PFAS EA Restart Plan

PFAS Exposure Assessment (EA) Restart Plan – last updated 6/11/2020

Introduction

The Per- and Polyfluoroalkyl Substances (PFAS) Exposure Assessments (EAs), and associated activities, including introductory meetings, recruitment, biological sample collection, and environmental sample collection are critical public health activities that should continue in the remaining EA communities if there is evidence of minimal community transmission of SARS-CoV-2, the virus that causes COVID-19, capacity to investigate cases, and open capacity at hospitals and urgent care centers. Data collection activities (introductory meetings, recruitment, and sample collection) have been completed at five sites with activities remaining in Fairbanks North Star Borough, Alaska; El Paso County, Colorado; and Orange County, New York. When possible, we propose alternative strategies for completing essential EA activities to minimize face-to-face interaction and potential for transmission of SARS-CoV-2.

Restarting PFAS EA field work will require that precautions be put in place to ensure that staff, contractors, and members of the public are protected from COVID-19. This plan is based on interim CDC guidance for non-COVID-19 public health activities that require face-to-face interaction during the COVID-19 pandemic and will be used to outline practices for conducting PFAS EA activities.

Changes in the initial EA procedures are proposed to reduce or eliminate close contact (within 6 feet) between CDC/ATSDR staff, CDC/ATSDR contractors, and the public when possible to prevent the spread of SARS-CoV-2 during PFAS EA activities. The precautions and personal protective equipment (PPE) recommended in this plan will be reevaluated at least monthly and more often as needed to ensure they are still in line with CDC and state COVID-19 guidance and may be revised to add or remove precautions as needed. Precautions may vary from site to site based on conditions on the ground and the timing of when activities are conducted.

Plan Objectives

• Minimize risk of exposure, illness, and spread of disease among staff conducting PFAS EAs

• Minimize risk of exposure, illness, and spread of disease among members of the public as a result of PFAS EA activities

• Preserve essential functions of PFAS EAs

Schedule

Schedules for resumption of field work activities will be determined on a site-by-site basis. Work at some sites may resume earlier than others. Decisions about when to restart activities will be made in consultation with regional ATSDR staff as well as state and local public health officials. Scheduling activities will take into account

• the level of local COVID-19 transmission (number of new cases, emergency department visits, and percent positive for testing in each community as available)

• state and local guidance/mandates

• other site-specific factors as described later in this document

Modifications to EA Procedures

Staffing:

Staff travel for PFAS EA activities will be voluntary. Staff will be briefed on their potential role as well as risks prior to travel and will be given the opportunity to opt out of any travel. Staff will be provided with clear information about new procedures and PPE requirements (as shown in the table at the end of this document). All PPE will be provided to staff prior to initiation of activities. Staff will have an opportunity to ask questions about the precautions and PPE requirements prior to travel. Staff at higher risk for severe illness from COVID-19, including age (older adults) and underlying medical conditions, will be encouraged to discuss any concerns with their supervisors and supervisors will stress that any travel for this field work is voluntary.

Cloth face coverings are required for the protection of others and are not PPE for the wearer. Cloth face coverings should not be placed on anyone who has trouble breathing, or is unconscious, incapacitated or otherwise unable to remove the mask without assistance. The cloth face cover is meant to protect other people in case you are infected. In situations where PPE is required for respiratory protection, staff will be provided with appropriate PPE (surgical masks or N95 respirators). In cases where participants arrive to an appointment without a cloth face covering, they will be provided with a surgical mask due to disposability. If participants are unable to wear a cloth face covering or surgical mask due to medical conditions, staff will maintain at least six feet of distance at all times and will wear a surgical mask if closer interaction is required.

Community Meetings:

In April 2020, CDC/ATSDR transitioned to a virtual format for all PFAS EA introductory public meetings. These meetings will provide the same content as has been provided in previous introductory meetings but will be delivered using video-conferencing technology with opportunities for question and answer sessions from participants. This modification is in compliance with an administrative order from New York restricting large social gatherings of more than 50 people and CDC guidance on community gatherings.

While all essential information about the EAs will be presented at the virtual introductory meetings, we recognize that there may still be a need for limited in-person interaction to answer questions and build trust with community members who may not be able to attend virtual meetings. To serve the needs of these community members, we propose holding in-person small group question and answer sessions. Community members will be able to sign up for a small group session in advance. CDC/ATSDR staff will communicate guidance for social distancing, wearing a cloth face covering, and symptom screening with participants when they schedule an appointment. Each session will include two CDC/ATDSR staff and a maximum of seven community members. All attendees will be screened by CDC/ATSDR staff for COVID-19 symptoms with a symptom questionnaire, visual assessment, and temperature check prior to entry and sessions will be setup to promote social distancing of CDC/ATSDR staff from community members and among community members. CDC/ATSDR staff will deny entry to participants if they report symptoms of COVID-19, have a temperature over 100.4° F, or if CDC/ATSDR staff observe signs associated with COVID-19 (e.g. coughing, feeling feverish). If a participant is denied physical entry, we will offer to have a phone conversation to answer any questions they might have. Cloth face coverings for CDC/ATSDR staff and community members will be used in accordance with CDC guidance and hand washing facilities with soap and water will be provided. Hand sanitizer (minimum 60% ethanol or 70% isopropanol) will also be available near the door, and surgical masks will be provided for participants who do not bring their own cloth face covering. Cloth face coverings are not PPE and will be worn by staff and community members to protect others. If a participant exhibits symptoms after entering the facility they will be asked to leave and the facility will be cleaned and disinfected with a disinfectant listed on EPA List N, following CDC guidance, before reopening.

Door to Door Recruitment:

Staff engaged in door to door recruitment will follow current guidance for personal protective measures and PPE as directed by the Office of Safety, Security, and Asset Management (OSSAM) and specified in the table at the end of this document. Short additional content will be added to door to door recruiter training on briefly and sensitively acknowledging COVID-19 infection control measures taken to protect participants (e.g., “We are wearing surgical masks and standing back here to keep some social distance so we are all safer from COVID-19.”). The procedure for door to door recruitment will be that staff will approach a home and knock or ring the doorbell and then step back to a minimum of six feet from the door. If a resident answers the door, staff will remain at least six feet away while sharing information about the EA. If a resident exhibits symptoms, staff will encourage them to seek medical advice. Staff will leave printed educational materials with residents or at the door if there is no answer. Under no circumstances will staff enter homes during door to door recruitment.

Biological Sample Collection (Blood and Urine):

All staff will be screened daily for COVID-19 symptoms prior to entry to the sample collection location using a symptom questionnaire and temperature check. Staff will follow current guidance for PPE as outlined in the table at the end of this document. Staff will also be instructed to stay home (or at their hotel) if they are experiencing any COVID-19 symptoms and will be screened twice daily and enrolled in Text Illness Monitoring (TIM). If symptoms develop, staff will be instructed to contact the Occupational Health Clinic (404 639 3385) for guidance in appropriate actions to take.

EA participants will be instructed not to come for their appointment if they are experiencing COVID-19 symptoms (as defined in the list below). All EA participants will be informed of screening procedures and asked to wear a cloth face covering to their appointment when appointments are scheduled. Participants will be asked about symptoms in a reminder call the day before their scheduled appointment. If community members are found to have symptoms during screening, they will be denied entry to the sample collection venue and will be encouraged to consult with their primary care provider. If a participant exhibits symptoms after entering the facility they will be asked to leave and the facility will be cleaned and disinfected, with a disinfectant listed on EPA List N, following CDC guidance, before reopening. If there is a potential exposure, CDC/ATSDR staff will contact the Occupational Health Clinic for guidance on appropriate actions. Staff will share information about the interaction that led to a suspected exposure and will follow guidance from the clinic on appropriate actions. All staff in the field will be monitored for symptoms during their travel and for 14 days after returning regardless of any potential exposure.

Additional actions that will be used to reduce the potential for SARS-CoV-2 transmission include:

• Selecting facilities for use (e.g. conference suites) that are large enough to physically distance stations by at least 6 feet for intake, waiting, consenting, sampling, etc.

• Scheduling appointments such that never more than 9 individuals (staff and participants, based on the size and configuration of the space) are in the facility at the same time

• Increase physical space between employees and participants (e.g., physical barriers such as partitions)

• Use signs, tape marks, or other visual cues such as decals or colored tape on the floor, placed 6 feet apart, to indicate where to stand when physical barriers are not possible

• Requiring use of surgical masks for staff and cloth face coverings or surgical masks for participants

• Limiting sampling area access to a maximum of 9 people (based on area size and configuration) at a time, with a door monitor allowing one person inside for each person that exits

• Providing proper hand washing facilities

• Providing hand sanitizer and surgical masks for participants who do not bring their own cloth face covering upon entry into the facility for a physical appointment

• Providing signage showing reasons for precautions and proper wear of cloth face coverings

Questionnaires will be transitioned from in-person to telephone administration. At the testing location, each EA participant will complete informed consent and provide blood (collected by a contract phlebotomist) and urine samples and will be scheduled for a telephone appointment to complete the questionnaire. This change will reduce contact time between participants and EA staff and result in a need for fewer staff to travel to the field locations.

We will install physical barriers within the biological sample collection location where feasible. Administrative controls, including staff education on COVID-19, instruction on appropriate PPE for given tasks and how to don and doff PPE, hand hygiene instruction, how to briefly and sensitively acknowledge precautions with participants and note COVID-19 infection control measures taken to protect participants, and instructions for staff to remain home if experiencing any symptoms will be instituted.

There will be a separate area for eating/drinking for staff. These areas will be set up with limited seating to promote social distancing. Breaks areas will be cleaned and disinfected a minimum of two times per day. Juice or other supplies for phlebotomy recovery will be provided only if participants experience symptoms associated with giving blood (feeling faint etc.), will be kept in a separate area, and will be consumed only in a separate unused area near the phlebotomy area. Participants will not enter the staff food area.

Environmental Sample Collection:

Participants will be informed of screening and protective procedures at the time home appointments are scheduled. Staff will confirm that there are no individuals with COVID-19 symptoms in the house before entering. Staff will briefly and sensitively confirm that no individuals on the staff team have symptoms, staff entering the home will wear PPE (N95, coveralls, and gloves) to protect themselves and the household residents, and any other COVID-19 infection control measures they are taking to ensure protection of the household residents. Participants will be asked to wear a cloth face covering while staff are inside their home. If they do not have a cloth face covering, a disposable surgical mask will be provided to them. If a resident exhibits symptoms, staff will recommend they consult with their primary care provider and then leave the home. Informed consent will be obtained outside the home without entering. Staff will wear appropriate PPE as directed by OSSAM for entering participant homes. The number of staff entering the home and duration spent inside will be minimized. All equipment preparation and disassembly will be conducted prior to entry or after leaving the home. After leaving the home staff will discard all disposable PPE (respirator, gloves, and gown) and engage in proper hand hygiene. Staff will use alcohol based hand sanitizer immediately and wash hands with soap and water as soon as convenient after leaving the home.

Travel

During travel, staff will be directed to the considerations for travel in the United States. Staff will also be provided with the guidance below.

Protect yourself and others during your trip:

• Clean your hands often.

  • Wash your hands often with soap and water for at least 20 seconds especially after you have been in a public place, or after blowing your nose, coughing, or sneezing.

  • If soap and water are not readily available, use a hand sanitizer that contains at least 60% alcohol. Cover all surfaces of your hands and rub your hands together until they feel dry.

• Avoid touching your eyes, nose, and mouth with unwashed hands.

• Avoid close contact with others.

  • Keep at least 6 feet of social distance from others.

  • Avoiding close contact is especially important if you are at higher risk of getting very sick from COVID-19.

• Wear a cloth face covering in public to protect others.

• Cover coughs and sneezes.

• Considerations for visiting a restaurant while traveling.

When staying in a hotel:

• Take the same steps you would in other public places—for example, avoid close contact with others, wash your hands often, and wear a cloth face covering.

• When you get to your room, clean and disinfect all high-touch surfaces. This includes tables, doorknobs, light switches, countertops, handles, desks, phones, remote controls, toilets, and sink faucets.

  • Bring an EPA-registered disinfectant and other personal cleaning supplies, including cloths and disposable gloves.

• Considerations for visiting a restaurant while traveling.

Screening of Personnel

All personnel (CDC/ATSDR staff and contractors) will be screened for symptoms prior to travel and twice daily while in the field. CDC/ATSDR staff will be enrolled in CDC’s Text Illness Monitoring (TIM) and contractors will report any symptoms to their management daily. Screening will include a temperature check as well as questions about the presence of any signs or symptoms associated with COVID-19. Questions on symptoms will include presence of any of the following:

• Fever or chills

• Cough

• Shortness of breath

• Fatigue

• Muscle or body aches

• Headache

• New loss of taste or smell

• Sore throat

• Congestion or runny nose

• Nausea or vomiting

• Diarrhea

If any employee develops symptoms they will be instructed not to come to work, to inform the site lead, and to contact the Occupational Health Clinic (OHC) 404-639-3385 and the ATSDR site lead. (Contractor staff should inform their supervisor). Site-specific health and safety plans will be developed to include instructions for seeking medical care should any staff develop symptoms while working in the field. If a staff member develops symptoms consistent with COVID-19, we will pause all activities. If the staff member subsequently tests negative, we will consult with CDC and local/state public health before resuming activities. If the staff member tests positive we will notify all staff and participants who have been in contact with the positive individual and consult with OSSAM and local/state public health to determine additional actions.

CDC/ATSDR employees will continue to self-report symptoms in TIM for 14 days after returning from the field and will follow instructions from the OHC should any symptoms develop.

Protective Measures

Specific EA activities are shown in the table below with recommended PPE, and additional precautions. All PPE for CDC/ATSDR staff will be provided by CDC/ATSDR. Contractor will provide PPE originally required for EAs, CDC/ATSDR will provide additional PPE as needed from the table below.

Activity	Description	PPE	Additional Precautions
Travel	Time spent in ride share/public transportation, in airport, on airplane, time spent in public venues while traveling	None	Frequent handwashing Cloth face coverings General travel precautions Ride sharing and public transportation
Small Group Question and Answer Session	Small group conversations (2 ATSDR staff and maximum of 7 community members) in an indoor setting	None	Symptom screening prior to allowing entry to facility Providing access to soap, water, and proper hand hygiene facilities Hand sanitizer station at the door Cloth face coverings Providing disposable surgical masks for community members if they do not have their own cloth face covering Layout room to promote social distancing (at least 6 feet of space between chairs, visual cues for social distancing) Restrict occupancy to maximum of 9 people (including staff) at a time Cleaning and disinfection of surfaces between groups
Door to door recruitment	Knocking on doors in the community, having conversations outside, distributing printed materials	Disposable surgical mask, disposable gloves	Frequent handwashing Maintain at least six foot distance from community members No entry of homes (already part of door to door protocol)
Biological sample collection screener	Greet participants outside the sample collection venue, take temperature, ask symptom screening questions	Disposable surgical mask, disposable gloves	Confirm participants are symptom and fever free before allowing entry to sample collection venue Ensure occupancy limit allows entry
Biological sample collection paperwork	Check in participants, perform verbal informed consent, schedule telephone questionnaire, check out	Disposable surgical mask, disposable gloves	Frequent handwashing Layout of room to promote social distancing Cleaning and disinfection of surfaces between participants/groups Physical barriers between participants and staff Transition questionnaire administration to telephone format
Urine sample processing	Take urine samples from participants, process samples and place in storage	Disposable surgical mask, disposable gloves (already included in protocol)	Frequent handwashing Cleaning and disinfection of surfaces between participants/groups Physical barriers between participants and staff
Blood sample collection	Collect blood sample in one red top tube (approximately 6 mL)	Phlebotomists: Disposable surgical mask, disposable gloves (already included in protocol), disposable gown (already included in protocol), face shield or goggles	Frequent handwashing Cleaning and disinfection of surfaces between participants Blood and plasma collection precautions
Blood sample processing	Moving collected blood samples to processing area, centrifuging of blood samples, aliquoting of serum into cryovials, packaging of serum for shipment	Disposable surgical mask, disposable gloves (already included in protocol)	Frequent handwashing Cleaning and disinfection of surfaces between participants
Environmental sample collection	Entering participant homes, collection of water sample from household tap, collection of dust samples from floors, verbal consent (outside)	N95 mask (to enter home), surgical mask for staff that remain outside, disposable gloves (already included in protocol), coveralls	Minimize staff entering home to only necessary personnel Confirmation that no members of the household have symptoms prior to entering Hand washing after each home Disinfection of sample collection materials after each home

Site Specific Scheduling Considerations:

Alaska – There is an order requiring travelers entering Alaska to have a negative COVID-19 test within 72 hours of boarding a plane for Alaska. If paperwork is not in order, travelers can be tested on arrival or be subjected to a 14-day self-isolation. If this requirement remains in effect, all staff will be tested for COVID-19 prior to traveling to Alaska.

There is also an order requiring that any business conducting operations in Alaska file a written plan outlining steps that will be taken to ensure that the communities where work is taking place are protected. Businesses are currently reopening state-wide. There have been local concerns that migrant workers may increase the spread of COVID-19 in the coming months. We will continue to monitor the situation and consult with local partners to identify requirements for restarting field work in Alaska.

Colorado – Colorado is currently reopening with no expected impediments to scheduling or conducting field work. We are having conversations with state and local health officials to determine any impediments to field work.

New York – New York started a 4 Phase reopening by region on May 15. Orange County is in the Mid-Hudson Region. This region entered Phase 1 of the reopening on May 26. This phase will last a minimum of two weeks and will be followed by Phase 2, Phase 3, and finally Phase 4 (fully reopened) for a minimum of two weeks in each phase. The Mid-Hudson Region entered Phase 2 of reopening on June 9.

Campus Access Considerations for NCEH/ATSDR Leadership

1. We need a few staff (including contractor staff) to have access to Chamblee Building 102 in order to pack and ship urine collection kits. All materials for these kits are stored in the call center and staff will need to be physically present on campus to get these sent out to participants. Staff will also need to access campus to store and access PPE. Staff will maintain at least 6 feet distance from each another during packing and shipping of urine collection kits. Staff will wear cloth face coverings when in CDC/ATSDR buildings and will have access to facilities for proper hand hygiene.

2. Biorepository and NCEH laboratory staff will need to provide on-campus services for shipping and receiving of samples and supplies as well as sample analysis. We have confirmation that shipping and receiving can begin now and that sample analysis will restart when staff resources permit.

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