By Brystana Kaufman, Jeremy Yi, Sophie Hurewitz and Marta Wosinska
Early in the COVID-19 epidemic , urban centers like New York city led the nation in COVID-19 burden. Yet, even before shelter-in-place orders were expiring, many of the places with the most cases per capita  were small cities and rural communities in the Midwest and South. By mid-May, counties with or near meat packing plants had almost twice the rate  of known COVID-19 infections as the national average. Without appropriate safety precautions, workplaces such as meat processing plants may have harbored the virus as work continued during the lock downs and presented opportunities to seed new infections when states reopened. To facilitate the eventual return to normal, we must address the essential worker issue, particularly among high risk essential work places such as meat processing plants.
Plant outbreaks increase COVID-19 burden in North Carolina
Meat processing plants have spawned outbreaks  in North Carolina, Iowa, Nebraska, Wisconsin and South Dakota. North Carolina is one of the largest pork and poultry producing states . In April and May, large outbreaks were reported at the Tyson Foods poultry plant in Wilkes County, the Butterball turkey plant in Duplin County, and the Smithfield pork plant in Bladen County. By mid-May North Carolina had the highest number of meatpacking plant outbreaks  and the highest number of complaints  in the nation. As of late June, a spokesperson for the N.C. Department of Health and Human Services reported that at least 2,772 meatpacking workers tested positive  at 28 different meatpacking plants. Even with rising rates of positive cases, the N.C. Department of Health and Human Services has decided not to publish outbreaks by facility  and no citations  have been issued by the NC Department of Labor.
Challenges to the public health response
Meat packing is already  one of the most dangerous industries in the United States, and workers now face a high risk for exposure to COVID-19 due to long periods of time in close contact with other workers. In addition to the natural epidemiology of transmission, systemic and socioeconomic factors contribute to COVID-19 burden. Employer policies that are standard in the meat processing industry, such as a lack of paid sick leave , encourage employees to stay at work even if sick, therefore supporting COVID-19 spread.
Stopping the train of transmission starts with testing , but also requires isolating infected people, identifying their contacts, and quarantining those who were exposed. Test reporting and contact tracing may be inhibited by health privacy regulations and immigrant status . In North Carolina , local officials lacked the information needed to follow up with infected workers and trace contacts. The number of departments playing a role in the coronavirus response contributed to a lack of clarity over which agency had the authority to order meat packing plants to make changes or shut down.
Occupational Safety and Health Administration (OSHA) enforced  CDC guidelines for the H1N1 influenza in 2009 ; however, during the COVID-19 epidemic OSHA has been left out  of the White House Coronavirus Task Force and the agency rolled back safety standards  and restrictions  for the meat processing industry. Until recently, OSHA has focused its on-site inspections on nursing homes and biomedical laboratories due to limited capacity. Following months of worker complaints, Pennsylvania meat packing workers filed a lawsuit  against OSHA for not enforcing provision of protective gear or social distancing policies in the factory. State and local efforts to enforce standards were limited  by an April executive order  declaring meat packing plants critical infrastructure.
Additionally, Congress expanded Employee Paid Leave Rights through the Families First Coronavirus Response Act  (FFCRA) to reduce pressures on employees to work while sick. The FFCRA Act requires two weeks paid leave for specified reasons related to COVID-19, including self-quarantine or caring for a sick person, or children unable to attend school; however, the Act does not apply to most meat packing workers because most  meat processing companies exceed the 500 employee threshold. The North Carolina legislature considered including local enforcement of worker safety and two weeks of pay for infected workers in their COVID-19 economic relief bill , which included $10 million for meat processing plants; however, these measures failed to pass.
Recommendations for protecting essential workers
Although problems pervade worker protections policies across all industries, the disproportionate impact in the meat processing industry and other employers of vulnerable groups requires immediate action. Clear regulations and processes for testing and tracing is needed in order to protect the health and safety of at-risk employees. Finally, we must limit the economic incentives that encourage essential workers to continue working when they are sick that counteract public health efforts to trace and isolate cases.
- Strengthen reporting requirements and data sharing infrastructure to support contact tracing efforts in coordination with public health departments. The lack of coordination and transparency of testing information has contributed to the inability to contain plant outbreaks. Public health officials and meat packing employers need to work together on improving containment. Meat packing industry is required to report occupational injuries, and this reporting system may be leveraged to improve contact tracing and identify clusters of infection that require further intervention.
- Implement Emergency Temporary Standards to address worker safety issues related to the COVID-19 pandemic, and expand OSHA capacity for inspections. While federal legislation  to direct OSHA to issue an Emergency Temporary Standard  (ETS) has stalled in the Senate, states like Virginia  are enacting their own ETS regulations to strengthen worker protections. Increased funding could facilitate the increase in OSHA inspection capacity. The federal COVID-19 task force should consider OSHA’s role in a coordinated plan for supporting employers, specifically meat processing industries, in maintaining a safe workplace.
- Expand FFCRA benefits to cover companies with more than 500 employees. Under the current law, large employers are not required to provide sick leave, and the benefits are set to expire in December 2020. The House coronavirus stimulus bill (H.R. 6800 ) would have expanded FFCRA requirements to include all employers through 2021. The Senate responded with a bundle of bills called the HEALS Act , and the current version further limits rather than expands the sick leave benefits and worker protections. A feasible solution for the proposed legislation may include a time-limited benefit for paid leave when the employee is under COVID-19 quarantine or isolation.
When essential workers are not protected, the whole community is at risk. By improving protections and support for essential workers, we can mitigate community spread and support state’s efforts to reopen non-essential businesses. If the current policies persist, meat packing plants and other high-risk industries will continue to seed outbreaks, increase community spread, and potentially lead to renewed shelter-in-place and closure orders.
Brystana Kaufman, PhD, MSPH is an Assistant Professor in Population Health Sciences at Duke University and Core Faculty at the Duke-Margolis Center for Health Policy. She is also an investigator with the Durham VA Center of Innovation to ADAPT.
Jeremy Yi is a student at Duke University majoring in Economics alongside a minor in Computer Science & Global Health. He is also a participant in the interdisciplinary Bass Connections program at the Margolis Center for Health Policy.
Sophie Hurewitz is a student at Duke University majoring in Neuroscience alongside a minor in Global Health and a certificate in Child Policy Research. She is also an Alice M. Baldwin Scholar and participant in the interdisciplinary Bass Connections program at the Margolis Center for Health Policy.
Marta Wosinska, PhD, is a Consulting Professor and Deputy Director at the Duke-Margolis Center for Health Policy and at Duke University. Before joining Duke-Margolis, she spent 11 years in the federal government in roles intersecting economics and policy.