# 6150
I must confess that like a great many other Americans, I’ve become quite the fan of the British TV series Downton Abbey, just as I was of its 1970-1975 predecessor – Upstairs Downstairs.
Both series start in the Edwardian period (1901-1910) and chronicle the lives of the upstairs aristocracy and downstairs servants through the WWI years, and into the 1920s.
Both series, incidentally, featured a Spanish Flu episode that claims a major cast member.
As Crof noted in his blog this morning (see 'Downton Abbey' gets the flu — but does it get it right?), the final episode of season two ended last Sunday (here in the States) with the Spanish Flu, sparking a newspaper article that asks CIDRAP Director Michael Osterholm if the show got the details right.
This episode has also reignited a vigorous discussion on the allnurses.com forum over whether nurses, techs, and other HCWs (Health Care Workers) have a duty to report for work during a pandemic.
Since Sunday the discussion thread If There Was A Major Epidemic / Pandemic Would You Report For Duty? has generated more than 60 comments; highly recommended reading for any hospital administrator, nurse manager, or emergency planner.
All along, government planners have assumed that up to 40% of HCWs might be absent due to illness or staying home to care for ill family members.
But to this attrition rate we must also account for those who – for a variety of reasons – would decline to work during a severe infectious disease outbreak.
Not surprisingly, one of the major concerns of HCWs during a pandemic is the level of protection they will be afforded against infection.
As we saw during the opening weeks of the 2009 H1N1 pandemic, many hospitals had an inadequate supply of PPEs (Personal Protective Equipment) on hand, which led to a number of protests (see Nurses Protest Lack Of PPE’s , Report: Nurses File Complaint Over Lack Of PPE).
Ideally, the well-protected HCW (Health Care Worker) working in an infectious environment would be wearing an N95 respirator, gloves, gown and eye protection.
- In some cases nurses reported they were issued only one N95 mask to be used for an entire 8 hour shift, and told to don it only when in direct contact with a potentially infected patient.
- In other venues, HCWs were issued surgical masks in lieu of N95s, despite the recommendation at the time from the CDC that N95 masks were the preferred level of protection.
Their concerns were far from unfounded.
Last December we saw a study published in the SHEA journal Infection Control and Hospital Epidemiology that shows that the inadequate use of masks by healthcare workers during the opening days of the 2009 pandemic put them at greater risk of contracting the virus.
Transmission of 2009 Pandemic Influenza A (H1N1) Virus among Healthcare Personnel-Southern California, 2009.
Jaeger JL, Patel M, Dharan N, Hancock K, Meites E, Mattson C, Gladden M, Sugerman D, Doshi S, Blau D, Harriman K, Whaley M, Sun H, Ginsberg M, Kao AS, Kriner P, Lindstrom S, Jain S, Katz J, Finelli L, Olsen SJ, Kallen AJ.
Source
Epidemic Intelligence Service, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia.
We’ve a press release from SHEA with the details.
Study finds inadequate mask use among health care workers early in 2009 H1N1 outbreak
Inadequate use of masks or respirators put health care workers at risk of 2009 H1N1 infection during the earliest stages of the 2009 pandemic in the U.S., according to a study published in the December issue of Infection Control and Hospital Epidemiology, the journal of the Society of Healthcare Epidemiology of America.
Over the years we’ve seen a number of studies that suggest anywhere from 25% to 40% of hospital staff may elect not to work during a severe pandemic.
In 2008, in a blog called Australia: Will Doctors Work In A Pandemic? we looked at a study that found that 30% of the doctors they asked expressed reluctance to work during a pandemic.
This appears in the eMJA, the Medical Journal of Australia.
How will Australian general practitioners respond to an influenza pandemic? A qualitative study of ethical values
Olga Anikeeva, Annette J Braunack-Mayer and Jackie M Street
ABSTRACT (excerpt)
A number of GPs said they would not practise in the event of a pandemic, as they felt their responsibility to their families outweighed that to their patients.
In a blog from 2009 called And The New Survey Says . . . we looked at a couple of studies, including this one that indicated that a significant percentage of hospital and home nursing staff might not work during a severe pandemic outbreak.
How would Australian hospital staff react to an avian influenza admission, or an influenza pandemic?
Authors: Martinese, Franco; Keijzers, Gerben; Grant, Steven; Lind, James
Source: Emergency Medicine Australasia, Volume 21, Number 1, February 2009 , pp. 12-24(13)
Researchers found that up to 38% of personnel would not report to work unless antivirals, vaccines, and adequate PPEs were immediately available.
They write in their conclusion:
Conclusion:
High absenteeism among hospital staff should be anticipated if patients are admitted with either avian or pandemic influenza, particularly if specific antiviral preventative measures are not immediately available.
Measures to maximize the safety of staff and their families would be important incentives to attend work.
And in 2009, we saw a study that appeared in journal BMC Public Health (see UK Poll: Will HCW’s Work In A Pandemic?) that suggests during a severe pandemic, up to 85% of hospital personnel may be absent.
While adequate PPEs, antiviral medications, hospital security (often mentioned as a concern in what would likely be a chaotic environment) and (eventually) vaccines may not be enough to coax all reluctant HCWs to report to work, a failure to provide them will all but guarantee higher levels of employee absence.
Just as we cannot expect a firefighter to rush into a burning building without bunker gear, we should not expect HCWs to work in an infectious and dangerous environment without proper protection.
The catch-22 to all of this is, even if they were willing to valiantly work without protection, the attrition rate of HCWs due to infection and illness would quickly reduce their numbers and effectiveness.
Prior to the 2009 H1N1 pandemic there was a lot of talk about stockpiling large quantities of PPEs in anticipation of a bird flu pandemic.
In 2008 OSHA even issued Proposed Guidance On Workplace Stockpiling of Respirators and Facemasks for Pandemic Influenza that recommended that every nurse with direct patient contact would need roughly 480 - N95 respirators for a 12 week pandemic wave.
Over the past three years, I’ve rarely seen the subject publically addressed. It’s as if preparing for a pandemic today is so 2006.
You have to wonder - after the shortages we saw in the opening weeks of the 2009 outbreak - how many hospitals today are well enough stocked with PPEs to last even a couple of weeks into a severe pandemic wave.
With a surge in global demand for PPEs all but assured, timely resupply is hardly guaranteed.
This is one of those `elephant in the living room’ problems that everyone knows exists, but because of the costs and logistics of addressing, no one wants to talk about.
But if healthcare systems hopes to stay functional during a severe pandemic, they need to be taking steps now to protect their most valuable (and irreplaceable) asset.
The caregivers.
