HHS: Hospitals should stockpile antivirals for HCWs

Fed stockpile is for containment, treatment

In its Guidance on Antiviral Drug Use During an Influenza Pandemic, the U.S. Department of Health and Human Services places the responsibility for stockpiling for worker protection on employers. This is an excerpt that specifically addresses health care employers:

• Prophylaxis of critical healthcare workers and emergency service providers

Maintaining effective healthcare and emergency response services (includes Emergency Medical Services, fire, and law enforcement personnel) will be essential in preventing adverse health outcomes and protecting public safety in a pandemic. The healthcare sector will face a massively increased burden while coping with a work force diminished by illness and possibly other causes of absenteeism — for example, caring for an ill family member or due to fear of becoming infected in the workplace. In a survey of public health personnel in three Maryland county health departments, only 54% of respondents indicated that they would likely report to work during a pandemic.

In a multivariable analysis, one factor significantly associated with the likelihood of reporting was confidence in one's personal safety. Respondents were not directly asked about antiviral drug treatment or prophylaxis and responses to a hypothetical scenario must be interpreted with caution. Limited information from the 1918 pandemic and experience in Toronto, Canada, during the recent SARS outbreak suggest much lower rates of absenteeism among healthcare workers. Nevertheless, the Maryland findings raise the possibility that absenteeism could be substantial, and that antiviral prophylaxis may reduce absenteeism both by preventing illness and by improving perceptions of safety in the workplace.

Several potential strategies for prophylaxis in healthcare and emergency service settings could be considered. Because exposure to ill persons during a pandemic outbreak will be frequent for healthcare workers and emergency service personnel with direct patient contact, post-exposure prophylaxis would be essentially equivalent to outbreak prophylaxis — as soon as one 10-day course of PEP ended, another would likely begin.

A modification of the PEP strategy may be to dispense PEP only when "unprotected" exposure occurred. Potential concerns with this approach for those with frequent high-risk exposures include whether it would be sufficient to reduce absenteeism that may occur due to fear of occupational infection, whether unprotected exposures could be accurately identified and how frequently they would occur in a heavily exposed population. In addition, there is a lack of data on the effectiveness of personal protective equipment measures in preventing influenza transmission.

A hybrid strategy that includes outbreak prophylaxis for workers with frequent high-risk exposures and post-exposure prophylaxis when unprotected exposure occurs for those who have less frequent or intensive patient contact tailors the intervention to the level of risk and is the preference of the working group. Although data on the effectiveness of outbreak prophylaxis are limited, two studies of zanamivir report protective efficacies in adolescents, healthy and high-risk adults in the same range as seen for post-exposure prophylaxis.

Estimating the number of antiviral drug regimens needed to support prophylaxis for healthcare and emergency service workers using this strategy requires defining populations of workers with more frequent higher-risk exposures and those at lower risk. Of the approximate 13 million workers in the healthcare sector as defined by the Bureau of Labor Statistics, we estimate that two-thirds of healthcare workers, or about 8.7 million including those in hospital-based, outpatient, home health and long-term care positions may have frequent high-risk exposures along with 2 million persons in emergency services sectors, encompassing Emergency Medical Services, fire service and law enforcement personnel.

The remaining 4.3 million healthcare sector workers would receive post-exposure prophylaxis when unprotected exposure occurs, estimated as four times during a 12-week community outbreak. Based on these estimates, a total of 102.8 million antiviral regimens would be needed. Additional work to define specific groups at higher and lower risk and their respective numbers is needed.

The health benefits of this prophylactic strategy cannot be easily quantified. Several studies suggest that healthcare workers who have patient exposure have increased rates of seasonal influenza infections. In addition to the direct effect of reducing pandemic influenza illness and its consequences, prophylaxis also would reduce the risk of transmission to family members, co-workers, and to patients. Influenza prevention by vaccination of healthcare workers has been shown to reduce nosocomial infection in acute care hospitals and mortality in long-term care facilities for the elderly. An additional impact would be to reduce absenteeism among workers in these critical sectors, improving the quality of healthcare and public safety. Many studies have shown improved health outcomes with a greater staff-to-patient ratio. During an influenza pandemic when healthcare burden is markedly increased, this effect may be even greater.

(Editor's note: For the complete document, go to: www.pandemicflu.gov/vaccine/antiviral_use.html.)