Challenges for occupational medicine during the pandemic of a new coronavirus infectious disease (COVID-19)

Introduction

Occupational medicine is an integrated field of preventive and curative medicine, aimed at managing the state of health of an employee; the subject of occupational medicine is the scientific justification and practical implementation of means and methods for health preservation and strengthening [1]. According to the specialty passport “3.2.4. Occupational Medicine”, the content of this specialty implies “the study of a person in the process of labor activity and the impact of working conditions on the human body in order to maintain and strengthen health and performance, prolong life, prevent and treat both occupational and professionally caused diseases”.

In the current conditions of the spread of a new coronavirus infection, maintaining and strengthening the health of employees as a socially significant category of citizens is becoming a priority for occupational medicine. At the same time, occupational medicine faces the need to maintain and strengthen the professional health and performance of people who have already experienced COVID-19.

Occupational medicine and healthcare during the COVID-19 pandemic

The pandemic has posed challenges for occupational medicine and practical healthcare that require an interdisciplinary approach and joint efforts of healthcare professionals, occupational health and safety specialists, psychologists, etc. to solve them.

Occupational medicine considers the coronavirus SARS-CoV-2 causing COVID-19 as a new biological factor in the work environment. The high pathogenicity of the SARS-CoV-2 virus allows attributing it to pathogenicity group II¹, which is taken into account when resolving issues of a causal relationship between the disease and the profession.

Today, one of the important tasks of occupational medicine is to assess the risks of COVID-19 infection for employees in various sectors of the economy and to prevent pandemic-related stress-induced health disorders.

The need to assess the risk of COVID-19 infection is relevant for both medical and non-medical workers [2–7].

Studies by a number of authors [8–12] allowed identifying the following main risk groups for contracting COVID-19 in the workplace:

• healthcare and emergency services workers;
• workers caring for the elderly;
• transport workers, taxi drivers;
• employees of grocery stores, retailers;
• police, correctional and immigration officers;
• employees of warehouses, meat processing plants.

Socioeconomic status can also act as a risk factor for infection. According to the ILO guide (2020)², social sectors of the population that are particularly susceptible to infection with COVID-19 include the following people:

• young people due to possible unemployment and underemployment;
• women, especially those employed in the service or health sector;
• unprotected workers, including the self-employed;
• migrant workers.

The main risk factors for nosocomial transmission of COVID-19 by medical workers are contact with infected patients, insufficient provision of personal protective equipment (PPE), non-compliance with personal hygiene rules [13], microorganisms of pathogenicity groups 1–1U when working in the laboratory,³ or the lack of knowledge about anti-epidemic measures in the workplace [14–15].

Among non-medical workers, service workers (bank workers, personal trainers, teachers, hotel staff, cleaners, and others) who have contact with people, money, or goods may be at risk of COVID-19 infection [16].

Recently, there have been reports of numerous outbreaks of COVID-19 in meat and poultry processing plants [8], where a high transmission rate of the SARS-CoV-2 coronavirus has been established [17]. According to Durand-Moreau et al. (2021), during the COVID-19 pandemic, the work environment in these facilities is conducive to SARS-CoV-2 persistence (metal surfaces, low temperatures, and relative humidity) and to SARS-CoV-2 transmission (crowded workplaces, shared transport, aerosol and droplet generation). In addition, the transmission of infection is facilitated by a vulnerable low-paid workforce forced to continue working despite the symptoms of coronavirus infection [17].

The risk group for COVID-19 infection includes truck drivers involved in the transportation of goods over long distances and being in contact with a significant number of people [18].

Today, the possibility of contracting COVID-19 outside the workplace is being considered, for example, through regular social contacts with colleagues outside of work [19], which is especially dangerous for workers from high-risk groups [20].

In the context of the spread of COVID-19, infection prevention issues occupy an important place in occupational medicine.

Non-specific prevention of COVID-19⁴ is performed in relation to the source of infection (a sick person and an asymptomatic carrier), the mechanism of transmission of the infectious agent (use of PPE for medical workers, disinfection measures, personal hygiene, disinfection and disposal of class B medical waste), and susceptible contingent (restrictive measures, isolation measures).

At the same time, given the importance of using PPE to prevent the spread of COVID-19, a number of researchers draw attention to the side effects of using various PPE (dermatitis of the face and neck, facial pain, dry nose, etc.) due to their long-term wearing (from 6 to 12 hours a day, for example, in medical workers), which requires the adoption of preventive measures, in particular, reducing the time spent wearing PPE, reducing overtime work to ensure safe and reliable working conditions [21].

In the context of the COVID-19 pandemic, it became necessary to increase control over epidemiological safety and prevention of healthcare-associated infections (HCAI). The relevance of this issue was confirmed at the VIII Congress with international participation held in November 2020⁵, where the experience of organizing the work of medical institutions during a pandemic, legal and regulatory regulation in the field of epidemiology and prevention of HCAI, protection of medical staff from HCAI, organization of epidemiological surveillance and control of HCAI, and introduction of advanced technologies for the prevention of HCAI were discussed.

In order to prevent both infection and the formation of severe cases of COVID-19 during a pandemic, it is necessary to apply the following basic provisions of the National Evidence-Based Guidelines for the Prevention of HCAI⁶:

• improvement of the regulatory, legal, and methodological support of the HCAI prevention system, harmonization with international requirements;
• improvement of state and epidemiological surveillance of HCAI;
• expansion of scientific research in the field of HCAI prevention.

Vaccination is an important means of specific prevention of COVID-19.

Vaccination of the population against COVID-19 is performed in accordance with the temporary guidelines “Procedure for vaccination against a new coronavirus infection (COVID-19)” approved by the Ministry of Health of the Russian Federation)⁷.

The following vaccines are registered in the Russian Federation for the specific prevention of COVID-19 in adults⁸:

1. Combined vector vaccine (Gam-COVID-Vac), registration date – November 8, 2020. It is used to prevent COVID-19 in adults over 18 years of age.
2. Combined vector vaccine (Gam-COVID-Vac-Lio), registration date – August 25, 2020.
3. Vaccine based on peptide antigens (EpiVacCorona), registration date – October 13, 2020. It is used to prevent COVID-19 in adults over 18 years of age.
4. Inactivated whole-virion concentrated purified coronavirus vaccine (CoviVac), registration date –February 19, 2021. It is used to prevent COVID-19 in adults aged 18–60 years.
5. Vaccine (Sputnik Light), registration date – June 5, 2021. It is used to prevent COVID-19 in adults over 18 years old.
6. Peptide antigens-based vaccine (EpiVacCorona-N), registration date – August 26, 2021. It is used to prevent COVID-19 in adults aged 18–60 years.

The current system of occupational pathology service in Russia allows solving complex issues of diagnosing occupational diseases among employees in various sectors of the country's economy. The pandemic caused by a new coronavirus infection dictates the need to consider the possibilities of establishing a causal relationship between COVID-19 and the profession, especially among employees with a high risk of infection in the workplace [22].

In a number of foreign countries (Belgium, Italy, Germany, South Africa, and Canada), COVID-19 has been considered up until recently as a consequence of occupational exposure of the SARS-CoV-2 coronavirus to the body [23]. To date, COVID-19 has been defined as a new occupational disease that gives employees the right to compensation and is proposed for recognition worldwide [24].

According to the international definition, an occupational disease is a disease that has developed “as a result of an exposure to risk factors arising from work activity” [25]. In Russia, the concepts of occupational disease and occupational risk are approved by law⁹ (“Occupational disease is a chronic or acute illness of the insured, which is the result of exposure to a harmful production factor (factors) and resulting in temporary or permanent loss of his professional ability to work and (or) his death”, “Occupational risk is the likelihood of injury (loss) of health or death of the insured, associated with the performance of his duties under an employment contract and other established by this federal law cases”).

The concepts of occupational disease and occupational risk adopted in Russia determine the fundamental approaches to establishing the relationship of a disease with a profession and are taken into account in the order of the Ministry of Health of Russia No. 36n¹⁰.

In 2020, in the structure of occupational pathologies, “for the first time in 10 years, diseases caused by biological factors took the second rank (20.19%)” and came after diseases caused by physical factors¹¹; moreover, the vast majority of diseases (92.7%) in this group were induced by the SARS-CoV-2 coronavirus.

At present, guidelines have been developed in the Russian Federation on the procedure for examining the relationship of COVID-19 with the profession of medical workers, as well as the substantiation of COVID-19 as an occupational disease among health workers and the algorithm for linking this pathology with the profession¹². The necessary documents for resolving expert issues are the sanitary and hygienic characteristics of working conditions, a map of the epidemiological investigation of the focus of an infectious disease, the conclusion of an infectious disease specialist, a copy of the work book, as well as data on medical examinations and an extract from the employee's medical records¹³. According to these recommendations, if an employee becomes infected with COVID-19 while performing his/her job duties, a causal relationship of a new coronavirus infection with the profession is established. At the same time, the diagnosis of a new coronavirus infection assumed by the doctor must be confirmed by an infectious disease specialist, then the patient is consulted by an occupational pathologist and referred to an occupational pathology center for an examination of the connection between the disease and the profession.

To date, issues have been developed on organizing an investigation into insurance cases of harm to the health of medical workers being in contact with patients with diagnosed or suspected COVID-19¹⁴.

In Russia, the main approaches to maintaining the health and safety of medical workers during the pandemic are being developed and implemented, such as a comprehensive assessment of the risks of COVID-19 infection and health status, optimization of preventive measures, addressing issues of professional suitability examination, etc.¹⁵

Changes in working conditions during the COVID-19 pandemic are accompanied by pronounced work stress and the formation of stress-induced syndromes (diseases), in particular, mental health disorders of employees manifested by anxiety, depression, and burnout [26–28]. In medical workers, mental disorders are associated with a significant uncontrolled workload, isolation, and a high risk of contracting COVID-19 [29–30].

Due to the possible long-term impact of COVID-19 on the mental health of medical personnel [31], in Russia, when providing medical care to patients with COVID-19, a system of comprehensive psychological support for the activities of employees of medical organizations has been developed and is being implemented. The specified system includes special measures to reduce the psychological burden on the staff, special measures for the protection of personnel, maintaining a healthy climate in the team, and organizing professional and competent psychological assistance¹⁶.

According to the WHO, during the COVID-19 pandemic, “mental health care is essential both at work and in the community”¹⁷.

The methodology for assessing occupational risks developed by domestic scientists allows considering the possibilities of predicting work-related diseases [32].

The currently known features of the development and course of a new coronavirus infection (long-term symptomatic and post-COVID syndromes), the formation of severe forms of the disease in risk groups (elderly patients, people with comorbid diseases) allow assessing the prognosis of COVID-19, which creates the prerequisites for the scientific substantiation of therapeutic and preventive measures based on the experience of managing occupational infections and accumulated knowledge about a new coronavirus infection.

Taking into account the urgency of the COVID-19 problem and the need to train medical personnel on the diagnosis, prevention, and rehabilitation of patients who have undergone a new coronavirus infection, training manuals have been created on the professional aspects of maintaining the health of medical workers during the pandemic [33] and medical rehabilitation of patients who have suffered COVID-19 [34].

In connection with the established long-term multiple organ manifestations of the disease, including the post-COVID period, there is a need to combine the efforts of practical health care and occupational medicine to develop effective methods of interdisciplinary work and ongoing cooperation [35][36].

In the context of a pandemic of a new coronavirus infection, the most important issues include the following ones: proactive restoring of the health of patients, the widespread use of telecommunication technologies, as well as telerehabilitation programs [37]. It is recommended to begin medical rehabilitation of patients with coronavirus pneumonia in intensive care units (ICUs) and continue it after completion of inpatient treatment at home.¹⁸

Patients treated for COVID-19 in the ICUs experience a long-term decline in quality of life in the post-COVID period, especially in the area of “physical functioning” (performing daily activities and tasks), which complicates returning to work and remaining able to work in the profession [38].

Currently, Russia has determined the procedure for discharge of patients who have experienced COVID-19 from a medical organization and the procedure for admission to employment¹⁹: “Discharge of patients for employment (training), admission to organized teams after treatment (both inpatient and outpatient) and recovery are performed without a laboratory examination for COVID-19 in case when the treatment takes seven or more calendar days. If the period of observation of a patient with laboratory-confirmed infection with the COVID-19 pathogen is less than seven calendar days, then discharge to employment (training), admission to organized teams are performed after receiving one negative result of a laboratory examination for COVID-19, done no earlier than three calendar days after receiving a positive result of a laboratory examination for COVID-19”.

However, returning to work after contracting the new coronavirus remains one of the debated issues. Cavasin et al. (2021) believe that excessive search for negative polymerase chain reaction results leads to a waste of resources and an additional burden on the healthcare system [39]. Joyce et al. (2020) consider that the most pragmatic approach to addressing issues of return to work should include both the results of serological testing and the disappearance of clinical symptoms of the disease [40]. The issue of returning to work after suffering COVID-19 is widely discussed due to the emerging social stigma regarding COVID-19. Prejudice is spreading against people who have recovered from COVID-19, including against medical workers, which makes it necessary to provide both the employee and the employer with information to combat this stigma [41].

According to Kobayashi et al. (2021), during the pandemic, various measures were taken to reduce the risks of workers’ infection with COVID-19, such as organizing work from home (30%), reducing working hours (24%), and providing unpaid leave (19%) [42].

The pandemic caused by the new coronavirus infection has created a number of problems for the working population (financial difficulties, remote work and social isolation, increased workload on workers in socially important professions, the stressful situation associated with the pandemic, difficulties in assessing the professional suitability of workers after suffering a coronavirus infection) [43].

In foreign practice, when addressing the issues of professional suitability examination, the occupational risk of SARS-CoV-2 infection, vaccination status, psychosocial and economic factors, the employee’s subjective assessment of health and the possibility of returning to work, objective information about working capacity and workload [44][45], ensuring adaptation of working conditions to the employee’s capabilities are taken into account.²⁰

However, even when adapting working conditions or switching to remote work, patients report difficulty in performing work with the same efficiency, psychological problems, and recurrence of post-COVID symptoms after returning to work [46].

An examination of professional suitability is performed in order to determine the compliance of the employee's health condition with the possibility of performing certain types of work; it is implemented by the medical commission of a medical organization with the involvement of specialists based on the results of preliminary medical examinations and periodic medical examinations. Based on the results of the examination of professional suitability, the medical commission issues a medical opinion on the suitability or unfitness of the employee to work.

In Russia, in order to resolve the issue of admission to work of a person who has recovered from COVID-19, an examination of the professional suitability of the employee should be performed in accordance with the current regulatory documents^21,22. The professional suitability examination is aimed at determining “the compliance of the employee's state of health with the possibility of performing certain types of work”²³. Professional suitability examination is implemented by a permanent medical commission of a medical organization while taking into consideration the results of mandatory preliminary or periodic medical examinations.

The medical commission of a medical organization makes one of the following decisions and recognizes the employee²⁴ as fit (for health reasons to perform certain types of work), temporarily unfit (for health reasons to perform certain types of work), permanently unfit for health reasons to perform certain types of work.

When determining the temporary unfit for work of an employee for health reasons, “the rationale for this decision and the timing of temporary unfit for work are indicated with recommendations for additional studies/ consultations with specialists and (or) appropriate treatment”²⁵.

After receiving disability due to COVID-19, an employee must be sent by the employer for an extraordinary medical examination²⁶ followed by an examination of professional suitability to work.

Currently, there is a need to expand knowledge and increase research on COVID-19 from the perspective of occupational medicine.

New approaches to the assessment of the production biological factor are being formed. For medical workers, a biological production factor is a potential hazard at the workplace, an occupational health risk factor, which must be taken into account when conducting a special assessment of working conditions [47].

As specified by GOST 12.0.003-2015²⁷, the factor of biological nature – the SARS-CoV-2 virus – should be considered from various positions (occupational medicine, labor protection, occupational health, industrial sanitation), both in terms of the nature of penetration and the characteristics of the impact on the employee's body.

In the context of the spread of coronavirus infection, the role of a comprehensive assessment of the work environment as a determinant of employee health disorders is growing. The physical work environment, the psychosocial environment as well as the lifestyle are the components of a healthy and safe workplace model²⁸. This three-component model is the basis for an integrated approach to maintaining the occupational health of workers [48].

The physical work environment in the context of the COVID-19 pandemic, associated with exposure of the employee to the new biological production factor of the coronavirus SARS-CoV-2, is currently combined with numerous psychosocial factors that have emerged in the workplace. At present, the relationship between traditional (physical, chemical) and psychosocial factors has been established.²⁹

The pandemic demands for a systematic approach to assessing the work environment, in particular, the psychosocial work environment affecting the health of employees. The psychosocial work environment includes the “macrolevel” (economic, social, and political structures, including modes of production, division of labor, types of social security or legal system), “mesolevel” (workplace structures – type of employment contract, staffing), and “microlevel” (factors acting on an individual or group of individuals) [49][50]. The psychosocial work environment is considered a key area of research aimed at establishing the relationship between social structures, environmental influences, and psychological and psychophysiological processes affecting the health of an employee [50].

In modern conditions, one of the crucial areas of occupational medicine is the prevention of stress in the workplace [51].

In order to reduce stress, improvement of psychosocial factors of work (increasing control over the situation at work, providing adequate social protection or job security>³⁰) is recommended.

In the context of the COVID-19 pandemic, the tasks of occupational medicine include strengthening the occupational health of employees (health in the workplace). The occupational health paradigm implies the need to control workplace hazards and health risks, as well as rehabilitation, support, and health promotion in the workplace [52].

One of the concerns for the occupational health of employees associated with the COVID-19 pandemic is the need to work remotely. A new type of work appeared to be possible for certain professions (computer systems, law, architecture, management, etc.) or has limited opportunities for others (catering, education, healthcare) [53][54]. Currently, the possibilities of adapting the workload to an isolated environment are being considered to preserve the productivity, well-being, and health (primarily mental) of employees engaged in remote work [55][56]. Recommendations for maintaining the productivity of working from home have been published [57]; it is proposed to form a comfortable online work environment, create network structures of the workplace and resources [58].

During a pandemic, employees performing temporary and low-paid work deserve special attention [59]. This category of employees, as well as working women, is most affected by the impact of COVID-19 on the labor market³¹.

In the post-COVID period, patients who have suffered from COVID-19 can both return to their previous job and find employment in other jobs, including non-standard types of work that provide for new regulation of labor relations (for example, work hours depending on the load, work schedule at the choice of the candidate, work anywhere and/ or at any time, etc.). Moreover, regardless of the form of employment, employees must exercise their right to a fair wage, be provided with guarantees and compensations due to labor relations, and be protected by collective agreements and agreements in the field of labor [60].

The challenges posed by COVID-19-related work changes require occupational health and safety professionals to analyze risks, guidance, and best practices to ensure the future health of employees [61], develop and implement interventions to promote work engagement by increasing employees’ autonomy in the workplace [62].

In recent years, there has been a shift in the occupational safety paradigm from measuring specific individual risk factors to studying the system “employee – work environment – employer” [63]. It has been established that the risks existing in the workplace are most often associated with the organization of work and the subsequent harm affects mental health more than the physical one [64].

One of the main directions of preserving the health of workers at present is the development of comprehensive measures to assess and manage health risks [65].

During the accumulation of scientific and practical information in the context of the COVID-19 pandemic, one of the priority areas of research is the identification of risk factors for the development and complicated (severe) course of infection. The many-sided nature of the disease development and the variability of its manifestations from an asymptomatic course to severe multiple organ disorders require timely correction in the development of therapeutic measures [66].

In the context of a pandemic caused by the new coronavirus infection, there is a need to expand research on COVID-19 from the perspective of occupational medicine in order to preserve the health of the working population as a socially and economically significant category of citizens ensuring the welfare of the country.

Discussion

At present, the new coronavirus infection COVID-19 is an acute health problem associated with both high levels of morbidity and mortality, including in the post-COVID period, and significant socio-economic damage caused by it.

In occupational medicine, the new coronavirus infection is considered an occupational disease among medical workers directly involved in the provision of medical care to patients with COVID-19, as well as among employees in other sectors of the economy from high-risk groups of contracting COVID-19 at the workplace.

Prevention of infection and development of severe forms of COVID-19 is based on the integration of hygienic and epidemiological measures. The accumulation of experience in the work of occupational health and safety services in a pandemic has shown the need to control the risks of infection, taking into account both droplet, aerosol, and contact transmission of infection, as well as to ensure effective disinfection measures not only in the main rooms, but also in the back rooms of medical organizations [67][68].

Numerous cases of contracting COVID-19 at work required a quick review of the strategy to combat the pandemic, followed by a comprehensive investigation of this situation [69]. To date, international cooperation has allowed the development of evidence-based guidelines for managing the risks associated with COVID-19, approaches to optimizing anti-epidemic measures, tactics for managing patients with comorbid diseases, organizing respiratory and cardiological resuscitation of patients with COVID-19, and infectious safety of medical workers [70].

The pandemic has posed a number of problems for the working population related to maintaining professional health, efficiency, well-being in the workplace and, as a result, maintaining a sufficient level of life quality, which is of undoubted medical and social significance for society as a whole [71].

In the future, constructive collaboration within the international scientific community to assess potential causal relationships between COVID-19 and post-COVID syndrome will be essential in order to prevent persistent health problems in the post-COVID period, creating opportunities for a return to normal life³².

Conclusion

The tasks of occupational medicine in the context of a pandemic caused by new coronavirus infection are as follows:

• optimization of measures to reduce the risk of employees contracting COVID-19 at the workplace;
• identification of risk factors for the development of a severe course of COVID-19;
• implementation of comprehensive preventive measures to reduce the risks of stress-related mental health disorders among employees;
• improving the knowledge of employees on the prevention of physical and mental health disorders during the pandemic;
• development and implementation of an integrated approach to ensuring the prevention of disorders of somatic and mental health of employees using the initiative and organizational practice of employers and employees;
• concentration of efforts on restoring the health of workers by an interdisciplinary team of specialists, using telecommunication technologies to provide preventive and rehabilitation programs;
• development of scientific research in the field of effective prevention of COVID-19 by combining the efforts of all specialists involved in the development and implementation of a strategy for maintaining the occupational health and working capacity of employees during the pandemic.

During the period of the spread of the new coronavirus infection, the preservation and strengthening of the health of employees is possible provided that the occupational health service and practical health care are integrated, which meets the goals and objectives of occupational medicine.