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Employers must address workplace safety for immunocompromised employees

As COVID-19 case rates drop, employers prepare to reopen

By Jeff Levin-Scherz, MD, MBA | February 23, 2022

Employers are responsible for creating a safe work environment for all and must be prepared to offer accommodations to decrease COVID-19 risks for those with weakened immune systems.
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Risque de pandémie

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About the series

Dr. Jeff Levin-Scherz provides regular updates on the latest COVID-19 developments with a focus on the implications for employers and guidance on how they can tackle pandemic-related challenges to keep their workplaces safe. Explore the series.

Newly diagnosed cases of COVID-19 are down by about two-thirds over the last two weeks, and new hospitalizations are down by over a third. Deaths remain over 2,000 per day, but death rates are a trailing indicator so we’d expect to start seeing the decline in March.

These indicators show the risk of COVID-19 has declined across the country, although transmission rates remain high in the vast majority of counties. Furthermore, wastewater samples, which can be an early warning sign of a wave of infections, show a decrease in coronavirus genetic material in 77 of the 99 areas reported by the Centers for Disease Control and Prevention (CDC), and Biobot in eastern Massachusetts shows rates of coronavirus genetic material approaching zero.

Seven-day average cases: 112,653, hospitalizations per day: 7,831.
Daily trends in number of COVID-19 cases and new patients admitted to hospitals in the U.S.

Source: CDC, February 18, 2022. Yellow line is seven-day average of new cases per day; blue line is seven-day average of new hospitalizations per day.

Implications for employers:

  • These indicators are further evidence that the Omicron wave is subsiding, and the risk of COVID-19 for remote workers returning to the workplace is less than it was amid the peak in mid-January.
  • Risk for people who are unvaccinated and without previous infection, or those who are immunocompromised remains high.
  • Employees can protect themselves by wearing high-quality, well-fitting masks.
  • Employers should continue efforts to improve ventilation and increase vaccination and booster rates to provide more protection for a possible subsequent wave of COVID-19, which many researchers believe is likely.

Employers grapple with addressing safety for immunocompromised people

As employers prepare to reopen workplaces, they should consider the safety of immunocompromised people. About 3% of Americans covered by employer-sponsored health insurance are on immunosuppressive drugs – so there are millions in the workforce who are unprotected from COVID-19 regardless of vaccination status. While some people with impaired immune systems can benefit from a fourth COVID-19 vaccination, many do not.

People commonly think of cancer and organ transplant patients as immunocompromised, but other conditions that weaken the immune system include multiple sclerosis, inflammatory bowel disease and rheumatoid arthritis. The medications that treat these diseases prevent patients from achieving effective immunity against the coronavirus. Therefore, it is important that both employers and other employees remain mindful of the risks COVID-19 poses for immunocompromised colleagues, customers, clients and family members.

Fortunately, a monoclonal antibody, Evusheld, provides six months of protection from COVID-19 for those unable to benefit from vaccination, but this medication is in short supply leading some hospitals to use lotteries to determine who will receive the limited doses.

Implications for employers:

  • Employers are responsible for creating a safe work environment and must offer accommodations to those with disabilities unless doing so results in “undue hardship” to the business. Employers should continue to:
    • Support those who decide to continue to wear masks, even when they are no longer required by state or local regulations.
    • Offer accommodations for immunocompromised employees to decrease the risk of infection. Accommodations could include continued remote working, but employers should make sure such an accommodation doesn’t impact promotion or advancement.
  • Immunocompromised employees face lower risks in workplaces with high rates of vaccination, which can be achieved through vaccine mandates.

Prior infection followed by vaccination leads to optimal immunity

Research has shown that people who have recovered from a COVID-19 infection often are protected for months or longer against a recurrent infection, regardless of their vaccination status. Most, but not all, studies show that vaccination provides greater protection than previous infection.

However, most of these studies were done before Omicron, which has eluded immunity from both vaccinations and prior infections. Both the vaccinated and those with prior COVID-19 infections have had lower hospitalization and death rates in the Omicron wave than those with no prior infections.

Furthermore, recent studies also show that those who have recovered from COVID-19 and who are then vaccinated have much lower rates of subsequent hospitalization — providing evidence that “hybrid” immunity (vaccination and prior infection) is the most protective.

Despite this research, the CDC has resisted giving “credit” for immunity for those who have already had COVID-19 and for good reasons. For starters, it’s easier to implement straightforward rules. Giving credit for past infection would make determining who requires vaccination more difficult. Additionally, the vaccines are exceptionally safe, making it less important clinically to filter out those who will benefit less from the vaccine.

Implications for employers: Employers should be cautious about offering medical exemptions for vaccine mandates to those with previous infections, especially since we don’t know whether those who recover from Omicron infections will have the same robust immune response as those who recovered from Delta or previous variants.

Few patients have been infected with COVID-19 during hospital stays

During the recent surges, many people skipped medical care for fear that they might get COVID-19 at medical facilities. However, new research suggests such fears were likely unfounded.

Researchers used hospital electronic medical records from 889 hospitals to track the risk of COVID-19 infection after hospitalization through this past fall and found that the risk of in-hospital transmission was very low. In the last half of 2021, the risk of converting from a negative to a positive COVID-19 status while hospitalized was well under 1%.

Implications for employers:

  • Patients should feel confident that the risk of coronavirus infection in medical settings is low.
  • Employers can encourage employees to return to preventive care and in-person chronic disease care as needed, as risk in an outpatient setting is likely even lower than for inpatient care.

Omicron led to a surge of sick days

The Wall Street Journal summarized data from the U.S. Census Bureau Household Pulse Survey that demonstrated the enormous impact of Omicron on days away from work. About 3% of those who were vaccinated missed work because they were sick or caring for someone with COVID-19, compared to about 5.7% of those who were unvaccinated.

Implications for employers:

  • This is further evidence of the business advantage of having a high vaccination rate among employees.
  • Employers can use vaccination levels to help develop business continuity plans for any future COVID-19 waves.

Preliminary data suggest that we might need additional boosters

The CDC released data recently showing that boosters dramatically decreased the risk of hospitalization for the first three to four months after boosting, although that impact waned by five months after the booster shot. This is based on data from 10 states in December and January (during Omicron), and the number of people five months out from their booster was small. Protection for the general population is likely to be higher since those at highest risk likely got boosters earlier. Nonetheless, some countries have begun giving fourth doses of the vaccine.

After five months booster effectiveness wanes from 87% (percentage at two months post-booster) to 31%.
Boosting improves protection against hospitalization, but impact wanes over time

Source: CDC February 18, 2022

Implications for employers:

  • Boosters prevent hospitalizations, which decreased by more than half for the first three months after boosting.
  • While this preliminary data suggest that further boosting might be beneficial, future data will include more healthy people five months out from their booster, which might be more reassuring.

Population Health Leader, Health and Benefits, North America

Jeff is an internal medicine physician and has led WTW’s clinical response to COVID-19 and other health-related topics. He has served in leadership roles in provider organizations and a health plan and is an Assistant Professor at Harvard Chan School of Public Health.

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