doses of the measles, mumps, and rubella (MMR) vaccine, with the first dose at 12–15 months of age and the second dose at four to six years of age. Adults who did not receive the vaccine as children can still be vaccinated.

According to the CDC, the MMR vaccine is very safe and effective. Two doses of the MMR vaccine are about 97 percent effective at providing immunity to measles (i.e., immunogenicity); one dose is about 93 percent effective. Because measles is highly contagious, about 90 percent of unvaccinated people exposed to measles will get the disease.

Vaccine-related complications are typically infrequent and, when they do occur, mild (e.g., fever, rash). The CDC has found no evidence that any vaccine causes autism or autism spectrum disorder (ASD). By definition of ASD as a developmental disability under the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5), adults, including those who receive the MMR or any other vaccine, do not develop autism later in life; cases of ASD diagnosed in adults have been present since childhood but not recognized until later in life.

The MMR vaccine is also effective at preventing measles when administered to a susceptible person within 72 hours following exposure. Because of the short period after exposure during which the vaccine is effective, healthcare providers may opt to give exposed individuals who may not be immune to the virus an additional dose of vaccine rather than waiting for laboratory testing to determine immunity. Unless otherwise contraindicated, extra doses of MMR are not harmful.

Immunoglobulin (IG) may prevent or lessen the severity of measles disease in susceptible people when given within six days following exposure and may be recommended for people who have contraindications for receiving the vaccine. (Note: healthcare providers should consult CDC recommendations for post-exposure prophylaxis, including guidelines for administering the MMR vaccine or IG, but not both.)

Testing for measles

The CDC recommends that healthcare professionals obtain a throat swab (specifically, from the nasopharynx) and blood specimen from all patients with clinical features compatible with measles (i.e., symptoms of the disease).

Healthcare professionals can contact their state and/or local health department to determine where to submit specimens and how to ship them. For information on sending specimens to the CDC from within the United States, please visit the CDC page on specimen collection, storage, and shipment.

Measles control and prevention

• Employers whose workers are at risk for exposure to measles should develop an infection control plan to reduce the risk.
• A control plan should include encouraging vaccination as well as early identification and isolation of any suspected or confirmed measles cases.

To prevent or reduce workers’ measles infection risk, employers whose workers are at risk of exposure to the measles virus should develop an infection control plan that addresses sources of measles exposure and provides infection prevention measures to reduce their risk.

The best way to prevent workers from getting measles on the job is to encourage workers at risk of exposure to get the measles, mumps, and rubella (MMR) vaccine if they have not already received it or if they have never had measles. Vaccination is safe and effective for the vast majority of people. When an employer is not covered by an Occupational Safety and Health Administration (OSHA) standard that requires an infection control plan, voluntarily developing a plan that includes offering the MMR vaccine to employees who are at risk of exposure and encouraging them to get it, can help keep workers healthy. Workers may be more likely to get the vaccine if it is available to them at no cost.

Workers who are concerned about whether or not they are susceptible to measles and possible exposures to the virus should discuss those issues with their healthcare provider. The Centers for Disease Control and Prevention (CDC) Pinkbook (Pinkbook: Epidemiology and Prevention of Vaccine-Preventable Diseases) measles chapter provides more information about who should be vaccinated or revaccinated and the appropriate schedule for doing so.

In addition to encouraging vaccination, employers who are likely to have measles-infected individuals in the workplace, such as in healthcare facilities, should ensure that their infection control plans include procedures for early identification and prompt isolation of suspected and confirmed cases. Isolating infectious individuals from workers, visitors, patients, students, and others can help prevent exposures and infections. Employers may also plan to keep workers, visitors, and others out of areas where a person with known or suspected measles has been for several hours until the air and environmental surfaces no longer pose an exposure hazard. Exposure prevention measures are also critical in other types of workplaces located in communities experiencing measles outbreaks.

OSHA’s Personal Protective Equipment (PPE) standards (in general industry, 1910 Subpart I and, in construction, 1926 Subpart E) require gloves, eye and face protection, and respiratory protection to help prevent worker exposure to measles virus. OSHA’s Bloodborne Pathogens (BBP) standard (1910.1030) also applies to workers who have occupational exposure to human blood, saliva in dental procedures, and other potentially infectious materials (OPIM) as defined in the standard. However, aside from saliva in dental procedures, the most common body fluids through which measles spreads are not covered by the BBP standard (1910.1030). Healthcare workers, childcare and school workers, and others who may be routinely exposed to potentially infectious body fluids may have some exposures that fall under the scope of the BBP standard and other exposures (such as to sputum or nasal secretions) that do not.

When the BBP standard applies, employers must implement universal precautions and other infection prevention measures, such as a written exposure control plan, engineering and work practice controls, PPE, and worker training. These measures could also serve as a framework to control infectious diseases like measles that are contracted through non-bloodborne exposures. A comprehensive infection control plan should include training on measles risks. A recommended best practice is for employers to explain measles risks to employees prior to them becoming pregnant

Employers must provide disposable gloves and encourage employees to use them for any activities that involve contact with body fluids. Latex-free gloves, such as nitrile and vinyl, are preferred to prevent allergic reactions. Require workers to discard gloves immediately after use and to wash their hands, preferably with soap and water, rather than use an alcohol-based hand sanitizer. OSHA’s Personal Protective Equipment (PPE) Safety and Health Topics page provides information on PPE selection and use.

Workplace surfaces that may be contaminated with body fluids should be cleaned regularly with disinfectant. Generally, Environmental Protection Agency-registered disinfectants suitable for Hepatitis B viruses and HIV (i.e., those on List D) will be effective against the measles virus. Commonly contaminated areas include countertops, tables, desks, cabinets, chairs, doorknobs, telephones, faucet handles, and equipment. In addition to the previous items, childcare workers should consider disinfecting any toys or small objects that may be contaminated with a child’s saliva or other body fluids.

When a worker is exposed…

Any worker who may have been exposed to measles should take the following precautions:

• Notify the employer immediately.
• Notify a healthcare provider immediately. Healthcare providers may be able to provide post-exposure care that protects against or lessens the effects of measles. For example, as the Medical Information page mentions, the MMR vaccine is effective at preventing measles when administered to a susceptible person within 72 hours following exposure.
• Watch for early signs and symptoms of measles, which typically develop within 10-12 days. It may take up to 21 days following exposure for a rash to develop. Seek medical attention if symptoms of measles develop.
• Before visiting a healthcare provider, alert the clinic or emergency room in advance about a possible exposure to measles so that arrangements can be made to prevent spreading it to others.
• When traveling to a healthcare provider, limit contact with other people. Avoid all other travel.

Risks to healthcare workers

• Healthcare workers who provide face-to-face care for sick patients are at increased risk for measles.

Healthcare workers, including clinical and support staff, have daily encounters with sick patients and are at an increased risk for exposure to measles. Workers providing direct, face-to-face patient care may be at the highest risk of exposure, especially in communities with ongoing measles outbreaks. However, as most measles cases in the U.S. result from international travel, domestic measles outbreaks are not the only scenario in which HCWs may encounter individuals with measles; travelers may return from abroad with the measles virus and seek care at U.S. hospitals, clinics, and other facilities. Other workers in healthcare environments, such as receptionists and food services assistants, may also share breathing air with infectious patients or encounter environments with potentially infectious measles virus.

Activities that can lead to HCW exposure include:

• Triaging or providing care to an infected patient-pediatric (i.e., child) or adult.
• Performing aerosol-generating procedures (AGPs) on an infected patient (e.g., intubation, airway suctioning). Although measles is already considered an airborne-transmissible disease, AGPs may increase transmission risk by adding to the concentration of measles virus suspended in the air in the work environment.
• Working in environments where an infected patient or coworker is or has been within the previous two hours.
• Cleaning or otherwise having contact with environmental surfaces contaminated with an infected person’s infectious body fluids (i.e., respiratory secretions, saliva).

Risks to child care workers

• Workers in child care facilities may be exposed to unvaccinated children with measles.
• There is a high rate of vaccine coverage for measles in most parts of the U.S.

In child care facilities and schools, workers may be exposed to unvaccinated children with measles. Like anyone with measles, children can spread the virus to others through breathing, coughing, and sneezing, as well as through infectious body fluids (e.g., respiratory secretions, saliva).

There is very little data available about measles infection among child care workers, especially because vaccine coverage in the United States is high. In 2010, 91.5 percent of children aged 19-35 months had received one dose of measles, mumps, and rubella (MMR) vaccine; during 2009-2010, 94.8 percent of kindergartners had received two vaccine doses; and in 2010, 90.5 percent of adolescents had received two vaccine doses. Pockets of unvaccinated individuals affect these vaccination statistics.

Activities that can lead to child care worker exposure include:

• Being near a child with measles, especially when the infected child is coughing or sneezing.
• Working in an environment where an infected child or coworker is or has been within the previous two hours.
• Wiping a child’s nose or mouth.
• Handling toys or utensils.
• Feeding a child.
• Providing first aid.
• Cleaning or otherwise having contact with environmental surfaces contaminated with an infected person’s infectious body fluids (i.e., respiratory secretions, saliva).

Risks to school workers

• Teachers and school employees may be at greater risk for measles exposure when they are not immune to the virus via vaccination or previous infection.

There is very little data about measles infection among teachers and other school employees. Some studies have found no evidence that teachers are at increased risk of measles as long as measles incidence (i.e., the number of cases) is low. However, teachers and other school workers may be exposed whenever they are around infected children or coworkers, and infection is much more likely among such workers who do not have immunity to the virus from vaccination or previously having had the disease.

Activities that can lead to school worker exposure include:

• Being near a child or coworker with measles, especially when the infected person is coughing or sneezing, or in an environment where the person has been within the previous two hours.
• Providing first aid.
• Cleaning surfaces contaminated with an infected person’s infectious body fluids (i.e., respiratory secretions, saliva).

Risks to laboratory workers

• Clinical and research laboratory workers may be exposed to the measles virus during outbreaks or when their work involves materials containing the virus.

Workers in clinical and research laboratories may be exposed to infectious materials containing the measles virus. Clinical laboratory workers’ exposure risks are increased during outbreaks when they are most likely to encounter throat swabs and blood samples from infectious patients. Research laboratory workers are most at risk of occupational exposure whenever their work involves materials containing the virus. These hazards are amplified when work tasks involving measles virus generate aerosols and/or are performed outside of biosafety cabinets (practices that should be avoided; see the Laboratory Workers guidance on the Control and Prevention page).

Risks to environmental services workers

• Environmental service workers may be exposed to measles through contaminated surfaces.

Environmental services workers may have exposure to contaminated environments and surfaces that can transmit the measles virus.

Activities that can lead to environmental services worker exposure include:

• Working in environments where an infected person is or has been within the previous two hours.
• Cleaning or otherwise having contact with environmental surfaces contaminated with an infected person’s infectious body fluids (i.e., respiratory secretions, saliva). Cleaning tasks that involve using pressurized sprays of water or cleaning chemicals can create potentially infectious aerosols.

Risks to workers who are pregnant or may become pregnant

• Pregnant women who get measles may have more severe complications than non-pregnant women, and can transmit the virus to the fetus, which can lead to complications.
• The CDC recommends the measles vaccination at least one month before becoming pregnant.

Measles can be especially hazardous for workers who are or may become pregnant. Pregnant women who get measles may experience more frequent or severe complications from the virus, including pneumonia and death, compared to non-pregnant women. Measles infection during pregnancy also may cause expectant mothers to have miscarriages, give birth prematurely, or deliver low-birth-weight babies.

Pregnant women who get measles can transmit the infection to the fetus if they have the virus within about 10 days of delivery. In addition to premature birth and low birth weight, measles can lead to other complications and death among infants born with the virus or infected shortly after birth. Measles may be especially severe among such infants.

Infected partners and other contacts of susceptible, pregnant women can also easily spread measles to them.

Because of the risk of adverse health effects associated with measles infection during pregnancy, the Centers for Disease Control and Prevention (CDC) recommends that anyone without immunity get the MMR vaccine at least one month before becoming pregnant. The MMR vaccine may cause complications if administered during pregnancy.

Risks to workers who travel abroad

• Travelers to areas where measles is endemic are at increased risk for exposure to measles.

According to the Centers for Disease Control and Prevention (CDC), anyone who travels outside the United States is at increased risk of exposure to measles. Measles is endemic (i.e., routinely spreading) or associated with epidemics (i.e., spreading currently, but not always circulating) in many countries throughout the world. Measles is a common disease in many areas of Europe, Asia, the Pacific, and Africa.

American workers who travel to countries with endemic or epidemic measles may be exposed to the virus. Not only are international travelers at risk of getting measles abroad, but they may also bring the disease back to the United States if they return before they develop measles or during the infectious period. Most U.S. measles cases result from international travel.