A Missing Link in Public Health Preparedness and Emergency Response: Engaging Private Sector Employers for Pandemic Workplace Policies

Introduction

Although cases of COVID-19 remain at low levels in almost all parts of the United States (as of August 2023), the pandemic's effects and impacts on community functioning remain. Public health officials assume that this pandemic is not the last infectious disease emergency the nation will face and are gathering lessons learned to incorporate into future emergency response plans. One of the key learnings was recognizing the important role of private sector employers to implement protective workplace policies during the pandemic. Among other critical capabilities, an effective response to the COVID-19 pandemic requires establishing and coordinating strategic partnerships across community sectors, especially between public health officials and private sector entities. These partnerships are critical to establish pandemic workplace policies that align with public health recommendations, in preparation for a future pandemic or health emergency. In addition, experiences with the COVID-19 pandemic have illustrated the need for establishing and maintaining public health and private sector partnerships to ensure critical functions; enabling rapid vaccine production, distribution, and administration; supporting general logistics; maintaining supply chains; collecting and analyzing surveillance data; producing and distributing supplies and equipment; developing and deploying pharmaceuticals; and expanding testing capabilities. ¹

The Impact of Private Sector Workplace Policies

Since the beginning of COVID-19 pandemic, it has become apparent that workplace policies deployed by private sector employers could have a major effect on the health and safety of their employees and, more broadly, for the communities in which businesses were located. Businesses that adopted flexible leave policies, modified the workplace to allow for more distancing, and used protective strategies like masking generally fared better than workplaces that did not adopt such protective policies. ² Outbreaks were noted in some businesses (like meat and poultry processing facilities) that had crowded conditions, poor hygiene and cleaning practices, and disincentives for sick workers to stay home. ³

In spring 2020, after the SARS-CoV-2 virus first emerged, public health officials recommended stringent mitigation measures to slow the onward transmission of disease, including promotion of remote work and closing of offices and many “nonessential” businesses. As the pandemic progressed, many employers struggled to interpret the changing public health advice and often did not know which guidance to use for workplace policies and how to plan for reopening. ⁴ In some jurisdictions, there was opposition and pushback about public health recommendations such as business closings, mask mandates, and the timing of reopening. ⁵ Additional challenges for employers emerged during the pandemic, including continued waves of infection that imposed threats to the health of their populations, absenteeism, economic hardships, disruption of the labor market by the “great resignation”—in which large numbers of employees voluntarily resigned from their jobs during the pandemic—and the need to address mental health issues and health and social disparities.^4,6

Approximately 159 million people are currently employed in the United States, representing approximately 47% of the population. ⁷ Because employers can collectively enact policies to affect a sizable population during a pandemic emergency, public health emergency planners should consider creating and building partnerships as part of ongoing preparedness. Although the mission, culture, and goals may differ between public health and private sector employers, ⁸ most private sector entities and public health officials aspire to protect their populations and ensure the continuity of enterprise and community functions during an emergency response. Therefore, emergency preparedness and response partnerships between public health and employers can be based on aligned goals.

There are several important ways in which these partnerships can support private sector workplace policies to protect human health during a pandemic. Public health officials can collaborate with employers by encouraging them to plan ahead to develop policies that incorporate public health recommendations and adopt practices that sync with public health guidance. During public health emergencies, employers can ensure that they promote and implement the latest recommendations from credible sources, especially when public health recommendations change as more is known about the characteristics and epidemiology of pandemic pathogens.

Employers have a duty to provide a safe working environment for staff that is “free from serious recognized hazards.” ⁹ During the COVID-19 pandemic, many employers established protective workplace policies as well as a combination of physical modifications to the office and building (or systems within it) as part of providing a safer workplace.^10,11 The Centers for Disease Control and Prevention (CDC) and the Occupational Safety and Health Administration (OSHA) recommended that employers use multiple strategies to reduce exposure to the virus, including promoting vaccinations, physical distancing, wearing face masks, hand hygiene, and improved indoor building ventilation.^12-14

Some employers, when possible, allowed staff to work remotely, which reduced crowding on community public transportation and in the workplace. Working remotely during the pandemic served as a key mitigation measure for many office-based businesses and other enterprises that could continue providing services outside of the workplace. Approximately 58% to 69% of full-time US workers reported they worked remotely, according to several polls.^15,16 Teleworking and hybrid work schedules are likely to be used as important mitigation strategies in future infectious disease emergencies. A recent Gallup poll found that approximately half of the US full-time workforce reported that their current job can be done remotely (at least part of the time). ¹⁷ Many employers have continued to support remote work, at least some or all of the time, as they found that this arrangement sustained employee productivity and reduced office costs, appealed to employees' requests for work–life balance, and helped with staff retention.^18,19

The Importance of Nonpunitive Leave Policies

One of the most important protective measures that an employer can implement during a pandemic is nonpunitive leave policies. ²⁰ During the current COVID-19 pandemic and future infectious disease pandemics, the CDC and public health officials will most certainly advise that sick people stay home and away from the workplace regardless of the level of pandemic severity. ¹² Staying home while sick prevents an ill person from infecting other people in the workplace. A number of studies have shown that access to paid sick days makes it more likely that a worker will stay home when they are ill. ²¹ Each sick person who enters the workplace may infect, at a minimum, 2 or 3 others, which can lead to workplace outbreaks, disruption in business continuity, and increased absenteeism. ²² A modeling study that focused on influenza found that the absence of paid sick leave in the workplace could lead to approximately 5 million additional cases of influenza-like illness in the general population and that offering paid sick leave can save US employers $0.63 to $1.88 billion in reduced absenteeism costs per year (in 2016 dollars). ²³ If the pandemic pathogen is extremely contagious and/or causes severe disease and poor outcomes, public health officials may also recommend that people living in a household with a sick person also stay home. ²⁴ Therefore, sick leave policies and business practices that encourage and support exposed or symptomatic or sick people to stay home can be beneficial to businesses and are a critical part of a community's disease mitigation strategy to slow the spread of disease. Businesses that produce critical goods and services need additional advance planning to support protective sick leave policies while ensuring continuity of function.

Offering paid sick leave can reduce presenteeism (eg, sick workers continuing to work while not fully productive) and improve employee retention, both of which are critical during a pandemic when many businesses are short-staffed. ²⁵ Nonpunitive leave policies are also important for employees who need to stay home while awaiting the results of testing and those who need to care for a sick household member. However, even with supportive sick leave policies in place, maintaining a sufficient workforce can be challenging if absenteeism increases because people are sick. This also places more responsibility on those at work. Without employer support for sick workers to stay home, those on the job may be reluctant to stay home if they become sick. Advance planning and preparation are needed to enact these policies during a public health emergency.

Closing the Gap: Paid Sick Leave

Although the CDC and other public health officials advised that sick people stay home during the COVID-19 pandemic, not every employer enacted leave policies that aligned with this guidance. Permitting sick staff to enter the workplace is likely to spread infection to others, which could increase absenteeism, loss of productivity, and costs. If the pandemic pathogen causes severe disease, protecting staff from workplace exposures becomes even more important. Early in the pandemic, employers had great concern and some confusion about how to restructure sick leave and other leave policies. About a quarter of all private businesses temporarily created or modified paid sick leave or paid time off plans because of the COVID-19 pandemic, with 45% of larger employers (those with 100 or more workers) more likely to amend their policies compared with 25% of smaller establishments (those with fewer than 100 workers). ²⁶ One of the largest employers in the country took the lead by enacting nonpunitive emergency leave policies early in the pandemic (March 2020) to allow sick or exposed workers to stay home. ²⁷

The United States is the only high-income country that does not guarantee that workers receive paid sick days or paid sick leave; unless sick leave is mandated by state law, businesses can therefore choose to offer (or not offer) this benefit to some or all of their employees.^28,29 Currently, only three-quarters of US private industry workers have access to any paid time off, and this benefit varies widely by job type and employment type. ³⁰ This means that approximately 33.6 million workers do not have access to paid sick leave. ³¹ Part-time workers often do not receive these benefits and only about a third of those earning the lowest salaries (those whose wages are $10.80 an hour or less) have paid sick leave, even though these workers are the least able to afford to take unpaid time off from work. ³¹ In addition, full-time workers in rural areas have less access to paid sick leave than full-time workers in urban areas. ³²

Before the pandemic started, more than half of service-sector workers employed by large companies (many were later considered “essential workers”) lacked access to paid leave, especially female workers and workers of color. ³³ Inaccessibility to paid sick leave exacerbated health inequities for some workers during the COVID-19 pandemic, especially for workers at the lower end of salary ranges. ³³ Approximately 30% of critical workers did not have access to paid sick leave during the pandemic and were at greater risk of infection compared to other workers. ³⁴ Many faced fears of exposure and worry about taking the disease back to their household. ³⁵ The provision of nonpunitive sick leave policies with pay can provide encouragement for those who become sick to stay home and the assurance that they have financial and job security.

The reasons that some businesses do not routinely offer sick leave to their employees include concerns that the leave may be overused or abused and that the cost of providing such leave and backfilling the position would not be affordable. However, providing sick leave during a public health emergency is likely to reduce rather than increase employer costs. After implementing paid sick leave, some employers experienced modest cost increases, but these were likely offset by improve employee satisfaction and retention, enhanced health and safety, and reduced presenteeism.^21,36

Providing paid sick leave can have additional benefits; one study found that businesses in US cities that mandated paid sick leave policies had higher COVID-19 vaccination coverage and narrower coverage disparities among employees. ³⁷ Studies prior to the COVID-19 pandemic found that the provision of paid sick leave reduced the incidence of frontline food service workers working while sick, which decreased the risk of disease transmission to other workers and customers.^25,38 A recent CDC report reinforced this finding; these researchers found that about 40% of 800 food poisoning outbreaks were associated with an ill restaurant worker. ³⁹ Less than half of the restaurants surveyed offered paid sick leave. The report's authors cited loss of pay and perceived pressure to work as 2 reasons why employees go to work while sick. Business operations and the surrounding community may suffer if sick employees go to work while ill to avoid losing pay or to avoid punitive discipline.

Although there has been no federal law that requires paid sick leave for employees of private sector businesses, 16 states, plus the District of Columbia, and dozens of jurisdictions in the United States have employer mandates in place to provide some form of paid sick leave to eligible employees. ⁴⁰ To make paid sick leave more accessible during the pandemic, the Families First Coronavirus Response Act ⁴¹ (FFCRA; as amended by the COVID-19-related Tax Relief Act of 2020⁴²), provided small and midsize employers (those with fewer than 500 employees) with tax credits to reimburse for the cost of providing paid COVID-19-related sick and family leave wages to their employees. This tax credit was in effect from April 1, 2021, through September 30, 2021. ⁴³ However, large employers were not included in these paid sick leave requirements, and not all small and midsize employers took advantage of these credits. One analysis found that states that gained access to paid sick leave through the FFCRA experienced about 400 fewer confirmed COVID-19 cases per state per day. ⁴⁴ There is no assurance that federal, state, or local sick leave benefits or tax credits will be enacted in future health emergencies. Therefore, employer-based policies are crucial.

Building Partnerships and Opening Clear Lines of Communication

Public health planners can reach out to private sector employers as part of preparedness efforts to discuss the importance of enacting nonpunitive leave policies and other protective actions during a public health emergency. Corporate leadership commitment is needed to develop and implement policies that protect and promote worker safety, health, and wellbeing. Commitment can be engendered by conducting outreach to business leaders and collaborating on pandemic preparedness efforts. Mass media and social media reports are often confusing and fraught with inaccurate information; direct communication is therefore needed to ensure that accurate and timely information for action is relayed to employers. Because implementing new workplace policies can take time and would need to be reviewed by multiple entities within a business, constructing draft policies in advance can speed up the finalization and implementation of key policies during an emergency. Even if those benefits are not routinely or currently provided to staff, public health planners can discuss with business leaders the importance of developing draft emergency sick leave policies to use when needed during a pandemic or other health emergency.^12,27

Public health planners can establish a trusted connection with private sector employers in their community well before the next health emergency emerges to establish lines of communication and provide preparedness and response guidance. One example of a successful community-level partnership is Challenge Seattle, which was convened by the Seattle and King County Public Health Department. This effort brought local businesses and organizational leaders together with public health officials to collaborate on the development of policies to improve workplace safety during the pandemic and coordinate reopening timelines. ⁴⁵ Although a formal evaluation of Challenge Seattle has not been published to date, the group published a guide to improve efficiency at COVID-19 vaccination clinics. ⁴⁶ In addition, published after-action reports and informal evaluations demonstrated that this public–private partnership “enabled efficient planning and warp-speed replication of a wide array of vaccination sites” among other achievements. ⁴⁷

Outreach between public health and private sector employers may be easier to achieve during a public health emergency—it may be more challenging to create these partnerships in the absence of a “burning platform.” However, establishing public health–private sector employer partnerships in advance of an emergency allows for establishment of trust, understanding of roles, and collaborative work on protective workplace policies that can be rapidly deployed during an emergency. If outreach is conducted through business organizations, business schools, and legacy partnerships formed during the pandemic, there may be more receptivity to sustaining ongoing collaborative emergency planning efforts. Public health, businesses, workers, and communities can benefit from planning ahead for emergencies through these collaborative partnerships.