Preparing for the Next Pandemic
IHs Are Needed Now More Than Ever
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Four years ago, before our world was upended by the COVID-19 pandemic, we authored an article titled “No Boundaries: IH’s Role in Preventing the Transmission of Highly Hazardous Communicable Diseases” that was published in the April 2018 Synergist. The purpose of that article was twofold: first, to reflect on our experience working in the Nebraska Biocontainment Unit during the 2014–2016 West Africa Ebola outbreak and share best practices, and second, to illustrate how industrial hygienists are well positioned to respond to highly hazardous communicable diseases as their incidence continues to rise worldwide. We did not intend for our 2018 article to be foreboding, but rather food for thought. Then, in early 2020, the role of IHs drastically changed as they acquired new responsibilities related to infectious disease mitigation and management. With our world getting smaller each day given the ease of transporting goods and people, as well as climate change’s negative environmental impact blurring the lines between animal ecosystems and pathogen reservoirs (as described in a 2017 paper published in Environment International), another pandemic in our lifetime is a real possibility. As we know, hazards unrelated to a pandemic do not disappear during pandemic times; rather, IHs are tasked with addressing these hazards and those arising from a pandemic simultaneously. As IHs, we need to be adept at controlling everyday hazards while responding to those brought about by infectious disease outbreaks. These past two years have demonstrated that a pandemic drastically increases the IH workload and can result in additional challenges that may increase or conceal everyday hazards. For example, extra personal protective equipment worn during infectious disease mitigation tasks can both increase heat stress and conceal visual cues associated with that heat stress. So, how do we prepare for the next pandemic when we have not yet recovered from nor understood the full, long-term impacts of COVID-19? What lessons have we learned, and how do we ensure that we don’t become complacent as the current pandemic appears to wane? HIERARCHY OF CONTROLS LESSONS LEARNED The hierarchy of controls is an important part of the IH toolkit. Two recent AIHA publications cover controls as well as planning, assessment, control banding, and other applicable considerations in infectious disease mitigation and management: Essentials of Pandemic Response: Considerations for Controlling COVID-19 and Other Infectious Diseases and the second edition of The Role of the Industrial Hygienist in a Pandemic. The following hierarchy-related takeaways may be relevant to the next epidemic or pandemic. Elimination. Early in the COVID-19 pandemic, each state responded differently—some by issuing no stay-at-home orders and others by issuing orders that lasted weeks for nonessential services in March and April of 2020. However, compared to other nations such as New Zealand and Taiwan, the United States’ effort to contain the virus through “lockdown” was minimal and only served to slow the inevitable unmitigated community spread. Quarantine and isolation will continue to be useful elimination measures and should be enforced when appropriate and possible. Substitution. Cleaning and disinfection are routinely employed against any microbial agent, but overapplication or improper combinations of chemicals can sometimes cause adverse human health effects. Substitution for less hazardous chemicals or less hazardous application techniques can reduce the overall negative human health impact while effectively decreasing the microbial dose. EPA and other credible sources widely publish disinfectant lists for known pathogens of interest, including EPA’s List N for COVID-19. Engineering controls. Heating, ventilation, and air conditioning (HVAC) adjustments have been shown to be effective engineering controls against airborne and aerosol transmissible diseases, including COVID-19. Actions such as increasing the number of air changes per hour allow for the quicker removal of viral particles from the air, and increasing filter efficiency while reducing HVAC air recirculation dilutes particles. (See the Essentials of Pandemic Response and The Role of the Industrial Hygienist in a Pandemic publications for additional information in this area.) Administrative controls. The pandemic has demonstrated that life indeed goes on without everyone in the office. Some studies have found increased job satisfaction due to remote work options (for a couple of examples, see the papers in the International Journal of Trade & Commerce-IIARTC and Sustainability in the “Resources” section below). To boost worker satisfaction and decrease the likelihood of turnover or resignation, these flexible work arrangements should continue fully or partially, with telecommuting schedules coordinated between employers and employees. Employers must also contend with the difficult task of addressing workers’ ergonomic needs in telecommuting environments. Personal protective equipment. The pandemic ushered in the widespread use of cloth face coverings, surgical masks, KN95s, NIOSH-approved filtering facepiece respirators, and other FFRs. Most people are now at least aware of different types of respiratory protection, but education is needed to teach the general public to utilize masks properly and within their limitations. Workplaces both with and without employees in mandatory respiratory protection programs have likely seen the formation of bad habits that calcified during the pandemic. For instance, some workers may not be wearing the correct fit-tested models. Skipped seal checks as well as improper storage and management of respiratory protection (for example, workers shoving respirators into their pockets between uses) are additional examples. Lax respiratory protection habits like these will require refresher training with hands-on skills practice to remediate these issues. COMMUNICATION Communication became a major problem for all parties—from federal agencies to employers—during the COVID-19 pandemic and will remain a struggle in any future pandemic. Intentional and unintentional misinformation is rampant, with social media facilitating the spread of this secondary pandemic of misinformation, as described in the journal JMIR Public Health and Surveillance. Throughout the COVID-19 pandemic, decisions have had to be made without complete information (particularly early on, for example, when researchers were still collecting data on the virus’s incubation period, modes of transmission, and infectious dose). Fortunately, IHs are problem solvers, skillful at extrapolating current knowledge and past experiences to provide direction when there is a dearth of reliable information and adjusting course when new information becomes available. However, we must ensure that the stakeholders and lay populations we work with understand that with an emerging pathogen comes evolving breakthroughs in knowledge and understanding, so we expect the information to change. Communication needs to be clear and transparent.
Workplaces both with and without employees in mandatory respiratory protection programs have likely seen the formation of bad habits that calcified during the pandemic.
Challenges in communication emerged when public health authorities assumed that the public understood health communications more fully than was true. Authorities also included a level of nuance in many communications that further confused the public; these perceived inconsistencies—in addition to not being well received—eroded public trust. (For more on this topic, see the papers from the International Journal of Preventive Medicine and Disaster Medicine and Public Health Preparedness under “Resources.”) Scholars will likely spend decades analyzing the successes and failures of communications surrounding the COVID-19 pandemic.
As IHs, we understand the importance of risk, risk perception, and risk communication to our stakeholders. We know that there is no such thing as an entirely risk-free environment, and we accept our role in trying to reduce risk. This concept proved difficult to communicate to some stakeholders who, during the pandemic, insisted on a zero-risk environment and faced difficulty returning to the workplace despite employing numerous risk mitigation strategies. Many did not understand the difference between reducing risk and eliminating it. Communications regarding these types of issues must frame the risks in relatable terms that the general population will understand. It’s also important to note that, as our world becomes increasingly filled with misinformation that is rapidly spread online and through social media, risk communication skills do not always translate to effective public communication.
On the opposite end of this spectrum lies the portion of stakeholders who denied that there was any risk or that the pandemic was occurring. Unlike physical hazards that are clearly visible to the human eye, this biological hazard presented seemingly insurmountable communication challenges. Many stakeholders seemed to adopt the point of view, “I can’t see it, so it doesn’t exist.” This is a group that many of us were inadequately prepared to address (papers listed under “Resources” on protest during pandemics and on scientific trust, risk assessment, and conspiracy beliefs about COVID-19 highlight this challenge). Despite the use of many methods—sharing facts, identifying a respected leader in their field to provide information, and providing financial incentives to get vaccinated, to name a few—some population segments still haven’t been reached. A number of interventions and studies are currently being conducted to try to determine the best ways to reach these populations. However, these groups are not monolithic and are influenced by many variables, such as politics, history, and geography. No single strategy will be successful; the approach must instead be multi-faceted, local, and targeted.
Many IH academic programs do not require courses on risk communication or health communication; these skills are often learned through work experience and continuing education. As conveying information in our world becomes increasingly complicated, colleges and universities should consider incorporating these types of courses into their IH curricula to better prepare new IH professionals for these challenges. We encourage IHs who are already practicing in the field to embrace continuing education opportunities to enhance our communication strategies.
MENTAL HEALTH IHs are not mental health professionals, but we can play a role in continuing to destigmatize addressing mental health in the workplace, which will be key going forward. COVID-19 is a collective community trauma, and it will take years to recover. COVID-19 has also exacerbated ongoing epidemics tied to mental health, including the opioid crisis. Mental health is no longer a topic that workplaces can continue to ignore. The onus of good mental health should not be put on the worker if structural issues are contributing to poor mental health.
Mental health services and interventions prove to be most effective when they are clearly supported by workplace leadership and the importance of worker mental health is woven into the fabric of an organization. Mental health services provided or subsidized by employers (for example, generous employee assistance programs or well-being programs) combined with manageable workloads, paid time off, and supportive management have been shown to increase worker job satisfaction, decrease turnover intention, and decrease presenteeism (these effects are described in the paper focused on training managers to support the mental health needs of employees and the book Employee-Organization Linkages in the “Resources” section of this article). IHs should work with management to integrate mental health resources within the occupational safety and health paradigm and utilize them ourselves as needed.
PSYCHOSOCIAL FACTORS OF WORK COVID-19 has made clear that our work and lives outside of work are inexorably connected and impact one another. Within the realm of occupational health psychology and safety research is decades of study examining the psychosocial factors of work. Psychosocial factors influence an individual psychologically or socially in relation their environment—in this case, their work environment—and can affect physical and mental health.
COVID-19 is a collective community trauma, and it will take years to recover.
Some key issues that have emerged throughout the COVID-19 pandemic have to do with work-family conflict, a phenomenon described in the 1992 Journal of Applied Psychology paper under “Resources.” Telecommuting has blurred the lines between work and home life, work arrangements are ever changing, and schools are constantly switching from in-person to online learning due to COVID-19 outbreaks or staffing shortages—all of which can put a strain on families. Work life can negatively affect family life or vice versa. Research has shown that COVID-19 exacerbated work-family conflict and placed more demands on working women, who bear the burden of traditional caretaking roles in our society (see the papers on work-family balance and work-family conflict in the “Resources” section for more on this topic).
COVID-19 continues to push workers’ well-being to the forefront as many are still working under stressful conditions, adapting to changing workplace policies, and navigating challenging economic conditions, among other difficulties. NIOSH’s Total Worker Health (TWH) approach, which the agency defines as “policies, programs, and practices that integrate protection from work-related safety and health hazards with promotion of injury and illness-prevention efforts to advance worker well-being,” includes strategies that can benefit workers and employers as well as communities. According to a paper published in 2020 in the journal Human Factors, more workplaces are moving toward integrative TWH frameworks, recognizing work as a determinant of health along with more widely recognized social determinants of health like healthcare access and food security.
The job demands-resources (JD-R) model, discussed in the Journal of Applied Psychology in 2001, is another relevant lens through which to examine the COVID-19 pandemic. The JD-R model is an occupational stress model that posits strain at work is a response to the imbalance between demands on a worker and the resources they have to deal with those demands. A paper published in the journal Work & Stress in 2019 shows that the JD-R model has been used to successfully predict burnout, work motivation and engagement, organizational outcomes, and more.
In addressing psychosocial factors of work, IHs must go beyond hazard recognition to understand additional factors that are driving workplace hazards. This is not to say that we need to become therapists or social workers but rather broaden our skillset—as many of us have done during the COVID-19 pandemic—to mitigate and manage workers’ exposures to infectious diseases and the cascade of consequences that impact the workplace.
OVERLOOKED WORKER POPULATIONS Overlooked populations—such as people overlooked due to race or ethnicity, socioeconomic status, or citizenship status as well as those at an intersection of several identities—experienced high rates of COVID-19 infection, hospitalization, and death throughout the pandemic. Many researchers have already pointed out the lack of COVID-19 surveillance data being collected in these overlooked populations. It is especially important for employers to collect employee illness data among overlooked worker segments (minorities working in healthcare and meat processing, for example) now and during future infectious disease outbreaks.
Overlooked populations are represented in the workplace; only by collecting illness and injury data can we better understand what control measures and culturally competent or tailored training are needed to better protect their health. While collecting this data is not a federal requirement for businesses with fewer than 10 employees, voluntary reporting to local or state-level health departments could better identify disease clusters and improve overall worker safety.
INVESTING IN PRIMARY PREVENTION Public health, mental health, occupational safety and health, and IH programs are all unfortunately burdened with similar funding issues. When things are deemed to be going well, our overlapping fields experience a lack of investment in primary prevention, maintenance of infrastructure, and baseline funding for necessary programs. But when things are going badly—such as during a global pandemic—we are asked why we have not done more despite our limited budget and resources.
Infectious disease response does not have to be managed as an emergency or tertiary treatment—addressed when people are already sick. There are many primary prevention methods we have implemented in the workplace that we would do well to maintain after the COVID-19 pandemic. These include heightened cleaning procedures, growing acceptance of masking when sick with a respiratory infection, practicing physical distancing, not attending or attending fewer public activities when ill, flexible work arrangements, and generous time-off policies. Tools like the JD-R model and research on the economic benefits of paid sick leave (for example, see the Journal of Occupational and Environmental Medicine paper under “Resources”) show how allowing workers to work while sick and spread disease is more financially detrimental to employers and businesses than investment in sick leave.
The pandemic has provided new insights into what can be done within the workplace to better support worker health as it relates to preventing infectious diseases and improving workers’ overall health. This will be an evolving area for years to come as workplaces adapt to worker expectations and determine what is sustainable for their needs and for employees.
THE VALUE OF IH The COVID-19 pandemic has demonstrated the value of IH in infectious disease response and shown that IHs are integral to successful mitigation and management. We all wish to put COVID-19 behind us, but we must continue to work to end this pandemic and prepare for the next one by embracing best practices and lessons learned. We hope this knowledge leaves the IH community and general public better prepared to address what infectious disease challenge is on the horizon.
AURORA LE, PhD, MPH, CSP, CPH, is the John G. Searle assistant professor of environmental health sciences at the University of Michigan School of Public Health. She served as a research assistant for the Nebraska Biocontainment Unit in 2015–2016 and assisted the Office of the Assistant Secretary for Preparedness and Response in developing a training curriculum on the management of highly infectious remains.
SHAWN GIBBS, PhD, MBA, CIH, is dean of the School of Public Health at Texas A&M University and professor of environmental and occupational health. He served as the director of research for the Nebraska Biocontainment Unit in 2009–2015. He also assisted CDC and the Office of the Assistant Secretary for Preparedness and Response in crafting guidelines on Ebola patient transport, decontamination, and handling of highly infectious remains.
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Digital Extra: Related Reading from The Synergist
Previous Synergist articles on the topics of COVID-19 and infectious diseases appear below. The articles are listed by publication date, with the most recently published ones at the top.
Sampling for SARS-CoV-2: PCR Versus Culturing” (August 2021)
After the Pandemic: Planning for a Better ‘Normal’” (April 2021)
From Best Practice to Policy: Developing a COVID-19 Prevention Program” (April 2021)
COVID-19 and the Art of Anticipation” (March 2021)
Spraying Disinfectants: Tips for Applying to Surfaces” (March 2021)
Confronting Two Crises: The COVID-19 Pandemic, the Opioid Epidemic, and the IH” (January 2021)
COVID-19 and Worker Fatigue: Lessons Learned and Mitigation Strategies” (November 2020)
COVID-19 and the Industrial Hygienist: FAQs on Practicing IH in a Pandemic” (May 2020)
No Boundaries: IH’s Role in Preventing the Transmission of Highly Hazardous Communicable Diseases” (April 2018)
IHs Play Key Role in Treatment of American Ebola Patients” (November 2014)
Academic Press: Employee-Organization Linkages: The Psychology of Commitment, Absenteeism, and Turnover (2013).
AIHA: Essentials of Pandemic Response: Considerations for Controlling COVID-19 and Other Infectious Diseases (2022).
AIHA: The Role of the Industrial Hygienist in a Pandemic, 2nd ed. (2021).
American Journal of Public Health: “The Health Impacts of COVID-19-Related Racial Discrimination of Asian Americans Extend Into the Workplace” (2021).
BMJ Global Health: “Ethnic and Racial Disparities in COVID-19-Related Deaths: Counting the Trees, Hiding the Forest” (2020).
Bridging Occupational, Organizational and Public Health: “A Critical Review of the Job Demands- Resources Model: Implications for Improving Work and Health” (2014).
CDC: “Risk for COVID-19 Infection, Hospitalization, and Death By Race/Ethnicity.”
Disaster Medicine and Public Health Preparedness: “Public Health Communication in Time of Crisis: Readability of On-Line COVID-19 Information” (2020).
Environment International: “Climate Change and Human Infectious Diseases: A Synthesis of Research Findings from Global and Spatio-Temporal Perspectives” (2017).
Human Factors: “An Integrative Total Worker Health Framework for Keeping Workers Safe and Healthy During the COVID-19 Pandemic” (2020).
Institute for Women’s Policy Research: “No Time to Be Sick: Why Everyone Suffers When Workers Don’t Have Paid Sick Leave” (2004).
International Journal of Preventive Medicine: “Effective Public Health Communication in the COVID-19 Era” (2020).
International Journal of Trade & Commerce-IIARTC: “Working from Home During the COVID-19 Pandemic: Satisfaction, Challenges, and Productivity of Employees” (2020).
JAMA Network Open: “Association Between Income Inequality and County-Level COVID-19 Cases and Deaths in the U.S.” (2021).
JAMA Network Open: “Experiences of Work-Family Conflict and Mental Health Symptoms by Gender Among Physician Parents During the COVID-19 Pandemic” (2021).
JMIR Public Health and Surveillance: “Misinformation of COVID-19 on the Internet: Infodemiology Study” (2020).
Journal of Applied Psychology: “Antecedents and Outcomes of Work-Family Conflict: Testing a Model of the Work-Family Interface” (1992).
Journal of Applied Psychology: “Changes to the Work-Family Interface During the COVID-19 Pandemic: Examining Predictors and Implications Using Latent Transition Analysis” (2020).
Journal of Applied Psychology: “The Job Demands-Resources Model of Burnout” (2001).
Journal of Managerial Psychology: “The Job Demands-Resources Model: State of the Art” (2007).
Journal of Occupational and Environmental Medicine: “Potential Economic Benefits of Paid Sick Leave in Reducing Absenteeism Related to the Spread of Influenza-Like Illness” (2017).
Journal of Work-Applied Management: “The Work-Family Balance of British Working Women During the COVID-19 Pandemic” (2021).
National Alliance on Mental Illness: “State Mental Health Cuts: A National Crisis” (PDF, 2011).
NIOSH: “NIOSH Total Worker Health Program” (2020).
Occupational and Environmental Medicine: “Effectiveness of Training Workplace Managers to Understand and Support the Mental Health Needs of Employees: A Systematic Review and Meta-Analysis” (2018).
PsyArXiv Preprints: “Scientific Trust, Risk Assessment, and Conspiracy Beliefs About COVID-19 – Four Patterns of Consensus and Disagreement Between Scientific Experts and the German Public” (2020).
Sustainability: “Social Isolation and Stress as Predictors of Productivity Perception and Remote Work Satisfaction During the COVID-19 Pandemic: The Role of Concern About the Virus in a Moderated Double Mediation” (2020).
The Synergist: “Beyond Risk Assessment: Integrating the Risk Sciences into the Profession of Industrial Hygiene” (September 2018).
Translational Behavioral Medicine: “Addressing Inequities in COVID-19 Morbidity and Mortality: Research and Policy Recommendations” (2020).
Trust for America’s Health: “The Impact of Chronic Underfunding on America’s Public Health System: Trends, Risks, and Recommendations, 2020,” bit.ly/tfah2020 (2020).
Work & Stress: “The Job Demands-Resources Model: A Meta-Analytic Review of Longitudinal Studies” (2019).
ZEW-Centre for European Economic Research Discussion Paper: “Spreading the Disease: Protest in Times of Pandemics” (2021).