Travel typically involves sometimes-close encounters with high numbers of potentially infected people, sharing the same space, breathing the same air, and touching the same objects. For essential business travel, the question companies face is: How can we make travel safer for our people?
A Message on COVID-19 from WorkSTEPS Chief Medical Officer Dr. Ben Hoffman
Business travel is yet another point of tension that companies need to navigate during this pandemic. The tension lies between two facts: 1) Business travel is sometimes necessary; and 2) Business travel typically exposes travelers to a risk of COVID-19 infection that is higher than their new-normal lives. Travel typically involves sometimes-close encounters with high numbers of potentially infected people, sharing the same space, breathing the same air, and touching the same objects. These factors add up to higher risk.
So, for essential business travel, the question companies face is: How can we make travel safer for our people? I think it is helpful to answer that question by answering three other questions:
I’ll illustrate the need to consider this question with a couple of extreme examples. It would not be advisable for a sales associate who is a primary caregiver to a child with Leukemia to travel to a college town the weeks surrounding a big football game. It would also be risky for an older, obese executive with diabetes and a heart condition to take a long, overseas trip.
The point: decisions about who travels where and when should reflect consideration of the infection risk of the destination and health/vulnerability of the person traveling.
To understand disease risk of travel destinations, the US CDC provides a map indicating COVID-19 risk levels for different countries, and a page with links to US state COVID-19 information. Unfortunately, just about everywhere is high risk right now, with some countries, states and cities standing out as particularly high risk. As such, it’s even more important to consider the health of employees in making travel decisions.
At a minimum, employees should be advised of the risk inherent in a travel assignment, be directed to information about who is at risk of serious illness from COVID-19 infection, and allowed to decide if they will travel. However, the real or implied pressure to travel may override a person’s judgment, so another option is a clinical consult. Managers or travel services can refer employees to the company’s clinical support service, where trained professionals can help the employee assess risks, and if needed, provide advice to help them travel more safely.
Risk reduction begins with travel planning. Car travel is safer than public forms of transportation. If air travel is needed, choose airlines that are keeping the middle seats empty. When possible, avoid multi-leg trips in favor of direct flights. Use trusted hotel brands. Rent cars instead of relying on mass transit, taxis or ride sharing.
Travel services should be instructed to prioritize safety, and if people are booking travel on their own, they should be given guidance – and travel policy latitude – to reduce their exposure to COVID-19 infection.
Further, employees should be directed to resources to help them prepare for safe travel, and to travel safely. The CDC provides a lot of useful information for travelers here. Additionally, employees who travel should be encouraged to share their experiences and safety tips to help everyone become more safety-savvy.
No matter how cautious, an employee may return from a business trip sick with COVID-19. And because people can experience asymptomatic illness or can transmit the virus before they experience symptoms, it is important to perform clearance testing to make sure returning travelers aren’t sick with COVID-19 before they return to work.
Last week's Brief discussed testing, and our recommended testing protocol for returning business travelers is included in Table 2 of the COVID-19 Testing Guidance document we recently updated.
I have traveled a number of times this summer. The experience has made me aware of two things:
You can’t reduce the risk to zero, but you can reduce the risk a lot. Traveling employees need to be alerted to the risk, educated to reduce their risk, and tested to make sure they don’t infect others on return if – despite their best efforts – they became infected while traveling.
If your company needs help navigating travel health policies, let us know. We’re constantly working with a lot of different companies to solve the same problems you’re likely facing. We’re here to help.
WorkSTEPS is hosting a series of informational webinars, each focused on a unique Covid-19 business challenge. Click here for more information and to register for the following:
Global: The WHO issued a serious warning for Europe as COVID-19 incidence continues to rise. Countries across Europe are reporting daily infections that are as high or higher than those seen in March - May. Resurgence of the virus is spread across the continent versus in individual nations. A number of countries enacted new restrictions. On Tuesday, United Kingdom’s Prime Minister Boris Johnson announced restrictions that require restaurants, bars and other entertainment venues to close at 10pm. British public health officials stated that if surge continues at current rate, the country may reach 50,000 daily cases by October. The new restrictions expected for at least six months. Spain is limiting traffic in and out of working-class neighborhoods with high case incidence. Italy has blacklisted travel from more Western European cities.
National: The U.S has lost at least 200,000 lives to COVID-19. The number of new daily cases in the U.S. increased more than 15 percent in the past 10 days and is the sharpest increase since the late spring. This uptick has arrived just before the official start of fall on Tuesday. The nation remains susceptible to a high fall increase because we never crushed the spread of the virus after the original outbreak. Cooler fall weather will start to hamper outdoor socializing and the remaining holidays with traditional family gatherings may further complicate mitigation measures.
COVAX (COVID Vaccines Global Access): On Monday, countries representing about 64% of the world population signed up to expand global access to COVID-19 vaccines by funding a purchasing pool organized by the WHO and other nonprofits. The COVID Vaccines Global Access alliance is largely being funded by 64 higher income nations that are participating and has 156 countries member nations. The alliance is committed to purchasing and distributing 2 billion vaccine doses by the end of 2021. The WHO released a report outlining the facility’s distribution plans, which include first rolling out vaccines for each country to vaccinate their frontline workers, followed by high risk populations.
Baricitinib: Eli Lilly announced preliminary findings from a study showing that baricitinib, a drug for rheumatoid arthritis, may benefit hospitalized COVID-19 patients when given in combo with remdesivir. The study was conducted under the Adaptive COVID-19 Treatment Trial (ACTT-2), is administered by the National Institute of Allergy and Infectious Disease (NIAID). This was a randomized, double-blinded, and placebo-controlled study which included more than 1,000 hospitalized COVID-19 patients. Eli Lilly plans to discuss the potential for emergency use authorization (EUA) with the FDA. While early data show promise, additional testing is needed to better show efficacy and safety.
Bradykinin Storm: Researchers at the Oak Ridge National Laboratory and several US universities found that an enzyme known as DABK accumulates as a result of SARS-CoV-2 binding to ACE2 receptors, which then triggers an increase in bradykinin in the body. Bradykinin is a molecule involved in a myriad of functions including lowering blood pressure, contracting smooth muscle, kidney diuresis, pain sensation, and triggering inflammation. The new analysis suggests it could potentially account for certain puzzling effects of coronavirus disease. Increased bradykinin could explain clotting issues in COVID-19, heart attacks or strokes as well “COVID toes.” Increased bradykinin could also cause lungs to become more watery or release blood and immune cells to their interior, leading to respiratory distress. The bradykinin theory could potentially explain increased severity in males compared to females. Females produce twice as much of a specific protein that protects against certain effects of bradykinin over-accumulation.
A Systematic Review of Antibody Mediated Immunity to Coronaviruses: Kinetics, Correlates of Protection, and Association with Severity: The authors review the scientific literature on antibody immunity to coronaviruses, including SARS-CoV-2 as well as the related SARS-CoV, MERS-CoV and endemic human coronaviruses (HCoVs). They reviewed 2,452 abstracts and identified 491 manuscripts relevant to 5 areas of focus: 1) antibody kinetics, 2) correlates of protection, 3) immunopathogenesis, 4) antigenic diversity and cross-reactivity, and 5) population seroprevalence.
Health-care Workers Make up 1 in 7 COVID-19 Cases Recorded Globally, WHO Says: Health-care workers account for 1 in 7 coronavirus cases recorded by the World Health Organization, the U.N. agency said this week. “Globally, around 14 percent of COVID-19 cases reported to WHO are among health workers, and in some countries it’s as much as 35 percent,” WHO director general Tedros Adhanom Ghebreyesus said at a news conference in Geneva. The figures are disproportionate: Data collected by the WHO suggests that health workers represent less than 3 percent of the population in the majority of countries and less than 2 percent in almost all low- and middle-income countries.
Transmission of SARS-CoV-2: A Review of Viral, Host, and Environmental Factors (Annals of Internal Medicine): This article presents a comprehensive review of the evidence on transmission of this virus. Strong evidence from case and cluster reports indicates that respiratory transmission is dominant, with proximity and ventilation being key determinants of transmission risk. In the few cases where direct contact or fomite transmission is presumed, respiratory transmission has not been completely excluded. Infectiousness peaks around a day before symptom onset and declines within a week of symptom onset, and no late linked transmissions (after a patient has had symptoms for about a week) have been documented. The virus has heterogeneous transmission dynamics: Most persons do not transmit virus, whereas some cause many secondary cases in transmission clusters called “superspreading events.”
Rapid Test for COVID-19 Shows Improved Sensitivity: Since the start of the COVID-19 pandemic, researchers at MIT and the Broad Institute of MIT and Harvard, along with their collaborators at the University of Washington, Fred Hutchinson Cancer Research Center, Brigham and Women's Hospital, and the Ragon Institute, have been working on a CRISPR-based diagnostic for COVID-19 that can produce results in 30 minutes to an hour, with similar accuracy as the standard PCR diagnostics now used. The new test, known as STOPCOVID, is still in the research stage but, in principle, could be made cheaply enough that people could test themselves every day.
Vaccine Poll: A poll conducted by the Pew Research Center found that only 51% of US adults would definitely or probably get a SARS-CoV-2 vaccine if it were available, a substantial decrease from 72% in late April and early May. Additionally, 77% of respondents indicated that they expect a vaccine to be approved before its safety and efficacy is fully studied, and 78% indicated that a rushed approval process is their greatest concern regarding the vaccine. More than 90 health organizations issued an open letter to the US FDA to address these fears, encouraging the FDA to complete Phase 3 clinical trials and utilize existing regulatory processes to fully evaluate and authorize a vaccine for public use.
Vaccine Race: To increase transparency regarding their vaccine clinical trials, AstraZeneca, Moderna Therapeutics, and Pfizer have chosen to disclose their Phase 3 clinical trial protocols. The Study protocols describe how the three big pharmaceutical companies intend to analyze the trial data and include outcomes of interest and conditions that would trigger early termination. The studies also describe points at which preliminary data will be analyzed and the circumstances conducive to applying for Emergency Use Authorization prior to the completion of the trial. Study protocols are typically not released to the public until after trials is completed. AstraZeneca’s Phase 3 trials were suspended as a result of a serious adverse event in one of the participants. The trials were resumed in the UK following an independent safety review, but is still under review in the U.S.
Transmission Potential of Asymptomatic, and Presymtomatic: Researchers from Switzerland published a large study that consisted of a systematic review and meta-analysis of COVID-19 literature from March to June and an analysis of 79 studies in 19 countries or territories involving 6,616 people. The researchers found that only 20% of coronavirus patients reported no symptoms at follow-up, and these patients appeared less likely than those with symptoms to infect others (relative risk, 0.35). Modeling studies included suggested that people with presymptomatic infections were more infectious than those with no symptoms. The reasons some COVID-19 patients have severe illness and some die, while others have only mild or asymptomatic illnesses remain unknown. The finding that approximately 80% of COVID-19 patients eventually have symptoms suggests that presymptomatic transmission likely contributes substantially to outbreaks of the disease, the researchers said. Researchers stated findings of this systematic review of publications early in the pandemic suggests that most COVID-19 infections are not asymptomatic throughout the course of infection.
CT Sewage Study: A study analyzed novel coronavirus genetic material present in the wastewater of New Haven, CT. Researchers measured coronavirus genetic material RNA present in sewage sludge in the city. Coronavirus RNA was detected throughout the more than 10-week study and used to track the rise and fall of cases seen in clinical test results and COVID hospital admissions. COVID-19 concentrations in sludge were 0–2 d ahead of COVID positive test results, 0–2 d ahead of the percentage of positive tests, 1–4 d ahead of local hospital admissions and 6–8 d ahead of SARS-CoV-2 positive test results by reporting date. The data show the utility of viral RNA monitoring in municipal wastewater for surveillance at a population-wide level. In communities facing delays between specimen collection and the reporting of test results, immediate wastewater results can provide advance warning of infection trends.
Wastewater monitoring is becoming more common. It is being utilized as an early detection tool to prevent outbreaks of COVID-19 in dormitories and select communities. Utilization of wastewater testing may be a tool in the future for large employers to monitor COVID-19 emergence at worksites.
The agency now says anyone exposed to an infected person for more than 15 minutes needs a test. An earlier guideline saying it might not be necessary had shocked public health experts.
Who Gets a COVID Vaccine First? Access Plans Are Taking Shape (Nature): A strategic advisory group at the World Health Organization (WHO) weighed in with preliminary guidance for global vaccine allocation, identifying groups that should be prioritized. These recommendations join a draft plan from a panel assembled by the US National Academies of Sciences, Engineering, and Medicine, released earlier this month.
The Work From Home WorkSTEPS Medical Team:
Tony Nigliazzo, MD
Loraine Kanyare, MSN, MPH, RN
Director of Case Management
Robert L. Levitin, MD
Lynda Phillips, LVN
Nurse Case Manager
Codey Church, LVN
Nurse Case Manager
Kerry Womack, LVN
Nurse Case Manager
Strategic Communications Consultant
This Guidance (“Guidance”) is provided for informational and educational purposes only. It is not intended as Legal Advice or Medical Advice. Adherence to any recommendations included in this Guidance will not ensure successful diagnosis or treatment in every situation. Furthermore, the recommendations contained in this Guidance should not be interpreted as setting a standard of care or be deemed inclusive of all proper methods of care nor exclusive of other methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific therapy must be made by the physician and the patient in light of all the circumstances presented by the individual patient, and the known variability and biological behavior of the medical condition. Similarly, this Guidance is based on current advice, comments, and guidance from the EEOC, CDC and the CMS made publicly available. The ultimate judgement regarding the propriety of any specific employment action must be made by the company and attorney in light of all of the circumstances presented by the company, state and federal rules existing at the time and the then current state of the National Pandemic. This Guidance and its conclusions and recommendations reflect the best available information at the time the Guidance was prepared. The results of future studies or changes in rules, regulations or laws may require revisions to the recommendations in this Guidance to reflect new data. WorkSTEPS does not warrant the accuracy or completeness of the Guidance and assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of this Guidance or for any errors or omissions.