Occupational safety and health guidelines in relation to COVID‐19 risk, death risk, and case‐fatality proportion: An international, ecological study

Abstract Background Coronavirus disease 2019 (COVID‐19) began in 2019 with several unknown factors. The World Health Organization (WHO) subsequently developed COVID‐19 occupational safety and health (OSH) guidelines to reduce occupational COVID‐19 transmission. Many countries also developed their own COVID‐19 OSH guidelines, but whether these guidelines included WHO's guidelines and whether including WHO's guidelines in countries' COVID‐19 OSH guidelines reduced COVID‐19 transmission is unknown. Objectives The objectives of our study were to (1) compare the COVID‐19 OSH guidelines of several countries to WHO's OSH guidelines, (2) estimate associations between characteristics of countries and their OSH guidelines and the number of WHO's OSH guidelines included in countries' OSH guidelines, and (3) estimate associations between WHO's OSH guidelines included in countries' OSH guidelines and COVID‐19 risk, death risk, and case‐fatality proportion. Methods This study represents international, ecological research of 36 countries from all six world health regions. Countries' COVID‐19 OSH guidelines were compared with WHO's OSH guidelines. Linear regression models adjusted for potential confounders were used to estimate associations of interest. Results The median number of WHO's 15 COVID‐19 OSH guidelines included in countries' COVID‐19 OSH guidelines was eight. Countries' COVID‐19 OSH guidelines focused on workers included significantly more of WHO's COVID‐19 OSH guidelines than countries' COVID‐19 OSH guidelines focused on general populations. Including “provide personal protective equipment for workers” and “create workplace policy for wearing personal protective equipment” in countries' COVID‐19 OSH guidelines were significantly related to decreased COVID‐19 risk, death risk, and/or case‐fatality proportion. Conclusions Countries' COVID‐19 OSH guidelines should include WHO's guidelines, focus on workers, and include “provide personal protective equipment for workers” and “create workplace policy for wearing personal protective equipment.”

or other government entities. Therefore, information from other sources, such as from legal websites that cited government guidelines, was used as needed. The following country's guidance documents were translated to English: Argentina, Estonia, and Luxembourg.

| Content analysis
A content analysis was conducted by comparing the 36 countries' COVID-19 OSH guidelines to WHO's OSH guidelines. WHO's COVID-19 OSH guidelines were considered as the gold standard comparison because of our study's international focus. These guidelines apply to workers in nonhealthcare settings. Fifteen specific guidelines in WHO's COVID-19 OSH guidelines were identified: 1. Determine workplace level of risk (through a risk assessment).
2. Decide on the ability to reopen according to risks. 3. Encourage regular handwashing. 4. Provide handwashing or sanitation stations in the workplace. 5. Provide personal protective equipment (PPE) for all workers. 6. Create a workplace policy for wearing PPE at work. 7. Require 1 m of physical distancing. 8. Rearrange the workplace to include physical barriers to promote physical distancing (such as glass, queue management, etc.). 9. Stagger shifts or have employees telework when possible. 10. Cancel/postpone work travel. 11. Disinfect workplace regularly (especially high-touch surfaces). 12. Create an environment with continuous COVID-19 education in the workplace. 13. Require sick/symptomatic workers to stay home and quarantine, as well as implement protocols, to limit their exposure as they leave the workplace if symptoms onset during work hours.
14. Increase ventilation rate by natural or artificial means (avoid recirculation, especially for medium-high risk workplaces). 15. Create a workplace plan of action for the prevention of COVID- 19. 5 Two raters were trained to review each countries' COVID-19 OSH guidelines and determine whether (i.e., "yes" or "no") they included WHO's 15 COVID-19 OSH guidelines. If the two reviewers disagreed, then a third trained rater review the discrepant guidelines and make the tiebreaking decision.

| Statistical analyses
SAS version 9.4 (SAS Institute Inc.) was used to conduct all statistical analyses, and the country was used as the unit of analysis. Percent agreement and κ, and 95% confidence intervals (CI) for κ, were calculated to estimate the agreement between the two raters' determinations of whether countries' COVID-19 OSH guidelines included WHO's OSH guidelines. 5 The US Census Bureau's information on the age of population for each country was available as the number of people in 5-year age categories: 0-4, 5-9,…, 90-94, 95-99, >99. 7 To calculate the average age of population for each country, the midpoints of each age category were multiplied by the number of people in that age category, the products were summed, and the sums were divided by the total population. COVID-19 risk per 1,000,000 people, COVID-19 death risk per 1,000,000 people, and COVID-19 case-fatality proportion were calculated for each country using WHO's information on COVID-19 cases and deaths, the US Census Bureau's information on population, and the following formulas 7 Provide personal protective equipment for workers 16 44 Create workplace policy for wearing personal protective equipment 23 64 One meter of physical distancing required 23 64 Rearrange workplace to include physical barriers to promote physical distancing 16 44 Stagger shifts/telework when possible 20 56 Cancel/postpone work travel 16 44 Disinfect workplace regularly (especially high-touch surfaces) 27 75 Continuous COVID-19 education in the workplace 18 50 Sick/symptomatic workers stay home and quarantine (limited exposure as leaving workplace)

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Increase ventilation rate by natural or artificial means (avoid recirculation), especially for medium-high risk workplaces 12 33 Create a workplace plan of action for the prevention of COVID-19 17 47 Number Handwashing is the best practice for stopping the spread of infectious diseases because people often touch their faces, eyes, and mouths. Germs on the hands can carry infectious diseases such as, but not limited to, salmonella, E. Coli O157, and norovirus. In addition, the US CDC found that 20%-30% of diarrheal sicknesses and respiratory infections can be prevented by regular handwashing. 59 A meta-analysis found that handwashing is effective for mitigating the spread of gastrointestinal illness. 60 Two other studies found the combined effect of hand hygiene (i.e., using alcohol-based hand sanitizer) and face mask wearing reduced incidence of influenza. 61 found "Noncompliance was strongly associated with weaker feelings of moral obligation and low trust in authorities, but also with characteristics related to antisocial potential." 65 Culture or inadequate policy may also play a role in noncompliance with COVID-19 OSH guidelines. For example, in Nepal, a motorcycle driver will wear a helmet because doing so is required by the law, but he or she will not put a helmet on his or her motorcycle passengers, such as a spouse, child, or baby, because there is no law that requires helmet use by passengers. 66 The connection between the COVID-19 OSH guidelines and deaths is maybe not direct as a majority of COVID-19 deaths is among retired elderly people. However, the percentage of elderly or retirement people in many countries who still work full-or part-time is increasing. 67

CONFLICTS OF INTEREST
The authors declare no conflicts of interest.