Emergency Temporary Guidance about Cal/OSHA Standards Requiring Medical Surveillance Examinations and COVID-19 Risks
During the current COVID-19 pandemic, medical providers and patients have been advised by the US Centers for Disease Control and Prevention and by the California Department of Public Health to avoid or postpone non-urgent medical visits, especially those requiring face-to-face contact, in order to decrease the risk of COVID-19 exposure. However, 28 Cal/OSHA standards require employers to offer their employees medical surveillance examinations and other medical services on a specified schedule, when employees may be exposed to certain workplace hazards above an Action Level (AL).
Under their fundamental duty “to first do no harm,” physicians and other licensed health care professionals (PLHCPs) must balance risks and benefits in deciding to offer any medical service.Applying this principle to occupational surveillance exams, a PLHCP may judge that certain surveillance exams are not needed urgently, because they are aimed primarily at detecting chronic health problems that may arise slowly over months-to-years. In these situations, the risk of potential COVID-19 exposures during a face-to-face encounter may outweigh the likely medical benefit, especially since COVID-19 is often spread by persons with no symptoms. Certain medical procedures, such as spirometry or audiometry in a closed hearing booth pose an especially high risk of exposing both patients and medical staff to infectious droplets or aerosols.
In Table 1, Cal/OSHA offers temporary emergency guidance to assist PLHCP’s who are planning to conduct mandated surveillance exams. The table suggests surveillance elements that might reasonably be delayed and which should not be delayed, along with specific advice about certain standards. The table separately lists those elements required at initial placement and those required at periodic intervals.
If an initial questionnaire or medical history might reveal information about an employee’s personal risk factors and thereby guide the PLHCP’s decisions about occupational exposures or the use of personal protective equipment (PPE), the PLHCP should obtain the history in a non-face-to-face setting. Similarly, an initial respirator exam and fit test must not be delayed when a respirator is required to protect an employee from airborne hazards. Certain toxicants such as lead can produce adverse effects within several weeks of exposure onset; surveillance exams pertinent to such toxicants should not be delayed.
The Table does not discuss surveillance examinations which are required after an “emergency” or “uncontrolled” workplace exposure, or when an employee reports a possible overexposure or occupational illness. A clinical evaluation in these situations should not be delayed.
Cal/OSHA emphasizes that this guidance does not relieve an employer of its duty to offer mandated surveillance exams. However, we also recognize that in the current pandemic many employees will be engaged in “essential” jobs and tasks, and that employers must rely on the medical judgment of a PLHCP in fulfilling these surveillance obligations.
When a PLHCP judges that the risk of a possible COVID-19 exposure outweighs the possible benefit of a surveillance exam, the PLHCP should supply the employer with written documentation outlining the reasons for such a decision. Additionally, we hope that PLHCP’s who continue to conduct surveillance exams will observe “best practices” for infection control, including the use of telemedicine and questionnaires whenever possible, in place of face-to-face encounters.
Finally, if certain elements of a required surveillance exam have been delayed because of a PLHCP’s medical judgment, we advise employers to prepare a written plan describing how they will bring any delayed surveillance exams up-to-date once public health authorities have finally declared the COVID-19 pandemic over.
For questions or additional advice, employers and PLHCP’s may wish to contact Cal/OSHA Consultation at (800) 963-9424.
|ATD||Aerosol Transmissible Disease|
|ATP||Aerosol Transmissible Pathogen|
|BeLPT||Beryllium lymphocyte proliferation test|
|BBP||Blood borne pathogen|
|BLL||Blood lead level|
|BMBL||Biosafety in Microbiological and Biomedical Laboratories|
|CBC||Complete blood count|
|CCR||California Code of Regulations|
|CDC||US Centers for Disease Control and Prevention|
|Cd-B||Blood cadmium level|
|Cd-U||Urine cadmium level|
|CSO||Construction Safety Orders|
|FEF||Forced expiratory flow rate|
|FEV1||Forced expiratory volume in 1 second|
|FVC||Forced vital capacity|
|GGT||Gamma glutamyl transpeptidase|
|GISO||General Industry Safety Orders|
|IGRA||Interferon-gamma release assay (TB blood test)|
|MMRV||Measles, mumps, rubella, varicella|
|PLHCP||Physician or other licensed health care professional|
|SGOT||Serum glutamic oxaloacetic transaminase|
|SGPT||Serum glutamic pyruvic transaminase|
|TST||Tuberculin skin test|