Catching the bug

What is the role of an NHS occupational health department in minimising the
impact of the influenza virus on health care workers?  By Kathy Hine

The occupational health department is pivotal to the prevention, treatment
and maintenance of health of its organisation’s employees.

This article explores the contribution made by OH staff to the physical and
mental well being of employees within an NHS Trust, with respect to the
influenza virus of 1999-2000, and evaluates local and national health plans.

Health promotion emerged during the 1990s and is now an important part of
health strategy. During the past decade there has been a steady increase in
health and safety regulations and this provides the OH team with an excellent
opportunity to improve health. Their practice incorporates the identification
of groups and individuals in achieving optimal health1.

The health care sector is a major part of the UK economy, accounting for
over 6.9 per cent of gross domestic product (GDP) in 1996. In some areas
occupational health advice is still undervalued by health care professionals2.

The modern approach to occupational health and safety relies upon risk
assessment. Once hazards are identified, harm should be assessed so that
appropriate control measures can be instituted.

Most large employees in the UK closely monitor the health of their
workforce, but good practice is not always common in the NHS. "Is this the
case of the cobbler’s children being poorly shod, or is it perhaps, that health
care is a low risk business?"2.

The influenza virus

Disease background
Hippocrates first described influenza as far back as 412BC and the first
described pandemic of influenza-like illness occurred in 15813.

Possibly as many as 31 epidemics have been documented since then, three of
which have occurred in this century – 1918, 1957 and 1968.

Influenza viruses are "typed" for identification purposes. The
1918 pandemic – known as "Spanish Flu" – was designated H1N1. This
means that the surface antigens were haemaglutinin type 1 and neuraminidase
type 14. The pandemics of 1957 and 1968 were due to an antigenic shift to
subtypes H2N2 and H3N3, respectively.

Influenza is generally described as an acute, self-limiting respiratory
tract infection caused by either influenza A or influenza B virus, which,
although not considered serious in otherwise healthy patients, has the
potential for rapid spread in populations. It is easily transmitted by close
contact, or more commonly, through airborne infected particles by sneezing,
talking or coughing. Patients present after two to three days with both
respiratory and systemic symptoms such as myalgia, headache, fever, cough,
shivering, malaise and anorexia.

The fever appears at the onset of the illness. The elderly and those with
pre-existing disease such as asthma or cardiovascular complaints are most at
risk of developing complications; so too are patients with kidney disease,
immuno suppressed patients and people living in residential care.

Every outbreak of influenza is variable in terms of size, severity and
duration but some degree of infection occurs every winter. In 1968 Hong Kong
flu occurred and each year since then the same virus has returned in a newly
mutated form, the change being a response to the immunity of the population.

Outbreaks of influenza usually occur in the UK between September and March.
Major epidemics occur typically after an antigenic shift of a subtype of the
influenza A virus. These antigenic changes have led to all the major pandemic
strains, including the 1918 Spanish flu, the Asian flu of 1957, the Hong Kong
flu of 1968 and the Russian flu of 1977.

All the genes of the influenza viruses are maintained in the aquatic bird
population – in gulls and ducks. After mutation they are transmitted to other
species including humans5.

The influenza pandemic of 1918 caused more fatalities than any other single
event, including World War 1. Between 1918 and 1919 it is estimated that 20-40
million people died of influenza. It was established that one-fifth of the
human population was infected and between 2-3 per cent died6.

Even though influenza is an ancient disease it continues to evolve to
acquire new genes and new hosts. It still has the potential to create the same
fatalities as the 1918 pandemic.

Burden of disease

Last year the Department of Health (DoH) issued a recommendation that all
people aged 75 years and over should be vaccinated against influenza. This
figure represents 8 per cent of a general practitioner’s total list for
1998-19997.

It is difficult to quantify exactly the impact of influenza morbidity and
mortality, as laboratory confirmation is required for exact diagnosis. However,
influenza is believed to cause a significant burden both in direct and indirect
costs.

Influenza is often associated with additional morbidity or mortality
particularly in patients who are elderly – over 65 years – or in patients who
have diabetes, or other conditions such as respiratory or cardiovascular
disease.

The most recent major influenza epidemic in the UK was in 1989-1990 when
29,000 excess deaths are estimated to have occurred, 39 per cent of which were
in private residential care8.

The role of the OH department

Occupational health services were originally designed to provide treatment
for employees who became injured or ill at work. The emphasis was on the
restorative nature of nursing and medicine and little attention was given to
the protection of workers9.

By the early 1900s opinion was changing. Sir Thomas Legg stated "the
workforce should be told something of the danger of the material which they
come into contact withÉ sometimes at the cost of their lives"10.

Health promotion today has a more structured approach. This is outlined in
Table 1.

It is estimated that 100,000 people in the UK are forced to leave or change
their jobs as a result of ill-health. The cost to the British economy is 2-3
per cent of 11 GDP.

The DOH has produced a resource pack for employers reminding them of their
statutory duty to prevent employees from becoming ill from work12.

The principles for controlling the ill health of employees are the same as
those for safety – by risk assessment.

Unlike safety risks the results of daily exposure to health may not become
apparent for months or years.

According to Popp, "the enhancement of health within a workforce is
that of shared responsibility between employer and employee – workers must be
educated to understand that their health is something for which they too are
responsible"13.

OH departments are entrusted with responsibilities for advising employees in
matters that will benefit their physical and mental health.

Ill health among staff has long been recognised by managers as a key factor
influencing the effective provision of OH services. The NHS has a high level of
sickness compared with the rest of the working population14. This poses the
question – how can staff be expected to provide health care when they
themselves are unwell?

Indications for immunisation

In September 1999 OH departments within the NHS received a circular from the
Department of Health. NHS trusts were asked to consider whether or not they
wished to offer immunisation to their staff and which groups of staff should be
offered the vaccine. No additional funds were to be made available for the
programme.

Experience of recent winters has shown that there is little margin in terms
of NHS workers coping with additional workload.

The circular suggested "even a modest amount of influenza at a crucial
period could threaten the ability of the NHS to cope with demand".

Were the seeds of doubt already being sown in September for OH departments’
abilities to cope with large numbers of ill staff, by a government that was
aware of an NHS about to crumble due to under staffing and under funding?

Reducing absenteeism due to influenza is of course an obvious benefit if
vaccination were offered – it has been calculated that influenza accounts for
10-12 per cent of absenteeism in NHS staff15.

Indications for continued immunisation

An effective way to reduce the risk of an influenza outbreak is to vaccinate
those considered at risk and those at risk of transmission. Health care workers
are potential reservoirs for transmission of influenza. A confined workplace is
ideal for the rapid spread of an influenza virus, and health ministers in their
government circular concluded that vaccination of NHS staff should be regarded
as an acceptable part of a trust’s winter planning arrangements.

OH departments and hospital clinicians were encouraged to set up programmes
of vaccination for staff, even though previous immunisation programmes among
large organisations have been associated with only a small reduction in
sickness absence16.

Dr Michael Goodman, in an article written in the Health Service Journal,
concludes, "I suspect everyone will pull together, and I suspect that the
Government suspects that too"17.

Health surveillance and maintenance

Among the key functions undertaken by OH departments is that of appropriate
health surveillance.

Following the publication of the DOH circular in 1999, "Influenza
Vaccination", our OH department at the Mid Essex Hospital Trust worked
closely with key members of the trust in determining our approach to the
recommendation. There were four main points to consider:

– There is an identifiable disease or adverse health concern related to the
work concerned

– Valid techniques are available to detect indications of the disease

– There is reasonable likelihood that the disease would mutate and spread
within the workforce

– Health surveillance would be likely to further the protection of the
health of employees18.

Health surveillance is a proactive measure as it is designed to identify
that control measures have failed before the impact on an individual is
significant19.

Monitoring staff health is a primary function of OH departments.
Benchmarking is a recognised means of comparison between performance and
acceptable standard. Our OH department used accepted best practice standards
and decided upon generic benchmarking undertaken with data from external
organisations, in this instance the Post Office, in making the decision whether
or not to embark on a vaccination and maintenance programme for staff.

Maintenance of a programme such as influenza vaccination may be difficult to
sustain: all control systems deteriorate over time. A structured campaign would
need to be implemented and an auditing and review process put into place. This
would provide a "feedback loop" to enable the organisation to
reinforce, maintain and develop, and ensure continued effectiveness.

Planned prevention

Legislation requires that healthcare workers be protected against hepatitis
B. This infection may occur through contact with infected body fluids. The
likelihood of infection occurring is about 30 per cent20.

Successive governments have implemented appropriate screening programmes and
provided funding for vaccination, thereby saving lives. No funding was made
available for a vaccination programme against influenza. In the UK, Department
of Health guidelines do not recommend immunisation of healthy adults. At
present they advise vaccination only for those persons most at risk of serious
illness or death if they contract influenza.

Cost v benefit analysis – Government data

In 1997 the Government issued a multiphase contingency plan for a pandemic
of influenza. This was revised in February 1999. Its aims and objectives are to
assist organisations in the health care sector, including OH departments, to
prepare contingency arrangements. In inter-pandemic years the virus can take 18
months to spread from the Far East via transportation routes thus allowing the
new strain to be incorporated into the UK’s annual vaccines. Sadly, new
pandemics can travel worldwide in six months.

In a milder pandemic phase in 1957, 30,000 deaths occurred in England and
Wales of which 6,716 were ascribed to influenza. An estimate from 29 GP
practices was 2.3 deaths per 1000 cases attended. Two-thirds of the deaths were
in patients aged 55 years and over.

Since these statistics were published, advances have been made in the
development of influenza vaccines. In the 1994-95 season six million doses of
vaccine were given at a cost to the NHS of over £3m. None of these vaccines was
available to staff.

During the 1999-2000 season Glaxo-Wellcome introduced Relenza – an oral
spray to be used for influenza treatment. The new NHS body with responsibility
for quality and standards, NICE (the National Institute for Clinical
Excellence) had been investigating the drug. The Government has followed its
advice. The cost per patient is £24. The Health Secretary instructed GPs not to
prescribe Relenza on the NHS, as a financially strained NHS would buckle under
the estimated £115m it would cost in the event of an influenza epidemic.

An article in The Guardian newspaper suggested that at an individual cost of
£5 it would be beneficial for organisations to vaccinate staff with standard
vaccines21.

The Department of Health circular for September 1999 did not advocate using
Government funds for vaccinating staff. Although it acknowledged that the NHS
was under severe strain it did not offer financial help. The HSC, a government
authority, with legislation in place for OH departments to provide, maintain
and improve the health status of its employees has statutory duties.
Communication did not occur between government departments.

Local data

Within my own OH department of a large NHS trust it was decided not to offer
vaccination to staff. It was the opinion of the trust that healthy staff who
came into contact with influenza would be better protected in the future by
building up their own antibodies. The view was also taken that immunised staff
who still contracted influenza could be considered malingerers, both by themselves
and by others. This could counter the goodwill created by vaccination and work
against a speedy recovery.

Using a benchmarking service – the Post Office22, which carried out the
first large study of the cost-effectiveness of the influenza vaccination in
1979, it was shown that there was no consistent benefit to those staff who were
vaccinated.

The five-year study did show an overall saving of 4 per cent in sickness
absence, although this could not be directly attributed to the vaccination
programme.

NHS Requirements

Referred costs
The number of new general practice consultations for influenza-like illness
can be expected to exceed 500 per 100,000 population per week. A practice of
10,000 would therefore expect 50 new patients a week.

As the influenza virus spread across the UK, health professionals, OH
departments and politicians were once again examining the options for dealing
with what the Government claimed to be the worst outbreak in 10 years.

Influenza was a concern also across North America and Europe. Health service
professionals in these countries felt that crises in their health services were
due to chronic funding shortages, lack of nurses and lack of emergency
services, for example intensive care unit beds23.

In Canada the Ontario Nurses Association claimed "there are just not
enough nurses – period".

One explanation for the ability of continental Europe to respond better than
the UK to an influenza epidemic is because more is spent on health and OH
services. France spends 9.7 per cent of GDP and Germany 10.7 per cent.

An increase in acute admissions of patients presenting with influenza and
respiratory illness causes a backlog of routine admissions. Not only are
medical beds taken up but also surgical beds are used causing cancellation of
routine operating. This leads to an increase in waiting lists and prevents
compliance with government guidelines for those waiting over 18 months under
the Patients Charter.

OH departments also bear the strain of referred costs – in my trust this was
not the added cost of vaccination for which we had conducted a risk assessment
but an increase in the numbers of staff with stress-related symptoms and
musculoskeletal disorders due to a combination of overtime, shift working and
under-staffing.

During the period November 1999 to January 2000 the Government was
repeatedly issuing statements regarding the "flu epidemic". Royal
College of General Practitioner consultation rates, however, show that an
epidemic did not occur. Were these statements issued by the Government
"spin doctors" to obscure the under-funding issue?

Preventing the spread of influenza

Agenda for action: providing for healthcare workers
Although an immunisation programme was not adopted by the Mid Essex
Hospital Trust, the OH department is investigating whether vaccination of
health care workers in geriatric wards would be an advantage. Potter says,
"vaccination of health care workers has been suggested as an additional
strategy that might reduce the transmission of influenza"24.

Work environments where health care workers are regularly in contact with
the general public may benefit from a routine immunisation programme. OH
departments will need to consider the following factors:

In such an environment the decline in patient care resulting in absenteeism
caused by influenza may be a significant factor. This should be weighed up
against the limited evidence of the cost-effectiveness of vaccination in the
workplace.

Vaccination will only provide cover for one year. The Post Office study of 1996
found uptake rate fell from 42 per cent in the first year to 24 per cent in the
fifth year.

Participants in this study were asked to describe their use of OH services
from the onset of influenza to the end of the episode.

Only those who presented to the OH department within five days of the first
symptom were asked to provide a baseline blood sample for serology testing. A
second sample was taken 21 days later. Both samples were tested for the
presence of antibodies to Influenza A and B. Predefined criteria was used to
assess the data25.

Immunising the community

Although the uptake in influenza vaccine has increased, reports suggest that
it is under-used. GPs can improve this by compiling lists of patients in at
risk groups. Sufficient vaccines could be ordered in advance and structured
immunisation clinics organised. Vaccination could also take place away from the
GP surgery. Strategies for vaccination are shown in Table 2.

Audit is an important part of clinical practice and it is essential that
agreed standards are met. Results of these audits could be discussed at Primary
Care Group (PCG) meetings with a view to improving coverage the following year.

Such activities would not only improve the health of the nation but also
provide important visibility of health promotion.

Legal issues

The HASAWA Act, 1974, and MHASAW Regulations, 1999, both place
responsibility on employers to take care of their employees’ health, and
conduct health surveillance. Both of these pieces of legislation recommend a
risk assessment approach, with training and information available for staff.
Same systems of work must be clearly identified.

COSHH Regulations 1999 recognise micro-organisms as biological agents. All
of this legislation requires that staff are able to make an informed choice
with regard to health surveillance.

The trust’s approach in deciding not to adopt a vaccination programme meant
that clear evidence would have needed to have been produced if the decision had
been challenged.

The DOH circular suggested only that NHS trusts considered vaccination. No
clear directive was issued.

Conclusion

This study presents an evaluation of the influenza virus and its impact on
health care workers. The report found that:

– When the general population gets influenza, a large percentage of
healthcare workers become infected

– There is a shortage of medical and ancillary staff

– There are implications surrounding bed availability, overloading and
closure of some accident and emergency departments

– There are shortages of intensive care and high dependency beds

– This has an impact on waiting lists for routine surgery. Government fines
of £2,000 per patient per week are imposed on NHS trusts for exceeding waiting
list targets.

The report highlights the complexity of managing this issue. The basis for
all management of Health and Safety is HSG65.

OH departments cannot prevent staff from contracting influenza and although
there are DOH guidelines for staff to be vaccinated there are moral and
financial implications to this

The literature research highlighted that vaccination of staff can prevent
deaths among geriatric patients and those with chronic disease. However,
immunisation of NHS staff, is not necessarily efficient in protecting them.
Influenza may still be contracted and staff may feel guilty if absent from
duties. This will balance out any "feel-good" factors brought about
by immunisation. It will not improve health or produce a more efficient
workforce. Immunisation lasts for one year as the virus in its mutated form
keeps changing.

My own trust decided against vaccination of its workforce after discussion
with the OH service; it concluded that it was not necessary to vaccinate
otherwise healthy staff and no vaccination programme was adopted.

The Government confirmed an epidemic in January 2000. But from data
collected from the eastern region there was no evidence of this. The number of
new cases per week required for such status was never reached.

Action plan

The Government is investigating the possibility of extending vaccination of
the elderly and their carers and those with chronic disease in future years

My own trust will continue with health surveillance and management of
influenza in medical and ancillary staff. Risk assessments will be undertaken
each autumn to determine if new strategies need to be adopted.

Meanwhile the influenza virus still continues to claim lives and have the
potential to kill millions in its ever-changing form.

References

1. Royal College of Nursing (1992) Powerhouse for change, RCN: London, UK.

2. Lichfield P. (1996) Health risks to the healthcare professional, Royal
College of Physicians: London, UK.

3. Oldstone MBA (1998) Viruses, plagues and history, Oxford University
Press: Oxford, UK.

4. International Influenza Education Panel. (2000) www.influenzanews.com.

5. Webster A, Monto AS, Keene O. (1999) Journal of Anti-Microbiology, Topic
B; 44:23-29

6. Oldstone MBA. (1998) Viruses, plagues and history, Oxford University
Press:Oxford, UK.

7. Influenza News (2000) Press Release, Influenza News; 29 January www.influenzanews.com

8. Ashley J. (1990) Deaths in Great Britain associated with influenza
epidemic, Population Trends; 65:16-20.

9. Fielding JE. (1990) Work site health promotion, Health Promotion
International; 5:75-84.

10. Legg R. (1934) Industrial maladies, Oxford University Press: Oxford, UK.

11. Hodges D. (1998) Occupational health nursing, Whurr Publishing:
Gateshead.

12. Oakley K. (1998) Occupational health nursing, Whurr Publishing:
Gateshead.

13. Popp RA. (1989) An overview of occupational health promotion, AAOHN
Journal; 37(4):113-120.

14. NHS Executive. (1998) Working together, securing a workforce for the future,
HMSO: London

15. Smith A. (1992) Influenza, colds and performance efficiency,
Occupational Health Review; 35:13.

16. Smith JWG, Pollard R. (1978) Vaccination against influenza – a five-year

study in the Post Office, Epidemiological Research Laboratory: London, UK.

17. Goodman M. (2000) Health Service Journal; 1:13.

18. MHASAW (1999)

19. Gee (1999) Health and safety, Gee Publishing: London.

20. Croner (1999) Blood borne infection control, Croner’s Health Service

Risks Management and Practice, Croner Publications Ltd, London.

21. Kogan H. (1998) Occupational Health;50(1):21-22.

22. Smith JWG, Pollard R (1978) Vaccination against influenza – a five-year
study in the Post Office, Epidemiological Research Laboratory: London, UK.

23. Lipley N. (2000) Millennium bug, Nursing Standard; 14:13-14.

24. Potter J et al. (1996) Influenza vaccination of healthcare workers
reduces the mortality of elderly patients, Journal of Infectious Diseases;
175:1-6.

25. Keech M, Scott AJ, Ryan P. (1998) Occupational Medicine; 48(2): 85-90.

Table 1: The current approach to health promotion

Setting objectives – specific, measurable, realistic
Controlling health risks – by risk assessment
Implementation – control measures
Measuring performance – benchmarking, periodic inspections
Reviewing performance – to improve systems
Auditing – independent and verified

Table 2: Strategies for vaccination

– GPs could vaccinate chronically ill patients while on rounds

– GPs should give the initial vaccination because of the limited risk of
anaphylactic shock

– District nurses and health visitors could also vaccinate patients

– Practice nurses could visit the house bound

– Matrons at residential and nursing homes could vaccinate elderly patients

– A written protocol must be agreed and signed by all partners in a GP
surgery

– Dedicated clinics could be set up

– Public awareness campaigns could be implemented each September, alerts
could be broadcast on television, targeting at risk groups

– Hospitals could assess the risk status of their admissions

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