A recent SOM/Royal College of Nursing webinar offered occupational health practitioners valuable advice on how to manage Covid-19 outbreaks as we head through the autumn and into the winter and how, despite all the added pressures it is bringing, the pandemic could actually be an opportunity for the profession. Nic Paton listened in.
As we head into the autumn there is a lot still that we don’t know or understand about Covid-19. One issue increasing becoming clear, however, is that the government’s so-called ‘whack-a-mole’ strategy for dealing with local flare-ups – implementing temporary local lockdowns or restrictions – is likely to cause challenges for occupational health as well as, potentially, community tensions on the ground.
Especially where an outbreak is centred on a specific employer or premises, it stands to reason that how that employer responds will be in the media and public spotlight, with the occupational health team, if there is one, also potentially likely to be centre-stage.
That was very much the case, for example, with the cluster of cases that emerged at food manufacturer Greencore in August, where occupational health provision is led by the highly regarded head of occupational health Julie Routledge.
Over the summer we also saw clusters emerging at, to pick out just a few, a Tesco Extra in Swindon, a food processing plant in Scotland, and a bar in Aberdeen. Indeed, a report by the European Centre for Disease Prevention and Control in August calculated that there had been 1,376 clusters of Covid-19 in occupational settings within the UK and 15 European Union/European Economic Area countries between March and early July, with the health sector, food processing and packaging, manufacturing and office settings all highlighted.
The role of occupational health practitioners in providing advice, guidance and leadership to employers and individuals in the event of a Covid-19 outbreak or cluster was at the heart of a recent webinar on OH and Covid-19 run by SOM, the Society of Occupational Medicine, and the Royal College of Nursing.
Chaired by SOM’s president, Professor Anne Harriss, the webinar brought together Susie Singleton, consultant nurse, health protection, and national lead for Integrated Personal Commissioning, Centres and Regions, at Public Health England, and Dr Shriti Pattani, chair of the NHS Health at Work Network and clinical director at London North West University Hospitals NHS Trust.
Defining an ‘outbreak’
Singleton began the event by recapping how the pandemic had unfolded since the beginning of the year and where we are now. As she conceded: “This is unprecedented. I have been involved in previous epidemics, pandemics, big outbreaks – but nothing of this scale. And I think that everybody is really trying to work hard to get the best information out to everybody as quickly as possible.”
When managing an outbreak, it was important, first, to recognise what was even meant by the term ‘outbreak’, she emphasised. “Within this country we have very defined terminology and, within epidemiology, it is normally defined as more than two cases related in place and time,” she said.
“But I must also stress that you can have an ‘outbreak’ with one case. If we have an unusual disease that is not normally associated with this country, or it has been imported; something like polio, then one case would constitute an outbreak, and we would then instigate outbreak control measures. So the definitions will change depending on what it is we are looking at,” she added.
It was also important to try to gauge whether what you are dealing with is a workplace outbreak or a workforce outbreak, she advised.
“We are seeing asymptomatic carriage within the community coming into the workplace. And then it can be transferred on to other colleagues at work. Some of the high-profile ones that have hit the news are some of the food manufacturing plants. So there is a lot of work undergoing and being underpinned in identifying what is happening within the regions and within the workplaces, and there are health protection teams and contact tracing teams up and down the country now.
“In some of the high-prevalence areas local authorities are also undertaking contact tracing when people are not responding to digital platforms or being contacted by email or telephone. Some of the local authorities are now contact tracing and going door to door. So there is a lot of work, and a lot of very tired staff out there,” Singleton said.
“It is really, really important to try and understand what we know, what we don’t know, what we actually think is happening; developing a sort of hypothesis, and then going on to test it to see if we can understand what is going on. This in public health terms also includes what I like to call ‘shoe leather epidemiology’.
“You can’t manage an outbreak from an office; you can’t manage an outbreak without physically going and seeing what is going on. Because a lot of the information we pick up is ‘soft’ intelligence. It might be about the environment, the ventilation, the airflows. It might be about waste control. It may be about human behaviours. So it is very, very important to talk to the people on the ground, and they are often the ones who will have the information that best helps to control the outbreaks,” Singleton added.
Key steps of effective risk assessment
Singleton also recapped on some of the key steps of effective risk assessment. “If you suspect an outbreak, then we need to investigate; it needs to be reported on suspicion and not wait until it is actually confirmed. We need to ensure that we have identified the hazard. We need to decide who might be harmed. We need to assess the risks and what action to take. We need to make a recording of the findings. We need to review the risk assessments. And we need to learn the lessons and cascade the lessons.”
The second speaker, Dr Shriti Pattani, focused on risk assessment for Covid-19 and the issue of protecting vulnerable staff within the workplace. She emphasised that, of course, risk assessment by itself is not enough. “It needs to be followed through with appropriate control measures and monitoring.”
Within this, it was important not just to look at how an individual might get Covid-19 but also the extent of harm that could occur if they became infected. “As OH practitioners, we need to make an assessment on the likelihood of that harm occurring to the individual health of the worker,” she pointed out.
This had led not only to an increase in workload for many within OH but also the need to be working with managers in a different way. “We [occupational health] promote the idea that they [managers] look at functional capacity, not individual health. I personally don’t know of any other risk assessments over my years of practising as an OH physician under health and safety law that has required this level of input from occupational health. In my department over the last month we have received 1,350 risk assessments that we personally needed to get involved with,” she said.
At her trust, the OH service had created a risk assessment tool with an appendix of all the health conditions outlined by Public Health England as making an individual vulnerable to Covid-19. “We asked managers to simply ask their member of staff, ‘do you have one of these conditions?’, and not to actually to go into the detail of the condition or what it is or any of the treatments. And that actually produced a very efficient way of dealing with this particular issue around managers having access to health information,” said Dr Pattani.
Along with the ongoing and updated guidance from the Health and Safety Executive and Public Health England (at least until is replaced by the government’s proposed new National Institute for Health Protection), Dr Pattani highlighted the Welsh Government’s Covid-19 risk assessment tool as being valuable, along with the ‘Covid age’ medical risk assessment tool developed by ALAMA (the Association of Local Authority Medical Advisors) and SOM’s suite of return-to-work guidance and toolkits.
New national clinical assessment toolkit
Dr Pattani also pointed to the development of a new national clinical assessment toolkit by the government that would be available for clinicians, including occupational health practitioners, “later in the year”.
As she outlined: “The idea is that we can actually give our patients, our workers, a consistent approach to assessing their clinical vulnerability. And, as healthcare practitioners – GPs, specialists and OH practitioners – we can all sing from the same hymn sheet and give our patients and our workers the same clinical risk advice.”
For all the challenges Covid-19 was posing for occupational health practitioners, and all the added pressure and workload it was creating, the pandemic was, arguably, also an opportunity for the profession to show its worth to employers and the wider public, Dr Pattani argued.
“I think there has never been a better opportunity for us to demonstrate the value that a well-resourced occupational health service can bring, and our special skills in actually managing and supporting and assessing the fitness to work of our workforce,” she said.
“Certainly, I know that in the NHS occupational health has had a very high profile and we’ve had many staff who have been redeployed in my service. We went from 12 staff to 36 within two weeks to deal with Covid hotlines, swabbing, antibody testing, risk assessment, now track and trace and the big asymptomatic staff testing programme that is starting,” she said.
“Nationally, certainly, there is more of a focus on investing in occupational health. So, I hope this might be a real opportunity for occupational health to be recognised as an important speciality [sic] in its own right, and an investment made in occupational health services,” she added.
Possibility of a Covid-19 vaccine
During the webinar’s question and answer session, Dr Pattani was asked to offer her advice on how OH should best be managing and supporting workers who are anxious or fearful about returning to physical workspaces. She emphasised it was vital to understand their anxieties – it could be, for example, it was more about travelling on public transport than actually being in the work environment – and whether the fears were more perception than reality.
In her trust, all workers who had been shielding had been sent individual letters outlining the trust’s risk mitigation actions, managers had arranged personal calls to run through a Covid risk assessment and, where appropriate or necessary, workers had been referred to the trust’s employee assistance programme. “For those who were extremely anxious, within occupational health we have been running Covid hotlines; so we actually called them to have an independent conversation with them as well,” she pointed out.
Susie Singleton was then asked for her view on the chances of a viable vaccine becoming available by the end of this year. “The rule of thumb has always been that, if we identify a new vaccine, it normally takes 10 years from lab to shelf or patient or client or whoever we are giving it to,” she pointed out.
“In reality, yes there are a couple of vaccines currently in the human trials aspect, and the UK is one of the leading lights in this. To have it one the shelf and ready by December I would doubt very much. It is the safety mechanism – there is a vaccine out there that is looking very, very promising – but in reality I would say, if everything goes to plan, we are probably looking at spring 2021 or after. I hope I’m wrong!” she added.
The webinar concluded with the results of a poll of participants asking how they felt OH professionals would be involved, and where they would most add value, if there was a second wave of Covid-19 this autumn.
The majority (90%) said return to work would be the key area, along with case management and managing sickness absence (84%), managing and supporting mental ill health (79%) and leading on risk assessment (78%).
- As well as contributing to the webinar, Dr Pattani has written about her experiences as an NHS occupational health physician during Covid-19 in the August edition of the journal Occupational Medicine. This has included how the trust set up a call centre-style hotline, a drive-through and community testing programme, and a seven-day OH and testing service. The article can be found at https://academic.oup.com/occmed/advance-article/doi/10.1093/occmed/kqaa137/5880346
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