Benefits of Paid Sick Leave During the COVID - 19 Pandemic

Multiple jurisdictions have adopted or adapted paid sick leave policies to reduce the likelihood of employees infected with SARS-CoV-2 presenting to work, which can lead to the spread of infection in workplaces. During the COVID-19 pandemic, paid sick leave has been associated with an increased likelihood of workers staying at home when symptomatic. Paid sick leave can support essential workers in following public health measures. This includes paid time off for essential workers when they are sick, have been exposed, need to self-isolate, need time off to get tested, when it is their turn to get vaccinated, and when their workplace closes due to an outbreak. In the United States, the introduction of a temporary paid sick leave, resulted in an estimated 50% reduction in the number of COVID-19 cases per state per day. The existing Canada Recovery Sickness Benefit (CRSB) cannot financially protect essential workers in following all public health measures, places the administrative burden of applying for the benefit on essential workers, and neither provides sufficient, nor timely payments. Table 1 lists the characteristics of a model paid sick leave program as compared with the CRSB. Implementation of the model program should be done in a way that is easy to navigate and quick for employers.

During the COVID-19 pandemic, paid sick leave has been associated with an increased likelihood of workers staying at home when symptomatic. Paid sick leave can support essential workers in following public health measures. This includes paid time off for essential workers when they are sick, have been exposed, need to self-isolate, need time off to get tested, when it is their turn to get vaccinated, and when their workplace closes due to an outbreak, with guaranteed salary payment regardless of duration of absence (minimum 2 hours, maximum 2 workweeks).
In the United States, the introduction of a temporary paid sick leave, was associated with an estimated 50% reduction in the number of COVID-19 cases per state per day.
The existing Canada Recovery Sickness Benefit (CRSB) cannot financially protect essential workers in following all public health measures, places the administrative burden of applying for the benefit on essential workers, and neither provides sufficient, nor timely payments. Table 1 lists the characteristics of a model paid sick leave program as compared with the CRSB. Implementation of the model program should be done in a way that is easy to navigate and quick for employers.

Summary
Background COVID-19 in the workplace causes a substantial burden of illness among essential workers and their families, and is a significant contributor to community transmission driving the third wave in Ontario. Workplace outbreaks result in economic loss and disruption of essential services. Public health measures such as workplace screening and testing, isolation of people with SARS-CoV-2 infection and their contacts can reduce transmission, and prevent workplace outbreaks. 1 Many essential workers lack paid sick leave that would support them in following these public health measures.

Questions
What has been the impact of COVID-19 on essential workers and Ontario workplaces?
What paid sick leave policies have been implemented nationally and internationally to support essential workers in following public health measures during the COVID-19 pandemic?
What is the evidence for the effectiveness of paid sick leave in supporting essential workers in following public health measures, preventing SARS-CoV-2 infection among essential workers, and mitigating COVID-19 outbreaks in essential workplaces?
What evidence can be extrapolated from the impact of paid sick leave in mitigating other infectious diseases such as influenza-like illness?
How can paid sick leave support COVID-19 vaccination among essential workers?
What is the economic impact of paid sick leave?
Which ethical principles and considerations should inform public policy on paid sick leave in Ontario?

Findings
Ontario workplaces are significant sites of SARS-CoV-2 transmission, and essential workers have experienced disproportionately higher rates of SARS-CoV-2 infection. National and international jurisdictions have implemented paid sick leave to support essential workers in following public health measures.
Real-world evidence from the COVID-19 pandemic and from influenza-like illnesses indicates that paid sick leave can support workers in following public health measures, reduce viral transmission and workplace outbreaks, promote higher vaccination rates among essential workers, increase work productivity, and reduce worker absenteeism. Paid sick leave also protects the larger public from harm by containing the spread of infectious diseases and optimizing economic stability. Paid sick leave is also supported by public health ethics principles.
In the United States, the introduction of a temporary paid sick leave, the Families First Coronavirus Response Act (FFCRA), was associate with an estimated 50% reduction in the number of COVID-19 cases per state per day.

Interpretation
During the COVID-19 pandemic, paid sick leave can support essential workers in following public health measures. This includes paid time off for essential workers not necessarily reflect the views of all of the members of the Ontario COVID-19 Science Advisory Table, its Working Groups, and its partners.
when they are sick, have been exposed, need to self-isolate, need time off to get tested or vaccinated, and when their workplace closes due to an outbreak, with guaranteed salary payment regardless of duration of absence (minimum 2 hours, maximum 2 workweeks). Paid sick leave will reduce overall cases, protect communities from the burden of COVID-19, and keep businesses open.

Background
Workplace spread of SARS-CoV-2, the virus responsible for COVID-19, causes a substantial burden of illness among essential workers and their families, and is a significant contributor to community transmission driving the third wave in Ontario. Workplace outbreaks result in economic loss, and disruption of essential services. Public health measures such as workplace screening and testing, isolation of people with SARS-CoV-2 infection, and quarantine of their contacts, can reduce SARS-CoV-2 transmission, and prevent workplace outbreaks. 1,2 Cumulatively, these measures contribute toward reduced cases of SARS-CoV-2 infection, COVID-19 hospitalizations, and COVID-19 deaths among both workers and their household and community contacts.
While many members of the Ontario workforce are able to work from home or have access to paid sick leave while ill or self-isolating, this is far from universal. In Ontario, 60% of workers do not have paid sick leave apart from the federal CRSB program. 3 Essential workers cannot work from home, and they most commonly work in trades, transport, equipment, manufacturing, utilities, sales, services, agriculture sectors, and health care. [4][5][6] An estimated 42% of Ontario's workforce is employed in occupations that could be conducted remotely. 7 Moreover, essential workers are disproportionately represented in jobs that do not include sick leave benefits. 8 In Canada most people without paid sick leave earn less than $50,000 in annual income, and more than 60% of seasonal, casual, or contract workers have no paid sick leave at all. 8,9 In Ontario, the highest proportion of SARS-CoV-2 infections are in neighbourhoods with the highest proportion of essential workers. 10,11 Financial support that enables Ontario workers to follow public health measures can limit SARS-CoV-2 transmission, reduce COVID-19 illness, and minimize economic loss. 8,9 The intersection between the absence of paid sick leave and lower or inconsistent levels of income creates a situation where essential workers face a tension between meeting basic needs (e.g., food and rent), and following public health measures (e.g., self-isolation, quarantine, testing, and vaccination).

Questions
What has been the impact of COVID-19 on essential workers and Ontario workplaces?
What paid sick leave policies have been implemented nationally and internationally to support essential workers in following public health measures during the COVID-19 pandemic?
What is the evidence for the effectiveness of paid sick leave in supporting essential workers in following public health measures, preventing SARS-CoV-2 infection among essential workers, and mitigating COVID-19 outbreaks in essential workplaces?
What evidence can be extrapolated from the impact of paid sick leave in mitigating other infectious diseases such as influenza-like illness?
How can paid sick leave support COVID-19 vaccination among essential workers?
What is the economic impact of paid sick leave?
Which ethical principles and considerations should inform public policy on paid sick leave in Ontario?

Impact of COVID-19 on Essential Workers and in Ontario Workplaces
While information about workplace transmission in Ontario remains incomplete, data from regions with high concentrations of essential workplaces, such as manufacturing facilities and warehouses, highlight workplaces as a significant sites for SARS-CoV-2 transmission. 12,13 In Ontario's Peel Region, 66% of community outbreaks from September to December 2020 occurred in workplaces. 14 Occupational exposure was the most common likely source of infection that resulted in secondary household transmission in August 2020 in the Peel Region. Between August and December 2020, 1,993 out of 7,874 surveyed workers (25%) in Peel reported attending a workplace outside of their home for one or more days following symptom onset, 80 of whom continued to work after the date that their positive SARS-CoV-2 result was reported to public health. 14 Many workplaces experiencing outbreaks use temporary workers who tend to have fewer worker income supports than permanent employees, and work in multiple settings. 14

Overview of Paid Sick Leave Policies in Canada and Internationally
The CRSB provides $450 after taxes per week for up to four weeks for workers who miss at least 50% of their work week because they are unwell or isolating from  This allocation is $100 lower per week than a full time (37.25 hour) weekly salary at Ontario minimum wage ($14.25 hourly). 16 Payments are not timely as it can take up to 4 weeks for workers to receive funds (see Table 1 above). 17 There are additional concerns that the CRSB cannot financially support workers in following public health measures. Because the CRSB does not cover shorter absences, it excludes worker time off to get tested or vaccinated, or those workers who stay home due to symptoms or exposure, subsequently test negative for SARS-CoV-2 infection, and are then cleared for return to work within 50% of their work week.
Since CRSB is limited to a 1-week period, is not renewable, and can only be used four times per year, it may not be enough for workers in high SARS-CoV-2 exposure occupations. The CRSB application places the administrative burden of applying for the benefit on essential workers, and requires computer access, internet literacy and an understanding of English or French. Taken together, these limitations and barriers of the CRSB may hinder adequate protection of essential workers and effective mitigation of workplace outbreaks during the COVID-19 pandemic.
A number of provinces and territories introduced unpaid sick leave of varying durations in response to the COVID-19 pandemic. 18 Only Yukon provides a paid sick leave benefit for workers who become sick, or who must quarantine or isolate, which guarantees 10 days of wages per employee. Employers can only access the program once per employee. 19 During the COVID-19 pandemic, paid sick leave has been implemented in several jurisdictions internationally to support essential workers in following public health measures. 20 In response to the COVID-19 pandemic, 16 of 38 Organization for Economic Cooperation and Development (OECD) countries temporarily expanded or initiated paid sick leave policies. 20 For example, countries like France and Ireland waived waiting periods for sick pay and benefits. Australia and Spain introduced additional dedicated sick benefits for workers with COVID-19 who exhausted accrued employer-provided sick-pay entitlements. The United States introduced the FFCRA, a temporary measure for employers to provide paid sick leave for reasons related to COVID-19. 21

Evidence for the Effectiveness of Paid Sick Leave
Reduction in mobility is a proxy for measuring the time individuals stay at home, and is associated with reductions in SARS-CoV-2 transmission and COVID-19 cases. 22 A study using GPS data from cellular devices found that the introduction of the FFCRA in the United States increased the average number of hours at home by 4.2%. 23 Figure 1 shows the estimated daily number of COVID-19 cases per state in states that introduced the FFCRA, relative to comparator states. After adjustment for a variety of factors, the introduction of FFCRA was associated with an approximately 50% decrease in confirmed COVID-19 cases per state per day. 24 This is equivalent to about 1 prevented case per day per 1,300 workers. Survey data from the United Kingdom found that non-adherence to public health guidelines for patients with COVID-19 was associated with factors including dependent children in the household, lower socioeconomic status, and being an essential worker. 25 Financial support, and wrap around services, are in particular associated with improved ability to self-isolate. 25,26 Figure 2 shows risk factors for influenza-like illness among a nationally representative sample of 2,042 adults from the United States during the H1N1 influenza pandemic in 2009. 27 Inability to work from home and absence of paid sick leave were associated with an approximately 50% increase in the risk of influenza-like illness. Kumar et al. 27 There are many studies demonstrating that paid sick leave policies at the state and municipal levels are associated with reduced transmission and outbreak prevention for respiratory infections. For example, influenza surveillance data in the United States shows that access to paid sick leave led to a decline of 290 influenza-like illnesses per 100,000 individuals per week. 28 An OECD report notes that that paid sick leave reduced influenza-like illness rates by 10% and total work absence by 18% in some American cities. 29

Paid Sick Leave and COVID-19 Vaccination
Evidence from the United States indicates that paid sick leave is associated with increased influenza vaccination rates among workers, since they are guaranteed to receive paid time off to get immunized. 30,31 A survey of 8,634 health care workers reported that they were much more likely to get vaccinated if direct financial support like paid sick leave were available. 32 As part of the Centers for Disease Control and Prevention (CDC) best practices for workplace COVID-19 vaccination, it is suggested that employers allow workers to take paid leave to get vaccinated and financially support transportation to off-site vaccination clinics. They further suggest that employers provide flexible leave policies for those who may have post-vaccination symptoms. 33 Recently, Saskatchewan and British Columbia mandated employers to provide paid time off for vaccination. 34,35

Economic Impact of Paid Sick Leave
Data from the COVID-19 pandemic and other epidemics demonstrate that paid sick leave is an important strategy for public health containment as well as for economic stability and recovery. 20,36,37 Paid sick leave can increase productivity, and reduces absenteeism by preventing outbreaks and the chance of workplace closures. Job losses and working hour reductions during the COVID-19 pandemic have been larger in American states without a paid sick leave system. 38 Small businesses that provide paid sick leave for their employees require compensation to ensure economic viability. Many OECD countries have lowered the costs for employers through government subsidization. 20 In the United States, California has recently extended eligibility criteria for paid sick leave to include being in quarantine, caring for a family member in quarantine, experiencing symptoms of COVID-19 and seeking a medical diagnosis, or missing work to receive the COVID-19 vaccine. 39

Ethical Principles Supporting Paid Sick Leave in Ontario
Paid sick leave as a critical public health measure is supported by public health ethics principles as summarized in Table 2. 40,41 It demonstrates efficiency by reducing worker absenteeism overall, and protects the public from harm by containing the spread of infectious diseases and optimizing economic stability and recovery. Moreover, it provides mutual support by reducing the burden on those disproportionately affected by their type of work and overall compensation; it is a fair, reasonable, and proportional response to the health and economic threats of the pandemic; and minimizes damage to collateral groups by isolating infectious and potentially infectious workers from others who are susceptible. Finally paid sick leave builds a common purpose in society when viewed as supporting critical public health measures, and building public trust in decision-makers.

Protection of the public from harm
A foundational principle of public health ethics is the governmental obligation to protect the public from harm. In a pandemic, this includes effective public health measures to contain the spread of infectious diseases and to reduce the burden of illness in workplaces. It also includes protecting the public from economic harms related to worker absenteeism, enhancing business continuity, and enabling economic stability and recovery.
The protective effects of paid sick leave will be important as the economy moves into recovery.

Reciprocity
Reciprocity requires that society supports those who face a disproportionate burden when protecting the public good. During the COVID-19 pandemic, individuals who must self-isolate, and their families, may experience significant social, economic, and emotional burdens.
Provincially mandated sick leave that is immediately accessible and eliminates or greatly reduces the financial burdens of compliance with public health measures meets the duty of reciprocity for essential workers.
Small businesses that provide sick pay for their employees should also be appropriately supported if the costs of doing so put their business in jeopardy.

Equity
Equity requires that measures be taken to redress health and other social inequities that are unfair and exacerbated by public health measures like quarantine and isolation.
Many essential workers are from disadvantaged groups who have fewer resources with which to protect themselves and their families and are therefore unfairly and disproportionately burdened by the impacts of COVID-19.
Policymakers are urged to consider the health risks not only to workers but also to those with whom they live.
Supporting workers to quarantine and isolate by providing paid sick leave also reduces harm for co-workers by reducing their exposure to COVID-19 and by respecting their right to a healthy workplace.

Proportionality
Proportionality requires that measures taken to mitigate the pandemic should correspond to the actual level of risk, or critical needs of the community.
As a public health measure, paid sick leave is a proportionate response to both health and economic threats posed by COVID-19 and will play an important role in maintaining safety, productivity, and business continuity as the relaxation of public health measures begins.

Interpretation
Observational real-world evidence suggests that paid sick leave is associated with a reduction in SARS-CoV-2 transmission and COVID-19 illness among essential workers, and an improvement in productivity. This has been found both during the COVID-19 pandemic and in observational studies reporting of paid sick leave for influenza-like illness, including increased influenza vaccination rates. No randomized trials are available to inform public health decisions about the implementation of this or any other public health measure used throughout the COVID-19 pandemic.
Most Ontario COVID-19 workplace outbreaks outside of long-term care homes have occurred in the manufacturing sector, as well as forestry, agriculture, fishing/ hunting, transportation and warehousing. 43,44 These services are essential to the functioning of society and to the Ontario economy. Workers in these sectors are paid relatively low wages and are often members of disadvantaged communities. 8 Further, these workers may live with other people who work in essential services, putting more individuals and workplaces at risk. 45 Paid sick leave preserves the jobs of workers who cannot work from home and prevents harms related to loss of income while following public health measures. In Ontario it is estimated that this accounts for 3 million essential workers. 46 Paid sick leave also increases job security and improves population health overall. 47 The absence of paid sick leave is often characteristic of insecure work, which is correlated with poorer overall health and worse occupational health and safety outcomes, and which contributes to health inequities in Ontario and disproportionate burdens from COVID-19 being born by essential workers. 48,49 The existing federal CRSB cannot financially protect essential workers in following all public health measures, places the administrative burden of applying for the benefit on essential workers, and neither provides sufficient, nor timely payments. Table 1 above lists the characteristics of a model paid sick leave program as compared with

Systemic resilience
Government has a moral imperative to prevent population level health harms. Anticipating public health threats and preparing for them is an ethical requirement for good public health governance. Paid sick leave will need to be considered with stepwise relaxation of public health measures, into the post-COVID-19 period. Preparing for future pandemics requires improving the adaptability of paid sick leave to the economic and health challenges posed by pandemics.

Solidarity
Paid sick leave reflects a sense of common purpose in society when viewed as an important public health measure. It also can help build public trust, which is essential for public health compliance.
To foster solidarity, we must protect the income and jobs of society's most economically and biologically vulnerable. Paid sick leave provides reassurance to workers that their wellbeing and dignity are being respected but it also represents what we would all want if we were in the same position.
Stopping COVID-19 requires a collective effort. Providing paid sick leave is a critical example of a public health measure that builds a sense of common purpose between workers, between workers and employers, between businesses and the public and between the public and government.
When public trust is increased through compensatory mechanisms, such as paid sick leave, it is beneficial for other aspects of outbreak response such as vaccine uptake. the CRSB. Figure 3 presents a proposed process for an essential worker and their employer accessing the model paid sick leave program. Implementation of the model program should be done in a way that is easy to navigate and quick for employers. Ontario's essential workers require paid sick leave that offers more money, is easily accessible, is immediately paid, and supports them in following all public health measures. This includes providing essential workers with paid leave when they are sick, have been exposed, need to self-isolate, need time off to get tested or vaccinated, and when their workplace closes due to an outbreak, with guaranteed salary payment regardless of duration of absence (minimum 2 hours, maximum 2 workweeks). 50 Reducing SARS-CoV-2 transmission is a collective effort across all sectors of society. Enabling employers to provide paid sick leave to employees during the pandemic ensures workplace safety, and protection of the public. Moreover, it is a measure that fosters a sense of common purpose among workers, employers, the public and government, and builds public trust which is essential for COVID-19 vaccine uptake. 51 Paid sick leave is an essential public health measure that, if applied in Ontario, will both help control the third wave of the COVID-19 pandemic and prevent the emergence of further workplace and community outbreaks prior to the vaccination of every willing Ontarian.

Methods Used in This Science Brief
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