OHNs have unique role in preparing worksite, employees for flu pandemic

Whether avian flu goes pandemic or not, preparing is time well spent

It may not be this year, and it may not be avian flu, or the H5N1 strain. But health experts agree that an influenza pandemic is inevitable, and occupational health professionals are looking closely at what they can do to prepare their employers and work forces for the impact.

Pandemics — global epidemics — most often occur when diseases that typically affect only animals mutate and are transmitted to humans, and then mutate again so that they are passed from human to human. As of early May, there have been documented cases of bird-to-human transmission of the avian influenza strain, but no human-to-human transmissions.

As of May 8, the CDC was reporting 63 cases of human illness from H5N1 worldwide in 2006, resulting in 39 deaths — better than 61% mortality. Since 2003, there have been 207 documented cases in humans, with 115 deaths. All documented cases were contracted by bird-to-human transmission, and were primarily reported in Asia and Eastern Europe.

"The thing is that nobody knows if it will mutate to human-to-human transmission, or when it might, and what the mortality would be if it does," points out Jim Reynolds, MD, of Mercer Human Resource Consulting's Denver offices. "Currently, with bird-to-human transmission, there is a reported 40% mortality rate, but we don't know what it might be if it mutates to human-to-human transmission."

Health experts around the world, however, have speculated about some of the most likely effects should H5N1 influenza create a pandemic:

  • potentially high death rate;
  • heavy demand on communities' entire resources to prevent spread and manage infections;
  • health services possibly overwhelmed;
  • absentee rates exceeding 40% from illness and fear of exposure put business continuity at risk worldwide.

That said, experts are still quick to point out that an influenza pandemic could be far less severe than the worst-case scenarios. The epidemic of 1918, which killed 40 million people worldwide, is often referred to as the benchmark for predicting bad pandemics; but the pandemics of 1957 and 1968 were far less severe — so much so that many people did not realize pandemics were underway.

Bush: Plan to keep America running

The Bush administration's Implementation Plan for the National Strategy for Pandemic Influenza was released in early May by the Homeland Security Council and calls on all employers, both public and private, to take steps now to protect continuity of operations and employees in the event of a pandemic.

Unlike other catastrophic events, a flu pandemic will not directly affect organizations' communications or physical infrastructure, but could, in the worst-case scenario, flatten its manpower.

Because 85% of the food production, medicine, and financial services vital to life in the United States are private enterprises, the federal plan emphasizes business buy-in to the federal strategy and serious attention to planning how America will keep going during the peak weeks of a pandemic.

The federal response plan recommends that organizations plan with the assumption that up to 40% of their staff may be absent for up to two weeks at the height of a pandemic wave, with fewer numbers of absentees in the weeks leading up to and following the peak. Absences will, of course, be caused by illness, but also result from employees who must care for ill family members, who might be quarantined, or who might fear coming to work and being exposed to the virus.

"Employers should be making plans for the fact that they'll have high absentee rates, and if there is truly an epidemic, in areas where people use mass transit, there might be shutdowns of mass transit or people avoiding mass transit, so planning from a workflow standpoint is important," says Reynolds, who says occupational health nurses have a unique role in planning for both protection of employee health and continuity of operations.

"Occupational health nurses will deal with potential workplace issues surrounding precautions to prevent infection, screening employees who develop fevers, and possibly being called on to [work in] other health care settings if manpower shortages in health care occur," he explains. "Health care professional will be exposed as much or more than any other group in the United States, so occupational health nurses, like other health care professionals, may find themselves called upon to serve in settings they normally aren't in."

Prevent where possible, cope with the rest

In helping craft prevention plans and coping strategies for their companies, occupational health nurses should keep in mind the effects a global pandemic will have on them locally. Because the movement of goods, services, and personnel would be crippled, to some extent, at the peak of the epidemic, planning for shortages of medical supplies as well as safety equipment is an important component of preparation. Basic medical supplies, personal protective equipment, and other crucial items should be stockpiled.

Each workplace location should have a supply of protective equipment. Reduced person-to-person contact and good hygiene practices should be stressed before outbreaks occur, so they become routine.

If a true pandemic develops, the virus will be brought into workplaces by staff, visitors, or vendors, and a policy should be developed far in advance that educates employees on what symptoms to be alert for and who to notify if they believe they or someone else is at risk. The policy should also address how to isolate sick people to minimize risk of spreading infection, provide them with the medical care they need, and safely transport them to appropriate medical and/or quarantine facilities.

The occupational health nurse would necessarily be closely involved in developing and carrying out such plans, Reynolds says. (See Characteristics of influenza transmission, below.)

The Department of Health and Human Services' pandemic guidelines offer these additional recommendations for employee health precautions in advance of an influenza epidemic:

  • Implement guidelines to modify the frequency and type of face-to-face contact (e.g., hand-shaking, seating in meetings, office layout, shared workstations) among employees and between employees and customers (refer to CDC recommendations, available at www.cdc.gov);
  • Encourage and track annual influenza vaccination for employees;
  • Evaluate employee access to and availability of health care services during a pandemic, and improve services as needed;
  • Evaluate employee access to and availability of mental health and social services during a pandemic, including corporate, community, and faith-based resources, and improve services as needed;
  • Identify employees and key customers with special needs, and incorporate the requirements of those people into the preparedness plan;
  • Develop and disseminate programs and materials covering pandemic fundamentals (e.g., signs and symptoms of influenza, modes of transmission), personal and family protection, and response strategies (e.g., hand hygiene, coughing/sneezing etiquette, contingency plans);
  • Anticipate employee fear and anxiety, rumors, and misinformation, and plan communications accordingly. Ensure that communications are culturally and linguistically appropriate;
  • Disseminate information to employees about the pandemic preparedness and response plan; and
  • Provide information for the at-home care of ill employees and family members.

Companies and organizations are being encouraged by the federal government and their insurers to take steps to cross-train key personnel to help continue operations in the event of a pandemic and widespread absenteeism. The occupational health nurse should examine those plans and provide guidance so that a workforce spread thin by illness does not beget more sick employees. (See tips on minimizing risk, below.)

Effectiveness of barriers uncertain

The problem with planning for a pandemic of a flu strain such as H5N1 is that because that particular strain has not yet — and might never — mutate to a version that will transmit from human to human, it is not possible to know absolutely what barriers and interventions will work best.

Face masks are frequently recommended as personal protection against influenza. However, according to an Institute of Medicine (IOM) investigation, evidence that disposable medical masks and respirators are effective against influenza is limited.

"Even the best respirator or surgical mask will do little to protect a person who uses it incorrectly, and we know relatively little about how effective these devices will be against flu even when they are used correctly," says Donald S. Burke, MD, an epidemiology professor at Johns Hopkins University in Baltimore who co-chaired the IOM committee that investigated the potential for development of a reusable face mask for use during a pandemic.

Masks likely to see widespread use during a pandemic are inexpensive, disposable and intended to prevent the spread of contaminants by the wearer, not to protect the wearer from contaminants in his or her environment. N95 respirators, properly fitted, are certified to protect against 95% of an aerosolized test substance.

But neither N95 respirators nor other forms of masking have been tested for their ability to protect against influenza viruses specifically, the IOM committee reports.

Burke says any method of decontaminating a disposable N95 filtering face piece or medical mask for reuse must remove the viral threat, be harmless to the user, and not compromise the integrity of the various parts of the device. "The committee found no method of decontamination that met all three criteria," he reports.

Woven, washable cloth masks used in some countries — or improvised by the general public — are unlikely to provide the protection a medical mask would, says Burke; he added that because there is insufficient data either supporting or disproving their effectiveness, the IOM committee does not discourage or encourage their use.

"We are concerned that their use may give users a false sense of protection that could encourage risk-taking," he points out.

Homeland Defense experts urge organizations to assess their workplaces and human interactions, and to consider intervention strategies that can minimize exposures. Transmission intervention involves the use of barriers such as face masks, and careful attention to hygiene. Contact interventions include avoiding face-to-face meetings in favor of teleconferences; telecommuting; "social distancing," in which employees are kept at least 3 feet apart; and tailoring liberal leave policies that free employees to stay home with sick family members and possibly avoid bringing the virus into the workplace.

One or both interventions may work better in some work settings than in others. In theory, experts say, a contact intervention that reduces an individual's contacts by 30% is equivalent in terms of risk reduction to transmission interventions that reduce the probability of disease transmission by 30%.

Companies not investing in plans yet

Health experts say that if a flu pandemic erupts, there are no reliable means of keeping it from spreading into the United States, even if the unlikely decision were made to close down U.S. borders.

Therefore, slowing transmission while maintaining continuity of key operations is the main thrust of the federal response plan. Slowing or limiting the spread of infection everywhere — not just in the United States — could ease the economic damage and give vaccine manufacturers more time to develop and produce strain-specific vaccine.

Reynolds says that while organizations and businesses in Asia have the current outbreaks of H5N1 and the fresh memory of the SARS epidemic to serve as reminders of what epidemics can do, the United States has no such "robust" examples to spur companies to put money behind planning yet.

"We are getting a high level of interest from companies globally," says Reynolds, who helps companies plan their responses to crises such as pandemics. "But even though we have a high level of interest from U.S. companies, their commitment to budgeting for a pandemic is lagging far behind their interest."

A survey conducted by Mercer on avian flu pandemic preparedness asked corporations and organizations around the world about plans they have made in response to the threat of a flu pandemic. To establish an organization's preparedness, the survey looked at five indicators: establishment of a budget for preparedness; development of a business continuity plan; formation of a crisis leadership management team; workforce planning; and development of employee communications strategy.

Based on those indicators, Reynolds says, the survey results are that while 90% of respondents believe they will suffer moderate to high impact from absenteeism during a pandemic, only 47% have established a business continuity plan. Globally, only 17% of those surveyed have budgeted for preparations for a pandemic; broken down by hemisphere, 29% of surveyed companies in China, which suffered the effects of SARS (with its 10% mortality rate), have budgets in place, while only 7% of U.S. companies have set aside money to prepare for a possible pandemic.

"Influenza pandemics are a given," says Reynolds. "They have occurred in the past, and they'll occur again. Even if it's not this strain of flu, the likelihood is very high that there will be a strain in the future that results in a pandemic, and I think companies that are going ahead and planning now are not wasting effort."

[For more information, contact:

Jim Reynolds, MD, Mercer Human Resource Consulting. Address: 1225 17th St., Suite 2200, Denver, CO 80202. Phone: (303) 376-0800. Avian flu information on the web at www.mercerHR.com/avianflu.

Donald S. Burke, MD, professor, international health and epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. E-mail: dburke@jhsph.edu.

"Reusability of Facemasks During an Influenza Epidemic: Facing the Flu," a report by the National Institutes of Health Institute of Medicine. Available from National Academies Press at www.nap.edu or by calling (800) 624-6242.

Implementation Plan for the National Strategy for Pandemic Influenza, Homeland Security Council, Washington, DC. Available online at www.whitehouse.gov/homeland/nspi_implementation.pdf.]