Ubiquitous employee temperature screening and symptom questions upon entry during the pandemic have not yielded much success in identifying sick healthcare workers (HCWs) and reducing the long-standing problem of presenteeism, according to David Kuhar, MD, of the CDC’s Division of Healthcare Quality Promotion.

“When I say presenteeism, I mean the act of attending work while ill and potentially infectious to others,” Kuhar said at the IDWeek 2021 virtual meeting, held Sept. 29-Oct. 3. “Presenteeism among healthcare personnel is actually very well reported in the literature.”

For example, during the 2009 H1N1 influenza A pandemic, one facility reported 65% of HCWs reported working with symptoms of influenza-like illness.1 In a recently published Swiss study conducted over two flu seasons that included 152 HCWs, 68% reported working with symptoms of influenza at some point.2

The reasons HCWs come to work sick are complex. “It can depend upon the job of the employee, their social status in the organization, and the care demands of their work,” Kuhar said. “Commonly identified reasons include local [work] culture, an unwillingness to disappoint colleagues, even a fear of consequences for taking days off. Are you going to develop a reputation for leaving work to colleagues? Someone’s individual work ethic can affect this.”

There might be financial pressures if the institution does not grant paid sick days to HCWs. “If you’re going to miss a paycheck when you stay home, people aren’t going to stay home,” Kuhar said. “In the same vein, for facilities that have policies with combined vacation and sick days — people are pulling from one pool of days they can use — people don’t want to replace a vacation day with a sick day. Really, any policies that limit time off due to illness can discourage people from taking time off when they’re ill.”

Yet among HCWs, there is a lack of perceived risk, with many thinking their symptoms are not a threat to patients or colleagues. “Many [sick workers] are highly contagious and can actually cause severe illness,” Kuhar said. “Roughly a third of community-acquired pneumonias can be from respiratory viruses or viral pneumonias. Depending on the population you look at, it could actually be up to half of them. That is a large number. Viral infections can predispose people to bacterial superinfections. They can also cause severe illness, especially among those who are predisposed to it — immunosuppressed people, those with pulmonary disease, cardiovascular disease. The very people who are often [receiving] healthcare.”

With other viruses circulating and seasonal influenza historically causing 9 million to 36 million cases annually, infected HCWs have caused hospital outbreaks or been infected during them.

“There are numerous reports of outbreaks in healthcare, such as in long-term care settings, where even the common cold, like a rhinovirus, can cause outbreaks, [including] some associated with severe illness among their residents,” Kuhar said.

During the COVID-19 pandemic, a common ritual at facility entry is checking temperatures and assessing symptoms for respiratory illness.

“Perhaps surprisingly, there are very few publications about the ability to detect cases among healthcare personnel [during the pandemic],” Kuhar noted. “However, we received anecdotal reports from professional societies, state and local health departments and facilities, that temperature screening was just not identifying many cases, if any cases at all.”

Airports have widely implemented screening among passengers, but modeling estimates show they are missing at least half the cases, Kuhar said. Another healthcare report indicated that among patients who were admitted with SARS-CoV-2 with positive tests, only 16 out of 68 had a fever.3

“Temperature screening during the pandemic has not efficiently identified cases, and it is not likely an efficient strategy for detection of other respiratory illnesses,” Kuhar said. “We know that people can have influenza and not have fevers, [even though] there may be pre-symptomatic [viral] shedding.”

Symptom screening looks for more data points, such as a sore throat, shortness of breath, and cough. “You’re able to cast a wider net,” Kuhar said. “The biggest cons are that it is not objective, and symptom screening really is only ever as good as people are aware of [symptoms] and willing to share them.”

Some hospitals started using electronic reporting of symptoms to speed the process and allow those with no symptoms to enter quickly. “There are minimal reports of symptom screening alone detecting infected healthcare personnel, which I found a little surprising,” he said. “However, from anecdotal reports, we heard from many facilities as well as health departments that very few cases were being identified with symptom screening at all, with some places reporting none.”

That does not necessarily mean there is no value to symptom screening, Kuhar added, noting it still might discourage presenteeism. “Active screening may end up discouraging personnel with symptoms from even testing the [facility] doorway and just staying home,” he said.

This can be complemented by more passive approaches, like encouraging workers not to report to work if they are ill. “There are a lot of limitations for temperature and symptom screening,” Kuhar said. “I can’t help but keep going back to focus on the underlying causes of presenteeism.”

One of the biggest problems is the culture of a facility, which must be set by the hospital administration. “Only leadership can really affect facility culture and effect change,” Kuhar said. “Without it coming from the top, it’s generally not going to happen.”

For example, leadership can remove barriers to taking sick days, like providing pay for those days to remove the financial pressure that drives presenteeism.

“Create policies that require restriction from work when ill,” he said. “It’s very different when the message is ‘We don’t want you to come to work when you are sick’ vs. ‘If you’re not feeling well, you don’t have to come to work.’ It’s really a different message when it’s clearly, ‘Do not do this.’”

Another option is for employee health to provide rapid-access medical evaluations for staff. “Have someone make the determination — ‘This may be a contagious disease and you should go home,’ or ‘We feel very good that it’s not [contagious] and you can proceed to work,’” Kuhar said. “This could prevent people from working when sick, while allowing some people who might have taken a day off to come in.”

The current challenge of staffing certainly is a factor, but there always has been some element of threadbare resources and limited backup in many facilities.

“There are actually reports of healthcare workers coming to work when ill — even with respiratory symptoms — and they have paid sick days that they simply haven’t taken,” Kuhar said. “If there’s no backup, if there’s no person to cover their job, people are going to be much less likely to stay out of work when they’re sick.”

REFERENCES

  1. Bhadelia N, Sonti R, McCarthy JW, et al. Impact of the 2009 influenza A (H1N1) pandemic on healthcare workers at a tertiary care center in New York City. Infect Control Hosp Epidemiol 2013;34:825-831.
  2. Kuster SP, Böni J, Kouyos RD, et al. Absenteeism and presenteeism in healthcare workers due to respiratory illness. Infect Control Hosp Epidemiol 2021;42:268-273.
  3. Mitra B, Luckhoff C, Mitchell RD, et al. Temperature screening has negligible value for control of COVID-19. Emerg Med Australas 2020;32:867-869.