All right, well, how much of the crowd have we lost? You know, a smaller percentage than the attrition of nurses in the COVID pandemic. So I guess that's not too bad. So I'm Dr. Melanie Swift. For those of you, I haven't had the pleasure to meet yet. And I'm at the Mayo Clinic in Rochester, Minnesota. And we debated on the planning committee, we sort of debated whether we were going to do this talk. I was going to actually cut it. But the thing is, you can get a bit inured and think, oh, everybody knows that. And then you get a call from someone who says, I'm a nurse in the ICU, and my child got exposed to someone whose soccer team had a tell that might have had MRSA on it, and can I come to work? So these questions still come up. And many of you, although maybe seasoned occupational physicians, these are some fairly specific questions that you may get asked that you might not have in your back pocket. So we want to make sure that you do. And since there was an important, though not fundamental, update to the SHEA guidelines for healthcare workers infected with bloodborne pathogens within the past year, we thought, OK, it's important enough that we should touch on it here as well. So your learning objectives for this little portion of the rodeo are to be able to do a risk assessment and create a risk mitigation and monitoring program for people with bloodborne pathogens. We had this question come up at the conference. Right. Dr. Rusci, we were sitting there, and someone came up and said, you know, I've got two workers I found have, they were non-responders to their hepatitis B series, and so we test them, and lo and behold, they are chronic hepatitis B infected workers, and they work in the OR. What do I do? So by the time you end this, does anyone sphincter tighten a little bit with that scenario? I'm surgical tech. I've got chronic hep B. OK. So the goal of this is to render that non-sphincter tightening for you. So that will be, this will be something that you're able to answer, because you'll have a methodology to approach it. And then the second is to prescribe appropriate work restrictions or work exclusions for health care workers who have other sorts of infections. So we all come to work with some given suite of cooties on any given day, some of which are more impactful than others. So a case, and I'm going to expand on a case that actually happened to me. A senior surgical resident embarking upon a transition to a fellowship at another program whom you evaluated after an emergency department visit for a scalpel cut. He had cut himself while doing a central line placement cut in on a patient who was crashing on the unit. It was a significant enough scalpel cut in a bloody field in the chaos of a code gone bad that he needed emergency room evaluation and sutures, restrictions, et cetera. And I'm not going to tell you the specifics. Let me ask you this. The source patient is positive for a blood-borne pathogen. On follow-up testing, this surgical resident now has contracted that blood-borne pathogen. Regardless of what the pathogen is, how comfortable are you that when he looks at you and he says, can I still be a thoracic surgeon? What are you going to tell him? The answer to that question has changed over the years, right? So some of you in the room may remember more parts of this timeline than others. But it's worth a historical perspective for just a moment. The OSHA blood-borne pathogen standard was passed in 1991, laying out the requirements for healthcare facilities to protect their workers, including the provision of hepatitis B vaccine. And in 2000, it was modified with the Needlestick Safety Prevention Act, which primarily emphasized the use of engineered safety sharps, blunt suture, double-gloving, et cetera. So all of those administrative controls to prevent exposure. Hepatitis B timeline began well before that, when in the 70s, healthcare workers, and earlier, were really at higher risk than the general public of getting hepatitis B. And this ended careers. Right? Because we had no treatment. Right? So although most did not become chronic, some did become fulminant, some were hospitalized, some died, some became chronic, could not work in healthcare, developed cirrhosis, hepatocellular carcinoma, et cetera. What changed that? Vaccines. Thank you, Dr. Berman. Vaccines. So when I started medical school, we had a few hepatitis B vaccines. We weren't sure which ones were best, but we were going to do some of them. And so I was vaccinated as an incoming medical student for the first time with my hepatitis B vaccine series. By 1991, this became written into the recommendations of the ACIP for universal childhood vaccination. So by the time my son was born in 1993, his hepatitis B vaccine was given on his first day of life. So there has been a sea change, and correlating with that is a dramatic reduction in the risk of occupational hepatitis B infection in our healthcare workers. Because they're vaccinated, yes, but also because their patients are vaccinated, right? So that's one timeline to be just aware of as we look at these guidelines. The second is the HIV timeline. So probably most of us in this room do remember the 1980s. We're going to talk more about the 1980s. The dark days of HIV-AIDS. And in the 1990s came a series of case reports, and sadly case series, of documented episodes of transmission of HIV from healthcare providers to their patients. And then out came the light. Early active antiretroviral therapies have rendered what was a death sentence into a manageable chronic disease. So that has changed. And then hepatitis C, which was, when I was in medical school, what did we call hepatitis C? There you go. We think there might be some other letters. We're not sure what they are, but they're not A and they're not B. And so we began to recognize it. And you remember the first recommendations where they said, okay, baby boomers, round them all up and test them, right? So we began to do screening. And there began to be, in the 2010s, gosh, feels like longer ago, but it wasn't that long ago, case reports of transmission of hepatitis C from infected surgeons and healthcare workers to their patients. So we're going to talk about that just a bit. I want to go back to 1990, the dark days, right? This is the first position paper by the Society of Hospital Epidemiologists of America, or SHEA, on what to do with the HIV-infected healthcare worker. And so this was a first attempt to sort of manage this. And the emphasis in this paper was on access to care and a lot of concerns about cognitive impairment. Think of what HIV was in the 1980s. Think of what happened to you after living with this virus in that era, HIV encephalopathy, right? And so there's a big emphasis in this paper on assessing the clinical competence and monitoring the clinical competence. And the recommendation was to counsel these people to just, you should restrict yourself from doing procedures that put your patients at risk, the ones that get epidemiologically linked. You'll read the literature. Monitor that. Stop yourself from doing those. There's no recommendation for any kind of monitoring. There was no recommendation to disclose it. But there was recognition of a need to disclose an exposure if you caused a patient to be exposed, right? So that's where we were in 1990. And then in 1991, any of you remember, other than Dr. Arusi, any of you remember this recommendation coming out from the CDC? The first official CDC recommendation on preventing transmission of HIV and hepatitis B to patients. They defined what an exposure-prone procedure was. We'll go into what that is. But said, you know, these are difficult for us to enumerate. Specialty societies should identify what are those exposure-prone procedures and tell your surgeons not to do them. If a healthcare worker who does these procedures has HIV or hepatitis B, because we didn't know about the other one yet, right, you should have an expert panel. Tell them what to do. But the big one, the most problematic of all of these, was a statement that if you know the worker has an infection, before you let them do an exposure-prone procedure on a patient, you have to tell that patient their status. We're wheeling grandma in for her open cholecystectomy, and on the way in, by the way, her surgeon has HIV. We're okay with that. So in 1991, this is true, the United States Senate, now not the entire Congress, this was never enacted in this form, but the Senate actually voted to impose a $10,000 fine and a 10-year jail sentence on any HIV-infected physicians, not surgeons, physicians, who treated patients without disclosing their HIV patient. Hello, I'm Dr. Swift. I have HIV. How are you today? Seriously. Senator Jesse Helm sponsored this measure, but explained his rationale. Let the punishment fit the crime. I believe in horse-whipping. I feel that strongly about it. Later Senator Helms wrote that the HIV-infected physicians who practice medicine should be treated no better than the criminal who guns down a helpless victim on the street. It's in the congressional testimony. It wasn't just politicians. You can't read this. But this is from the letters to the editor of JAMA, because the same debate was going on in our medical societies among us, right? We didn't know what the right thing was to do. There's some ethical, there's some risk. We haven't quantified the risk. We don't really understand it. I find little difference between the HIV-infected homosexual or intravenous drug abuser who continues to have unrestrained sexual activity, and the surgeon who's infected and continues to practice surgery. See the organization this physician represented? Physicians for moral responsibility. So are they scared to disclose their status? Damn right. 1997. What had happened over those ensuing years was not only this debate, lawsuits, terminations, loss of career, rampant. 1997, this paper came out, which was an update to the Shea Guidelines, which placed an increasing emphasis on the right to privacy of our workers, and argued for reason, and explicitly recommended against restricting of procedures, except for known highly infectious hepatitis B, E antigen workers, recommended against mandatory screening or those required competency checks for your HIV-associated cognitive impairment, and against the disclosure to patients prospectively. They also recommended against viral load monitoring, so that was going to change. So 2001, Shea Guidelines. This is the paper that I recommend everyone have, and it's in your handout, and not because it's not been modified since, it has. But what this set of guidelines did was really established exposure categories for a job task risk assessment, like, okay, let's herd the cats here, let's get a process in place. It also established some viral load guidelines for determining how infectious the person was for all three blood-borne pathogens, and established some management guidelines. So you need an expert panel oversight, some privacy protections. Yes, we can monitor viral loads, and they will be informative, and yes, you can have an agreement on how you're going to do this with the infected worker. In 2012, the CDC issued a similar statement, set of guidelines, specific only to hepatitis B, and following a series of cases in which particularly learners and trainees were denied access to medical school, dental school, residency, et cetera, because of their hepatitis B status. So it does have a strong educational emphasis in this paper, and it established some categories for procedures, viral load guidelines, and sort of said, here's when you might not actually need that expert panel. By and large, fairly concordant. What's been updated since then, so a Shea-White paper came out electronically last year. I think the print citation is actually January, February this year. In that update, since that time, what has happened in the last 12 years? There have been two cases of hepatitis B transmission from a healthcare worker to a patient. Neither of those patients had treated disease. Three cases of hepatitis C transmission outside of situations of intentional drug diversion. And zero cases of HIV transmission to patients. What's also happened is we now have highly effective treatment for all three diseases. We have the U equals U, undetectable equals untransmissible foundation for these infections. So what changed in this guideline? The viral load cutoffs were dropped. Not because patients are at greater risk, but because we can now achieve these. We can achieve these viral loads. Why not? It's the right thing to do. They identified a cut point for when can you stop already with hepatitis C monitoring after they've had curative treatment. So it's 12 weeks after they've had curative treatment. If they remain undetectable for hepatitis C, you can stop treatment. And it introduced a new recommendation. I don't know if this got much attention. And it's odd to have it in this paper. But they recommend if you have a known non-responder to hepatitis B vaccine, not infected, non-responder, and they do these exposure prone procedures, they're at risk, they're at high risk of getting hepatitis B virus occupationally and not know it. And so doing annual testing or screening, offering them annual screening, hey, that might be a reasonable thing to do. I say it's odd in this paper because when you have someone who's a hepatitis B non-responder, you're not thinking to go to the guidelines for infected workers. So that's the thing. But, you know, sometimes that happens. All right. So how do you approach these? It's really simple. What's the job and how infectious are they? And start with the job. We're OCDOCs. We know this. Right? What are their job tasks? So you do a risk assessment of their jobs. These are the procedure categories that Shea outlined in 2010. They're still relevant today. Category one, diminished risk, doing a physical exam on a patient. Category two are they call theoretically possible, but unlikely, not documented, hasn't happened. And category three are those in which there's a definite risk of bloodborne pathogen transmission. They're so-called exposure prone procedures. And the CDC also did categories, and just to confuse me, they switched the order of the category numbers. Right? So the category two are the lower risk, and the category one are the equivalent of the Shea category three. Just know that there's this crazy mix-up in terminology. These papers are being written at the same time. So the category three Shea equals the category one CDC. But really, what is it? It's really at the same time, you've got your fingers and something sharp at the same time in a poorly visualized or highly confined anatomic site. That's the definition from the 1990 Shea paper. It hasn't changed. But it's true. So you have to have a way to stick yourself to get a percutaneous injury that you can't see coming, and contain, and control, and prevent, and that's going to bleed into the patient, okay? So there are a few discrepancies, and they both list procedures. The lists are in your handouts, but there's a few little discrepancies. So the CDC calls an uncomplicated vaginal delivery, an EPP. And so remember, that's the paper, that's the guidelines, it really was focused on learners. Or the impetus for it was largely to be sure we're protecting learners and allowing them to do their training and their rotations. So what happens in a lot of uncomplicated vaginal deliveries that could cause a simultaneous presence of your fingers in a sharp object in a poorly visualized and constrained anatomic space? There you go, repairing a laceration, exactly, or an episiotomy repair, exactly. So if you are the student, you're the third year medical student, you're assisting with this delivery, and then the next thing you know, oh, there's a little tear, yeah, you can do that, you repair that, do you feel empowered to say at that point, actually, my viral load is blah, blah, blah, I should step away from this procedure at this time. Thank you, doctor attending, for giving me that opportunity. Yeah, probably not. So that's probably the main difference. A few others that Shay calls out that are theoretical risk, less important. All right, audience participation. This side, you guys are the known risk group, all right? So when I put a procedure up here and you think it falls in your bucket, I want you to say, and I'm going to say, is this a risk? I want you to say, yes, practice one more time, one time for me. Is this a risk? Yes. Thank you. You guys are the no risk group, are not high risk. But when I say, is this a risk procedure, and you think it's not, I want you to say no. Okay. Is this a risk? No. Thank you. All right. You guys, when we put these scenarios up, I want you to say it at the same time, we're going to see who's louder. Doing thoracic surgery, is that a risk for transmitting your infection to patients? Yes. A lot louder on the yes side. All right. Very good. Fingers, sharps, confined, yes. Cervical suturing, is that a risk? No. Thank you. You can see your hands. You're not inside the patient's body. You can see the sharp. That's fine. All right. Placing a chest tube, is that a risk? Yes. It's a quieter yes. There's even a no or two. Oh, you're so smart. Right. Placing a chest tube in someone in a trauma bay who's just had a pneumothorax from their chest wound, is that a risk? Yes. Why? What's in there that you don't know about? Shards of rib. Right? You're going to stick your finger up in there. You're going to stick your finger. You're the oncologist. Your patient has been hospitalized for a week. They need a tap because they have an effusion. You're going to do an ultrasound guided chest tube drainage. Is that a risk? No. Right. So you get what I'm saying. You've got to think a little bit more. You've got to talk to them a little bit more about what they do. Tooth cleaning or scraping, is that a risk? No. Are you doing it with a sharp object or are you doing it ultrasonically? Ultrasonic. Right? You've got to ask. You've got to find out a little bit more. I put that on known, on yes, but I was assuming with a sharp. Okay. What are the safe viral burdens? These are in your handout. I won't belabor it too much. The red line is the threshold set by CDC in 2012. The blue is the threshold set by SHEA in this most recent update. These units are in genome equivalents per ML or copies and they equate roughly for hepatitis B to 1,000 international units per ML and for hep C to 2,000 international units per ML. These are dramatic reductions from the 2010 guidelines, so if you're still following those, listen up. HIV is down to 200. It was 500. Okay. It can be really hard. We can get these labs from all over the place. There's no real clear conversion between copies to international units. There's a little bit of a guideline. You can try that, but you can just ask your lab. All right. Ongoing monitoring. For folks who do exposure prone procedures, those risk procedures, they should be monitored twice a year to make sure they stay below that safe viral threshold, ensure that they're getting care and get a release of information so that you can verify they're getting that care and you can also get their lab tests if you're allowing their doctor to do their lab tests. There are some issues with doing the surveillance. You got to determine who's going to pay for it. Do you accept the tests that are done as part of their care by their doctor? Doctor may not need to be testing them all that often for hep B, for instance, but decide that to determine how you're going to keep their test results confidential. So the expert panel. Old world. 2010. That was a big panel. It's like, you know, just bring in some HR, bring in someone from HR, bring in someone from hospital administration, bring in, you know, you need occ health, you need hospital epi, all that, et cetera. You might want an ethicist, you know, something like that. So now the other change in the latest guidelines and sort of the evolution of this, as we've all seen as we've done these, is that you really don't need a whole room full of people, you know. Usually the occupational health physician along with their hospital epidemiologist and or the individual's treating physician is perfectly capable of making this assessment. You might need to consult someone from the area, and you can do that often with and without disclosing the identity of the person, because you need to understand what's done in that particular procedure, you know. So in your cath lab, you know, who opens the chest if something goes bad? Is that the cardiologist? Is that the thoracic surgeon who's doing it? But the expert panel lets you do prospective oversight. Do it up front. Do it as soon as you know. Don't wait until something bad happens. It's a confidential review. No one else other than you, the occupational physician, needs to know the identity of the patient. And you can establish your agreement. This is key. This agreement. You're going to educate the person about their risk. They're going to know that they need to double glove, et cetera. But this agreement or contract sort of lines out so they understand and you know what is their monitoring plan. What are all the requirements in this? You know, usually folks have them sign it that I see I've understood this. What happens if they don't comply with treatment? What happens if they don't comply with monitoring? Who's going to pay for the testing, et cetera? You might at some point need someone to know. Someone in their chain of command. But I would argue that the agreement should say we will notify you. You can have some voice in who to pick to notify. And we won't notify them without you knowing that we're going to do so. And ideally we do it. We agree together we're going to do it. If you had someone that was not in agreement, you still have an institutional liability. This process takes that liability from the surgeon, the physician, the healthcare worker and places it on the institution. It says, okay, this is the level of risk with which we are comfortable. We can defend. We don't need to disclose to patients. You don't need to disclose to patients. And thank you for telling us. You follow this plan and we've got your back. Right? So we've come a long way. In 1990. Where you figure it out and maybe you should tell your patients. All right. Yes? Can you comment on prizing the patient if an exposure occurs during the procedure? Yes. So the one, yeah, the one time you do notify a patient is if they do sustain a reverse exposure during a procedure, you must notify the patient that they were exposed. That does not always mean that they need to know who the infected individual was. Right? So if they're getting a surgery and there are multiple operators involved, they don't need to know which of those individuals was the potential source of their exposure. They need to be notified. And you are usually consulting their treating physician on baseline and follow-up labs. So you take what you'd be doing for your healthcare workers and reverse it. Good point. Thank you for that reminder. All right. Beyond. Are we on time? So infectious diseases that are non-blood-borne, 10 minutes, okay. These are the questions people normally think to ask. How easy is this thing to spread? How susceptible are the people I'm working with? Am I on a myelosuppression unit? How serious is this illness? And honestly, how icky is it? Right? Scabies? Pretty darn icky. Right? Dangerous? Not so much. I would say really number three is the only one that's really not pertinent. How serious is it? You still got to evaluate. You may still need to restrict someone for even bedbugs. Right? Okay. So gastrointestinal illnesses, there's a long list of them. And the risk of transmission to patients has to do with the susceptibility of those patients. Are they vaccinated? Are they immunosuppressed? Et cetera. And how easy are they to transmit? So the x-axis here is the ease of transmission with norovirus at the far right. Highly contagious, one to two virus is all you need when you're infected, right? And the susceptibility of your potential contact. So most people are not that susceptible to C. difficile. Some people are vaccinated to hepatitis A, et cetera. But you know, the thing is, it's syndromic. Like Dr. Barman said earlier, we don't know what they've got most of the time. Right? It's a syndrome. They're sick. They're puking. They have diarrhea. Now, in an outbreak situation, you may know what their diagnosis is. A prolonged illness where they've had testing. You may know what it is. You usually don't know. So rule of thumb, restrict them from the workplace if they are throwing up. It's not hard to do. They're usually okay with that. And restrict them from a patient care environment and food handling until they've stopped throwing up for at least 24 hours. Few exceptions. Norovirus is 48 hours after the diarrhea stops. Unless you're cohorting them, we can talk about that later. Hepatitis A, seven days after the onset of jaundice. The questions you'll get, whoops. I had C. difficile. I've been off work. Do I need a negative still sample before I return to work? No. They need to wash their hands with soap after going to the bathroom. And they can return to work. I've been told I'm a salmonella carrier. Should I have work restrictions? Kind of depends. Depends on their job. Depends on your state health department restrictions. And so incomes. Something used to be called the big five. It's the big six now. So you should know that there is an FDA regulation regarding these particular enteric pathogens and food handlers. They may require extended work exclusions if they're symptomatic. They may need to be removed from work for asymptomatic post-exposure. And you may need to prove that their infection has been eradicated. So there's a website here where you can find this list of folks. HSP is highly susceptible populations. Hospitals are those populations. And you can see the specifics for each disease. Dermatologic conditions. There's a long list of them. There's a rule of thumb. If it's open, if it's oozy, if you can see it, that's bad. So open lesions, et cetera, must be dry, not draining or crusted or contained, covered in a dry dressing. There's some special considerations. So the worker with zoster really depends on whether they have disseminated versus local disease and whether they're immunocompetent or not. Dr. Berman referred to that in her talk, so I won't belabor the point. But localized zoster is generally not an issue for the workplace, even in healthcare. If it's disseminated or the worker themselves is immunocompromised, then you have a risk of respiratory spread. And so that's who should be removed from the workplace until, again, lesions are crusted. Lice, scabies, creepy crawlies. Just off work until they're treated, okay? All right. What causes 76% of outpatient soft tissue infections? MRSA, yeah. Where does it live? Right there. Right there. A few other places, too, fingernails, anus, other places. This is the most common place of colonization. And it's an occupational hazard, about three-fold more higher rate of colonization in our healthcare workforce than the general public. Think you ought to screen for this, decolonize. Work restrict them? No. Okay. So I won't go into it. But at this point, we can talk later. But generally, there's no indication for doing routine MRSA screening of healthcare workers. You may have an outbreak for which you need to do screening as part of an outbreak management mitigation. But in general, we wouldn't screen healthcare workers. Nor should they routinely be decolonized absent any other clinical indication to do so. What are the issues? Well, you know, there's a study from somewhere in South America. They swabbed workers at the end of their shift, healthcare workers working in the hospital, at the end of their shift, a bunch of them had MRSA, like something like 20% or something. And then they swabbed them the next morning as they came on shift, and half of them didn't have it anymore. Right? So it's transient. Carriage does happen. Treatment fails. You don't always successfully eradicate it. They can just turn around and get recolonized. You're not vaccinating them against it. They can go out and get it again. Same strain, different strain. But repeated decolonization is an important antimicrobial stewardship issue because you can introduce resistance. Respiratory conditions, you guys manage these all the time. The basics of this, COVID aside, influenza-like illnesses, they need to be afebrile for 24 hours and feel well enough to work. Pertussis, if they have pertussis, they need to have completed five days of antibiotics to return. Conjunctivitis, they just need their eyes to be clear. There's some other virus. What is it? Oh, yeah, that one. All right. So just know that the guidelines for returning to work after COVID-19, remember these are different for healthcare workers than the general public. This gets so confusing, right, because their whole family's got COVID, right? They're the healthcare worker. You know, my husband has to stay home. What are you saying? I can go back. What's the deal? So just know that, you know, have some simple messages. The rules for healthcare workers may be different. Follow your occupational health and institutional policies. And Dr. Berman went over all of this in detail earlier. I'm just going to mention some of the pain points for me. These are things that tighten my sphincters. Under the healthcare-specific guidance, let's assume that we're on the conventional staffing, we have the very clear guidance about, okay, be out for seven days, or if you get a negative antigen test day five or later, seven days. If you've had severe to critical COVID illness, be out for at least 10 days, up to 20. Is there a dart board somewhere that I don't know about? Okay. You can use a test-based strategy. Okay. We used to do that. You know, remember that? Like, for five minutes in April 2020, we did the test-based strategy. Okay. We don't have too many of those. Knock wood. Immunocompromised. Increasingly, we're finding people on biologics, et cetera. And for them, you know, the recommendations remain vexingly vague, don't they? A test-based strategy is recommended. Starting when? Starting day seven? Starting day 10? Starting day 20? Because there's concern for prolonged transmission. They previously gave us a nice 20 days. Thank you. 20 days. It's getting complicated now. Or in the CDC guidelines, they could consult with an occupational health specialist. That's us. Gosh. Frankly, we've kept to the 20-day routine restriction for the immunocompromised healthcare worker with flexibility in situations where they needed to come back, and then we would go ahead and implement a two-negative antigen test strategy to bring them back. And so the remaining challenges with returning workers after COVID really falls in this. These are my pain points. The immunosuppressed and those who had critical or severe COVID. There's so many different levels of immunosuppression. You can be on the same medication, but what's the dose? You know. So, you know, we have a conversation with the employee. They have a conversation with their prescriber to determine, you know, really tell what's your level of immunosuppression. And then that point I made about when do you start return-to-work testing in that group if you're going to do it. And then when we move to contingency and crisis staffing, these subgroup guidances for the immunosuppressed and those that were really, really sick go away. So they don't tell us what to do with those folks when you're on crisis staffing. And there's, of course, no uniform criteria for what constitutes crisis staffing. You know, we're still in contingency right now. It's not because the hospital's overwhelmed with COVID patients. It's because we're underwhelmed with nursing staff. So just to recap, for bloodborne pathogens, do a systematic risk assessment. What's their job? And if their job is one that puts patients potentially at risk, what's their viral load? Get that agreement and monitoring up front. If it's gastrointestinal, don't puke at work. It's not too hard. And then there's special rules for food handlers, and particularly around hepatitis A and norovirus for all healthcare workers and food handlers, the big six. On your skin, if it oozes, cover it up. If it's respiratory, 24 hours afebrile and pertussis, five days of antibiotics. And then the COVID-19 return-to-work criteria are going to depend upon your staffing shortage mitigation needs. All right. And that is it for me. How am I on time? Thank you.

Dr. Melanie Swift

bloodborne pathogens

healthcare workers

risk assessment

risk mitigation

monitoring program

vaccines

occupational infections