Dr. Hallgren had the opportunity to discuss reopening your business during the COVID-19 pandemic with over 50 business owners through the Entrepreneurs Education Collaborative’s COVID-19 Recovery series. In this post I will summarize the specific recommendations for minimizing exposure risk in the workplace that Dr. Hallgren discussed in his presentation and provide a transcript of the Q&A portion of the presentation.
For business owners deciding how and when to reopen their business they should first and foremost adhere to their city, county, and state directed health measures. Business owners should also look to the Centers for Disease Control and Prevention (CDC) for best practices on how to disinfect and manage exposure risk. For those of us in Omaha, NE the Douglas County website is the direct source for the directed health measures that impact our businesses and community.
As you are developing your plan to reopen you need to identify what the risks are for your specific business environment and develop strategies to minimize those risks.
Exposure risk in reopening your business during the COVID-19 pandemic can be simplified into three categories: aerosol risk, fomite risk, and low risk.
Aerosol risk for corona virus exposure happens when two or more people are close enough that sneeze or cough droplets can be spread between them. In simple terms if your workplace requires that people, customers and/or employees share close personal contact for extended periods of time then you must plan to address the risk of aerosol exposure. Salons, barbers, physical therapy, massage therapy, and healthcare settings all operate under this risk.
First, examine how you operate. Is there a way to minimize the amount of time people spend within six feet of each other? For example, can you reduce the time people spend waiting in your office by having them wait in their car and come in after you text them it is their turn?
Next, implement appropriate measures to reduce the transmission and exposure to aerosol droplets.
- Wash hands before and after each customer
- Wear a mask, preferably an N95 mask
- Disinfect all tools and surfaces between customers using the CDC best practices
- Wash hands before and after each visit
- Wear a mask
If your business doesn’t require people to be in close contact with each other but does have shared surfaces where multiple people throughout the day may touch, sneeze, or cough on them you need to be concerned about fomite risk. Fomites are objects that are likely to carry infection such as clothes, utensils, and furniture. Restaurants, libraries, and retail stores are examples of organizations that operate under this risk.
First, examine how you operate. Is there a way you can reduce the number of times objects and surfaces are touched by different people? For example, can you eliminate self-serve options where customers select items themselves and instead have an employee set selected items on the counter for the customer to pick up, reducing the number of times things are touched? Or can you set up a process where items customers handle are collected and put into a designated spot to be disinfected before they are returned to use?
Next implement appropriate measures to reduce exposure in high fomite areas:
- Employees must:
- Wash hands frequently and after customer interaction
- Wear a mask and gloves
- Disinfect all customer services items and surfaces between customer visits
- Wash hands before handling business items and after business visit
- Wear a mask in high traffic areas
You can consider your workplace to be lower risk if you do not have significant aerosol or fomite exposure concerns. Offices with spread-out work spaces and minimal traffic and outdoor workplaces like construction and landscaping are lower risk workplaces.
First, examine areas where there may be increased exposure risk and develop strategies to reduce that risk. For example, in the shared breakroom can you tape social distancing markers on the floor and post signage to instruct on the safest use of the space, like storing food items to take and consume in more private spaces? For outdoor workers can you help identify scenarios when social distancing may be breached and develop guidelines your workers can implement to reduce exposure risk, like wearing a mask when they speak with customers?
Here are protective measures for both employees and customers in low risk workplaces:
- Wash or sanitize hands before and after contact with other people
- Wear a mask if social distancing is likely to be breached
The important takeaway is to identify where there is exposure risk in your workplace, classify that risk as aerosol risk, fomite risk, or low risk and develop appropriate plans to minimize the exposure risk.
Below is the transcript of the Q&A portion of the presentation. Questions and answers have been edited for clarity.
Does UV light have any impact on disinfecting surfaces?
Dr. Hallgren: Yes, it does for sure. It’s a really good way to disinfect fomites. If you have the equipment it’s great and UNMC actually has a protocol on its website that you can use to do it. So yes, if you have that equipment, fantastic. If you don’t have the equipment disinfecting the old fashioned way with sanitizer or bleach is a good option.
Do you know of any resource that describes best practices that is broken out by industry?
Dr. Hallgren: I still think the CDC website is the best resource for best practices. The key is understanding your business in terms of fomite risk and aerosol risk and the likelihood of people breaking the six feet social distancing rules. It’s more useful to understand those concepts and then apply them to your business as you see fit, because a print shop is going to be a whole lot different than an accounting shop, which is going to be a whole lot different than a gymnasium.
Do you have any recommendations for small business’s break room spaces where employees would store lunches or get coffee?
Dr. Hallgren: Make sure that folks are wiping down their things that they bring from home. The safest thing is to maintain that six foot social distancing and most break rooms aren’t real amenable to having a bunch of folks in at a six foot distance. They’re just not big enough to maintain that social distancing. So using the break rooms as a staging area for food storage and drink prep, watching the number of people in there to maintain social distancing, wiping down things brought in and shared surfaces, and hand-washing are the fundamental ways you can reduce exposure risk in a break room.
Is hand sanitizer as good as hand washing?
Dr. Hallgren: Hand washing is better than hand sanitizer by a significant margin. If you have a sink, make sure people are using soap and water to wash their hands for at least 20 seconds. If they touch anything that’s a community item, have a sink, hand sanitizers, or a bowl of bleach water available to sanitize things.
If people bring things into your business, for example, apparel to be embroidered, how should I handle those items? Do I leave them untouched for a couple of days or do you have any other ideas? I should note that washing them is not an option.
Dr. Hallgren: Yes, washing them would be a great option. If you don’t have an option to wash them or otherwise disinfect them then practically speaking the safest thing to do is leave him for three days and then address the items since that is how long research tells us the virus can live.
Does increased air flow in a space necessitate increasing the minimum distance between people? For example, warehouses that have big doors open to the outside.
Dr. Hallgren: The extra airflow would be helpful if anything. If you’re in a big warehouse or an environment where you’re outside, moving air along will disburse any aerosols much more rapidly. So that would be a help versus a closed in office space where there’s not much airflow. Hospitals have big HVACs that suck air out and can really process a lot of potentially infectious aerosols very quickly. The vast majority of businesses do not have anything like that. So the more airflow you can get, the better to move in terms of minimizing exposure.
Are there any air purifiers that have been proven to kill viruses?
Dr. Hallgren: The simple answer is no.
What is your stance on Clorox wipes versus bleach and water?
Dr. Hallgren: They’re basically the same thing. So bleach and water is a field expedient method of doing the thing as Clorox wipes. The wipes may be easier to use but they aren’t going to necessarily be better than just standard bleach and water.
If a fitness facility is using a fan next to a treadmill in a gym helpful or will this cause the droplets to disperse further? I should note the equipment is at least six feet apart.
Dr. Hallgren: I don’t think it’s going to hurt. Whatever aerosol or droplets are generated from use of the treadmill is going to fall somewhere in that room. If you have a fan that’s directing the air behind the user and not into anybody else’s areas it’s probably gonna help more than hurt.
However, when you’re in an enclosed space, those droplets are going to go somewhere as they get generated. So it’s important to remember to not have sick people come into our places of work. If people are not coming in when they’re actively ill that minimizes exposure risk as well.
Can you discuss how the Mission Direct Primary Care office is handling the cleaning and disinfecting between patients, specifically shared items like pens, clipboards, computer keyboards, or computer screens?
Dr. Hallgren: Yes, great question. The way our clinic operates we don’t have huge throughput and that was true before COVID-19. Because of our membership model, our people don’t wait in a waiting room. We also have telehealth baked into how we serve our members so we can limit in office appointments to those that are truly necessary for preventive care or chronic disease management. It’s just the way we operate.
Because we’re a healthcare facility, we were already set up with very specific sanitizers that are designed to kill multiple types of viruses, multiple types of bacteria. We simply wipe everything down in between patients. We were well-stocked with hand sanitizer and all the disinfectant type things before this so we made very few changes in light of the pandemic.
Because we don’t bill or take insurance and all of our patients have established care with us through a very thorough wellness exam we basically have a paperless clinic with none of the medical history or insurance forms most people are used to, so we don’t really use clipboards or shared sign-in computers.
But if you do have those types of items I mentioned before it would be important to wipe all those down in between any customers you have. But for us at Mission Direct Primary Care, we ideally set up to operate in this environment. It’s just the way we set up the practice from the get go and turned out to make adapting to COVID-19 rather easy for my own business.
Do you know of any lights that can help detect germs on surfaces?
Dr. Hallgren: No. The short answer is absolutely not in any practical way to detect viruses. Very specialized labs have reagents, and other tools that you can use, but that’s a, that’s a whole different use case.
What are the current recommendations for quarantine if you or an employee get sick?
Dr. Hallgren: The CDC within the last two or three days has updated its recommendations in terms of self quarantine. So if you have somebody who has symptoms, fever, cough, shortness of breath, changes in smell, or any of the symptoms that are mentioned COVID-19, it was recommended that if your clock started once you had those symptoms and then went on for seven days and you had three days of no fever and improving symptoms and you could go back to work. The CDC has extended that now out to 10 days.
So once you have symptoms, your clock starts, and it’s a minimum of 10 days in self isolation. You must be fever-free for at least three days before you release from self isolation. To clarify that is no fever and no taking Tylenol or Motrin to eliminate a fever. You also must have had three days of significantly improved symptoms before you release yourself from self isolation and return to work.
In addition to what you’ve mentioned as far as the CDC and what was posted for Nebraska Department of Health, assuming that you were a lay person, business owner, operator, are there any other resources that you’d be paying close attention to right now?
Dr. Hallgren: For information the Nebraska DHHS and the CDC are far and away your best sources of information. Douglas County has also done a really good job of reporting things out.
I don’t think much is going to change in terms of protection for your business. It’s going to boil down to controlling fomites and aerosols and the interpersonal interactions that occur. I don’t think we’re going to see any changes in recommendations for what types of different disinfectants to use or what types of social distancing to use. The big thing to watch is the directed health measures and those are easily found with DHHS, news outlets, and the Douglas County Health website.
If you are working on a construction site, how could you handle client interaction and employee interactions?
Dr. Hallgren: If you’re working on a construction site I would regard that as a relatively low risk interaction. Crews should maintain social distancing and wear a mask if they are going to be face to face with somebody working on a joint project. But certainly customer facing interactions should be done with social distancing and a mask. Otherwise, those kinds of businesses are lucky in a sense because it’s a relatively easier task to keep things controlled.
What recommendations would you have for a classroom setting children in the classroom together or multiple back to back classes?
Dr. Hallgren: Interesting question because schools aren’t opening yet. You want to be careful to stick to social distancing rules and that can be tough to achieve depending on the age of the students. If you can do that and have the kids wearing a mask, and make sure you’re not violating any other directed health measures that would be my recommendation.
Depending on the type of classroom activity, pay very close attention to objects that might become infected because kids will, depending on the age, not be real careful with touching their face and then touching objects. Easy access to copious amounts of disinfected material would be really important.
What considerations would you give being in a counseling setting? Should I focus on increasing distance as much as I can between myself and my client and should I require my clients and myself to wear a mask?
Dr. Hallgren: The safest thing to do is to maintain a minimum of six foot distance and really, probably a bit more than that to give yourself room for mistakes like an uncovered sneeze. Wearing a mask is the safest thing when you are meeting in that type of setting, and never forget to wash your hands before and after client interaction.
I have a family member that started presenting symptoms. She was tested and her results are negative. The doctor or nurse told her that the current testing process is giving 20 to 30% false negatives. Do you know if this is true? Should she also get tested again after symptoms are no longer present?
Dr. Hallgren: A really excellent question that speaks a lot to the uncertainties with testing. So no test is a hundred percent able to detect disease or rule it out. This is true of most tests of this nature and usually there is a 10 to 15% false positive or false negative rate. It’s called the sensitivity and specificity of the tests. Given that the current COVID-19 test is consistent with other similar tests in terms of false positives and negatives the current recommendations for surveillance with testing is that you get one test and if it’s positive, then the test is good enough that we say, yes, you’ve COVID-19 and we will not test again. But the sensitivity is poor enough that we say a negative test doesn’t really mean you don’t have the disease. So the test is repeated after more than 24 hours. If you have two negative tests over the course of a couple of day then we say, okay, that’s good enough. You don’t have COVID-19 and you just go back to standard precautions.
What would you recommend for a daycare from a parent’s perspective? Our daycare has stayed open throughout all of operating within the rule of 10. When you’ve got younger kids about six foot or mask wearing becomes increasingly difficult. So any comments on the daycare situation?
Dr. Hallgren: I think they have expanded daycare class limits to 15 kids. I think they’re going to maybe look at expanding by fives as we work through this, however there are no guarantees. Kids typically sail through this illness if they have many symptoms at all. But of course that leaves family members at home vulnerable. If the child is going to be in a daycare setting on a routine basis every day, basically, there’s really not a practical way you’re going to be able to protect yourself from your child. It’s a calculated risk you have to take. There’s really not an ironclad way to protect yourself from your children coming back from daycare and that will lead to increased numbers of cases as we liberalize our social restrictions. Our health leaders will pay careful attention to increases in case rate and potentially limit things again to make sure that our health systems don’t get overwhelmed.
Are there any updates on how the disease is transmitted via skin? For instance, if you cut your hand and you touch an infected surface?
Dr. Hallgren: In that rare case where you had an open sore and you put that open sore or open cut right on a piece of snot that was sitting on a fomite then you could get the disease that way. That’s a really rare mode of transmission. The bigger concern is when you touch something that has an infectious material on it, then you touch your face, that simple act is still far and away the most common mode of transmission.
Any thoughts on travel? If we have an employee that wants to travel or take vacation, should they self quarantine when they get back before we let them back into the office? And also, does that change if they travel within the state versus out of state?
Dr. Hallgren: That’s a great question. The disease is so widespread in the US now, I don’t know that travel really matters much. I don’t think you’re going to travel from Omaha to Los Angeles any really know that your risk increases just because you’ve traveled to one place that has active community spread to another place that has active community spread. So I would say simply because of travel, no I would not recommend self isolation. However, it’s still part of the recommendations if you’ve traveled to an endemic area. But in all reality we’re all that way now. So I would say to rely on symptom monitoring.
What cleaning procedures or ways to stop transmission are basically an old wives’ tale? For example, I’m gonna rub vodka on my kitchen table and that kills the virus.
Dr. Hallgren: It is true that 60% alcohol content or more will kill the virus. So if you got a 120 proof vodka sitting around and you want to waste it on the table, that will probably still work. I can’t think of any poor advice regarding disinfectant. However, I do want you to be sure to use an approved hand sanitizer. You can look at the EPA website for specifics and usually it will say on the bottle. You can also make your own bleach solution which is totally safe to do.
Do you have any information on reinfection? Are we safe to assume it works like the flu where you can get it year after year?
Dr. Hallgren: We know very little about this virus. We know far less than we don’t know. We don’t know how robust our immunity is going to be once we’re infected. And that’s why I said that about the testing. So if you get an IgG test, that’s the antibody test that’s drawn from blood and you have IgG antibodies which indicate that you’ve had an infection in your body has developed some level of immunity to it. We don’t know what that level of immunity is. We don’t know that that means you can’t be reinfected quite soon and we don’t know that that means you can’t transmit the virus to anybody else.
I’m extrapolating from other corona viruses, the ones that spread common colds. If the immunity works similarly then there are probably some months, perhaps several months or even a year of immunity after infection. Because this disease seems to be more severe in a lot of people maybe we get a more robust immune response, but honestly the answer is we don’t know yet and it is just going to take time to monitor people who have been infected and see if they get reinfected and monitor their levels of IgG as we go forward. It’s just a slow process that there’s really no way around at this point.
If I have an employee that exhibits cold or allergy symptoms, symptoms, but no fever, do we recommend that they stay at home?
Dr. Hallgren: So if they’re sneezing this goes back to a judgment call and there’s no right or wrong answers. If the employee comes to work and they’re sneezing and somebody challenges them on why they’re there and they respond that this is my usual allergies and I don’t feel sick and I haven’t had a fever. I would say that’s okay. We’re in allergy season and there are other medical ailments going on besides COVID-19. But that is a judgment call and there’s no way of knowing. These are types of clinical uncertainties physicians deal everyday. However, it is always safest to send them home for 10 days if they have COVID-19 symptoms.
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