a deeper dive: returning to the workplace€¦ · director of service and marketing. he received...

A Deeper Dive:

Returning to the Workplace

April 29, 2020

Presented by:

David Bronstein, MDPediatric Infectious DiseaseKaiser Permanente Medical Group

INTRODUCTION

About Burnham

Employee Benefits Retirement Planning Property & Casualty

INTRODUCTION

Presenter Introduction

David Bronstein, MDPediatric Infectious Disease

Southern California Permanente Medical Group

Dr. Bronstein of Kaiser Permanente's Antelope Valley Medical Center, is currently

the Physician-In-Charge of the Palmdale Medical Offices and the Physician

Director of Service and Marketing. He received his medical degree from UC San

Diego and public health degree from UCLA. In addition, he is the Antelope Valley's

physician lead for culturally responsive care, performance improvement and

innovation, influenza vaccination, and pediatric quality improvement.

COVID-19: Return to Work

4

David Bronstein, MDPediatric Infectious Disease

Southern California Permanente Medical Group

5

What we’ll be covering

Why did workplaces close?

How do workplaces reopen?

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Why did workplaces close?

7

Workplaces would not have needed to close if…

the virus didn’t spread easily person-to-person.

▪ Person-to-person by respiratory

droplets (within 6 feet)

▪ Symptoms appear within 2-14 days

after exposure (most cases 4-5)

▪ Contaminated surfaces & objects

▪ Reproductive number

(R0) = 2 – 2.5

Transmission

8


we always know when someone is sick with it.

A person with COVID-19

is considered infectious

48 hours before the

onset of symptoms.

9

the virus didn’t make some people very sick.

Signs & Symptoms

▪ Congestion uncommon

▪ Diarrhea? Anosmia?

Severity

▪ Severe complications:

septic shock, ARDS,

multiple organ dysfunction

syndrome

Case Fatality (%)


3.7

5.5

5.7

6.9

9.2

10.2

12.3

13.5

13.5

13.9

15.1

Germany

China

US

Brazil

Mexico

Spain

Sweden

Italy

UK

France

Belgium

10

there were effective and available treatment options.

▪ Supportive care

▪ Oxygen, fluids, fever reduction

▪ Supportive care for sepsis, ARDS

▪ Indication for ventilators

▪ Most cases are mild

▪ Focus on prevention of

transmission to others

▪ Monitor for clinical deteriorationHOME

HOSPITAL

▪ Remdesivir

▪ Hydroxychloroquine

▪ Cytokine inhibitors

▪ Convalescent plasma

Therapeutics


11


▪ Remdesivir




Therapeutics


▪ Broad spectrum antiviral

▪ Promising initial study, with clinical improvement in

approximately 2/3 of patients

▪ Recent unpublished study from China showed no

benefit, but too few patients enrolled

▪ Larger clinical trial in progress

12


▪ Remdesivir




Therapeutics


▪ Antimalarial and rheumatologic medication with

laboratory activity against coronaviruses

▪ Initial studies showing effectiveness with flawed

designs

▪ More recent studies show lack of effectiveness

and high rates of dangerous cardiac side effects

13


▪ Remdesivir




Therapeutics


▪ Prevent tissue damage that may occur from a

runaway immune response later in the course of

severe illness

▪ Clinical trials underway

14


▪ Remdesivir




Therapeutics


▪ Plasma from those who have recovered from

COVID-19 infections used to treat patients with

serious or immediately life-threatening infections

▪ Small initial studies with promising results

▪ Difficult to obtain sufficient quantity

15

there was effective and available prophylaxis.


Chloroquine prophylaxis

There currently are no data

to recommend the use of

hydroxychloroquine as

prophylaxis for COVID-19,

but trials are underway

16

we had previous immunity to the virus.


Dec. 31WHO first alerted

to pneumonia

cases in Wuhan

Jan. 17Coronavirus

strain identified

Jan. 13First case

outside of

China

(Thailand)

Jan. 15First case in Japan

Jan. 31WHO declares “public

health emergency of

international concern”

March 11WHO elevates status

to PANDEMIC

▪ 118,000 cases

▪ 114 countries

Feb. 2First COVID-related

death outside China

Feb. 19First two cases

and deaths in

Iran announced

Feb. 21-25Sudden increase

in cases in Italy

March 9Nationwide

lockdown in ItalyJan. 21First case in U.S.

(Washington State)

Jan 30First person-

to-person

transmission

in U.S.

Feb. 29First COVID-related

death in U.S.

Jan. 10First death

reported by media

Feb. 26First case of community

spread in U.S. (California)

January 2020 February 2020 March 2020Dec. 2019

17

there was an effective and available vaccine.

35 companies and institutions currently working on multiple vaccines

Moderna

“Even if the research goes well, a vaccine wouldn’t be available for widespread use for 12 to 18 months.

— Anthony Fauci, MD, NIAID Director

Phase 1 clinical trial of mRNA-1273 started March 16, 2020

• Includes 45 healthy adult volunteers, ages 18 to 55

• Evaluating safety and ability to induce immune response

• Run by Kaiser Permanente Washington Health Research

Institute (KPWHRI) in Seattle


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the containment strategy was successful.


Home Isolation

Symptomatic person who

should remain at home

while ill

When to return to work:

At least 7 days after onset

of symptoms and absence

of fever for at least 72

hours

Home Quarantine

Asymptomatic person who

should remain at home

following high-risk exposure

When to return to work:

14 days from last high-risk

exposure

*Critical Infrastructure worker: Law enforcement, 911 call center, fusion center, hazardous material response, janitorial /

custodial, food and agriculture, critical manufacturing, informational technology, transportation, energy, government

Self-Monitor at Work

Asymptomatic person with

low-risk exposure or critical

infrastructure worker*

May continue to work:

Check temperature twice

daily while working and

report any symptoms to

supervisor

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But, the virus does spread easily person-to-person even before

symptoms develop, makes some people very sick, is not easily

treated or prophylaxed against, has not induced immunity from

previous circulation, cannot be immunized against currently, and

has not been successfully contained.

Containment

▪ Home isolation

▪ Home quarantine

▪ Self-monitor at work

Mitigation

▪ Physical distancing

▪ Shelter-in-place

20

Expansion of broad

range of telehealth

options

Postponement of

non-urgent

appointments

Restriction of visitation

and consolidation of

facilities

Healthcare – mitigation

21

Healthcare – surge preparations

Increase capacity of KP

facilities and flexible

staff redeployment

Voluntary transfer of

non-COVID-19 patients

to USNS Mercy

Pubic and private

partnership to form

LA Surge Hospital

22

The curve flattened.

Mitigation

strategies

appear to be

effective in

California

23

How do workplaces reopen?

24

If sheltering-in-place was so effective,

why do we need to reopen?

Economy Education

25

Can we reopen quickly?

Antibody studies show lack of herd immunity

Los Angeles▪ 2.8 – 5.6% positive → at least 94% uninfected

Santa Clara▪ 2.5 – 4.2% positive → at least 96% uninfected

New York City▪ 21.2% positive → at least 79% uninfected

Antibody tests are unlikely to help with return-to-work decisions

▪ High rates of false positive tests (low prevalence of disease in population and

cross reaction with other common coronaviruses)

▪ May have a positive antibody test and still have an active infection

▪ Positive test does not guaranty immunity

26

No lockdown

▪ Belarus

▪ Sweden

Easing restrictions

▪ Austria

▪ Czech Republic

▪ Denmark

▪ Finland

▪ Germany

▪ Iceland

▪ Italy

▪ Norway

▪ Spain

Countries Essential businesses

▪ Health care

▪ Essential infrastructure

(construction, public

transportation

▪ Grocery stores,

convenience stores

▪ Gas stations, garbage

collection, hardware stores,

plumbers, electricians

▪ Distance learning

institutions

▪ Childcare

▪ Banks, security, payroll,

laundromats

How do we know if workplaces are ready to reopen?

States

Reopening

▪ Alaska

▪ Georgia

▪ Oklahoma

▪ South Carolina

Expiring stay-at-home orders

▪ Alabama

▪ Arizona

▪ Colorado

▪ Florida

▪ Hawaii

▪ Idaho

▪ Louisiana

▪ Maine

▪ Minnesota

▪ Mississippi

▪ Montana

▪ Nevada

▪ New Mexico

▪ Tennessee

▪ Texas

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National guidelines for reopening

▪ Gaiting criteria

▪ State responsibilities

▪ Individual responsibilities

▪ Employer responsibilities

▪ Three phases of reopening

Released by the White House on April 16, 2020

28

Gating criteria

Symptoms Cases Hospitals

Downward trajectory of

influenza-like illnesses

and COVID-like cases

within a 14-day period

Downward trajectory of

documented cases and

percent positive tests

within a 14-day period

Treat all patients without

crisis care and robust

testing program in place

for healthcare workers

Before proceeding to Phased Opening:

29

State responsibilities

Preparedness checklist

❑ Testing

❑ Contact tracing

❑ Sentinel surveillance (early warning)

❑ Healthcare system surge capacity

❑ Prevention / protection

❑ Therapeutics (California)

30

Individual responsibilities

Know how

it spreads

Clean your

hands often

Avoid close

contact

Stay home

if you’re sick

Cover coughs

and sneezes

Wear a

facemask

Clean and

disinfect

31

▪ Designed to prevent droplet

transmission from health care

workers to surgical patients

▪ Protect the wearer from splashes

of biological fluids

▪ Not air tight

▪ Disposable

Types of Masks

▪ N95 respirators reduce inhalation

exposure to airborne particles by

at least 95%

▪ Form tight seal around face

▪ Require careful fit for effectiveness

▪ Can be reprocessed

Respirators Medical Masks Cloth Masks

▪ Reduces risk of spreading virus

to others

▪ Some reduced risk of infection for

uninfected people

▪ Prevention of asymptomatic

transmission

Recommended by the CDC for the

public where social distancing

measures are difficult to maintain

For healthcare workers doing

high-risk aerosolization

procedures

For health care workers in

COVID -19 exposure risk settings

32

Cloth Face Coverings

DIY Cloth Masks

▪ T-shirts

▪ Cotton quilting fabric

▪ Tea towels

▪ Flannel pajamas

▪ Coffee filters and paper towels

▪ Scarves and bandanas

▪ Filters and vacuum bags

33

Mask use in the community

Advantages Disadvantages

▪ Population-level effectiveness data in Hong

Kong, Taiwan, and South Korea (may be

confounded by testing)

▪ Increased level or risk perception

▪ Decreased stigma

▪ Decrease R0

▪ Reduced spread of other diseases

▪ Lead to shortages for health care workers

▪ Complacency, increased face touching

▪ No eye protection

▪ Mask contamination

▪ Uncomfortable

▪ Interferes with facial recognition on iPhone

Develop and implement policies regarding:

34

Employer responsibilities

▪ Social distancing and protective equipment

▪ Temperature checks

▪ Symptom monitoring

▪ Sanitation

▪ Use and disinfection of common and high-traffic areas

▪ Testing, isolating, and contact tracing (if COVID +)

▪ Business travel

“Do not allow symptomatic people to physically return to work until cleared by a medical provider.”

35

What happens when an employee has symptoms?

Employee has

fever and/or

symptoms

Send home for

home isolation

Employee

seeks medical

advice

Negative COVID test not

required to return to work

Positive test or

clinical diagnosis

of COVID

Return to work when

symptoms improve

and >7d after symptom onset

and no fever >72 hours

Negative testReturn to work

when recovered

COVID suspected

COVID testing

only for high risk*Employer should inform other

employees about a possible

exposure at work, but must

maintain the confidentiality of

the identity of the employee

who tested positive (ADA)

COVID not suspectedReturn to work

when recovered

* Testing criteria are changing on a daily basis as our capacity to

test more members increases. Currently we are testing

symptomatic patients who require hospitalization or are

considered high risk (adults>65, immunocompromised, cancer,

transplant, advanced HIV, chronic lung and/or heart disease,

diabetes with A1c>8.0, pregnancy, morbid obesity, and homeless)

and symptomatic health care workers and first responders.

36

KP Regional Reference Lab

▪ Roche Cobas 6800

▪ < 24 hours

Testing

KP Medical Center Lab

▪ Abbott ID NOW

▪ < 2 hours

FDA-authorized Laboratory

▪ Approx 2 days

▪ Testing currently available only with a doctor’s order

▪ No cost-sharing for COVID 19 screening or testing

37

Vulnerable: shelter-in-place

Public: maximize physical

distance (<10 people)

Socialize: <10 people

Travel: minimize non-essential

Individuals Employers Specific Employers

Encourage telework

Return to work in phases

Common areas: closed

Travel: minimize non-essential

Vulnerable personnel: special

accommodations

Schools & youth activities: remain closed

Hospitals & senior facilities: no visitors

Large venues: strict physical distancing

Elective surgeries: outpatient

Gyms: strict physical distancing

Bars: closed

Vulnerable: shelter-in-place

Public: maximize physical

distance

Socialize: <50 people

Travel: resume non-essential

Encourage telework

Common areas: closed

Travel: resume non-essential

Vulnerable personnel: special

accommodations

Schools & youth activities: reopen

Hospitals & senior facilities: no visitors

Large venues: moderate physical distancing

Elective surgeries: outpatient & inpatient

Gyms: strict physical distancing

Bars: diminished standing room occupancy

Vulnerable: resume public

interactions with physical

distancing

Low-risk: minimize time in

crowded environments

Unrestricted staffing Hospitals & senior facilities: resume visits

Large venues: limited physical distancing

Gyms: standard sanitation protocols

Bars: increased standing room occupancy

Phase

1

2Phase

2

Phase

3

38

Are employees ready to go back to work?

Consideration of employees’ feelings

▪ Hesitancy, anxiety

▪ Post-traumatic stress disorder

▪ High-risk family members

▪ Recovering from previous infection

▪ Childcare needs

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Role of healthcare to support reopening

▪ Evaluation and treatment

▪ Testing when indicated

▪ Prevention and management of

chronic diseases

▪ Mental health and wellness services

▪ Influenza vaccination

▪ COVID vaccination when available

Resume mitigation strategies and surge preparations if needed for future waves of COVID

Q & A

40

Join us next Wednesday

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a deeper dive: returning to the workplace€¦ · director of service and marketing. he received...

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