Catching the bug

first_imgRelated posts:No related photos. Catching the bugOn 1 Feb 2001 in Musculoskeletal disorders, Personnel Today Previous Article Next Article Comments are closed. What is the role of an NHS occupational health department in minimising theimpact of the influenza virus on health care workers?  By Kathy Hine The occupational health department is pivotal to the prevention, treatmentand maintenance of health of its organisation’s employees. This article explores the contribution made by OH staff to the physical andmental well being of employees within an NHS Trust, with respect to theinfluenza virus of 1999-2000, and evaluates local and national health plans. Health promotion emerged during the 1990s and is now an important part ofhealth strategy. During the past decade there has been a steady increase inhealth and safety regulations and this provides the OH team with an excellentopportunity to improve health. Their practice incorporates the identificationof groups and individuals in achieving optimal health1. The health care sector is a major part of the UK economy, accounting forover 6.9 per cent of gross domestic product (GDP) in 1996. In some areasoccupational health advice is still undervalued by health care professionals2. The modern approach to occupational health and safety relies upon riskassessment. Once hazards are identified, harm should be assessed so thatappropriate control measures can be instituted. Most large employees in the UK closely monitor the health of theirworkforce, but good practice is not always common in the NHS. “Is this thecase of the cobbler’s children being poorly shod, or is it perhaps, that healthcare is a low risk business?”2. The influenza virus Disease background Hippocrates first described influenza as far back as 412BC and the firstdescribed pandemic of influenza-like illness occurred in 15813. Possibly as many as 31 epidemics have been documented since then, three ofwhich have occurred in this century – 1918, 1957 and 1968. Influenza viruses are “typed” for identification purposes. The1918 pandemic – known as “Spanish Flu” – was designated H1N1. Thismeans that the surface antigens were haemaglutinin type 1 and neuraminidasetype 14. The pandemics of 1957 and 1968 were due to an antigenic shift tosubtypes H2N2 and H3N3, respectively. Influenza is generally described as an acute, self-limiting respiratorytract infection caused by either influenza A or influenza B virus, which,although not considered serious in otherwise healthy patients, has thepotential for rapid spread in populations. It is easily transmitted by closecontact, or more commonly, through airborne infected particles by sneezing,talking or coughing. Patients present after two to three days with bothrespiratory 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 withpre-existing disease such as asthma or cardiovascular complaints are most atrisk 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 andduration but some degree of infection occurs every winter. In 1968 Hong Kongflu occurred and each year since then the same virus has returned in a newlymutated 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 theinfluenza A virus. These antigenic changes have led to all the major pandemicstrains, including the 1918 Spanish flu, the Asian flu of 1957, the Hong Kongflu of 1968 and the Russian flu of 1977. All the genes of the influenza viruses are maintained in the aquatic birdpopulation – in gulls and ducks. After mutation they are transmitted to otherspecies including humans5. The influenza pandemic of 1918 caused more fatalities than any other singleevent, including World War 1. Between 1918 and 1919 it is estimated that 20-40million people died of influenza. It was established that one-fifth of thehuman population was infected and between 2-3 per cent died6. Even though influenza is an ancient disease it continues to evolve toacquire new genes and new hosts. It still has the potential to create the samefatalities as the 1918 pandemic. Burden of disease Last year the Department of Health (DoH) issued a recommendation that allpeople aged 75 years and over should be vaccinated against influenza. Thisfigure represents 8 per cent of a general practitioner’s total list for1998-19997. It is difficult to quantify exactly the impact of influenza morbidity andmortality, as laboratory confirmation is required for exact diagnosis. However,influenza is believed to cause a significant burden both in direct and indirectcosts. Influenza is often associated with additional morbidity or mortalityparticularly in patients who are elderly – over 65 years – or in patients whohave diabetes, or other conditions such as respiratory or cardiovasculardisease. The most recent major influenza epidemic in the UK was in 1989-1990 when29,000 excess deaths are estimated to have occurred, 39 per cent of which werein private residential care8. The role of the OH department Occupational health services were originally designed to provide treatmentfor employees who became injured or ill at work. The emphasis was on therestorative nature of nursing and medicine and little attention was given tothe protection of workers9. By the early 1900s opinion was changing. Sir Thomas Legg stated “theworkforce should be told something of the danger of the material which theycome into contact withÉ sometimes at the cost of their lives”10. Health promotion today has a more structured approach. This is outlined inTable 1. It is estimated that 100,000 people in the UK are forced to leave or changetheir jobs as a result of ill-health. The cost to the British economy is 2-3per cent of 11 GDP. The DOH has produced a resource pack for employers reminding them of theirstatutory duty to prevent employees from becoming ill from work12. The principles for controlling the ill health of employees are the same asthose for safety – by risk assessment. Unlike safety risks the results of daily exposure to health may not becomeapparent for months or years. According to Popp, “the enhancement of health within a workforce isthat of shared responsibility between employer and employee – workers must beeducated to understand that their health is something for which they too areresponsible”13. OH departments are entrusted with responsibilities for advising employees inmatters that will benefit their physical and mental health. Ill health among staff has long been recognised by managers as a key factorinfluencing the effective provision of OH services. The NHS has a high level ofsickness compared with the rest of the working population14. This poses thequestion – how can staff be expected to provide health care when theythemselves are unwell? Indications for immunisation In September 1999 OH departments within the NHS received a circular from theDepartment of Health. NHS trusts were asked to consider whether or not theywished to offer immunisation to their staff and which groups of staff should beoffered the vaccine. No additional funds were to be made available for theprogramme. Experience of recent winters has shown that there is little margin in termsof NHS workers coping with additional workload. The circular suggested “even a modest amount of influenza at a crucialperiod 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 wasaware of an NHS about to crumble due to under staffing and under funding? Reducing absenteeism due to influenza is of course an obvious benefit ifvaccination were offered – it has been calculated that influenza accounts for10-12 per cent of absenteeism in NHS staff15. Indications for continued immunisation An effective way to reduce the risk of an influenza outbreak is to vaccinatethose considered at risk and those at risk of transmission. Health care workersare potential reservoirs for transmission of influenza. A confined workplace isideal for the rapid spread of an influenza virus, and health ministers in theirgovernment circular concluded that vaccination of NHS staff should be regardedas an acceptable part of a trust’s winter planning arrangements. OH departments and hospital clinicians were encouraged to set up programmesof vaccination for staff, even though previous immunisation programmes amonglarge organisations have been associated with only a small reduction insickness absence16. Dr Michael Goodman, in an article written in the Health Service Journal,concludes, “I suspect everyone will pull together, and I suspect that theGovernment suspects that too”17. Health surveillance and maintenance Among the key functions undertaken by OH departments is that of appropriatehealth surveillance. Following the publication of the DOH circular in 1999, “InfluenzaVaccination”, our OH department at the Mid Essex Hospital Trust workedclosely with key members of the trust in determining our approach to therecommendation. There were four main points to consider: – There is an identifiable disease or adverse health concern related to thework concerned – Valid techniques are available to detect indications of the disease – There is reasonable likelihood that the disease would mutate and spreadwithin the workforce – Health surveillance would be likely to further the protection of thehealth of employees18. Health surveillance is a proactive measure as it is designed to identifythat control measures have failed before the impact on an individual issignificant19. Monitoring staff health is a primary function of OH departments.Benchmarking is a recognised means of comparison between performance andacceptable standard. Our OH department used accepted best practice standardsand decided upon generic benchmarking undertaken with data from externalorganisations, in this instance the Post Office, in making the decision whetheror not to embark on a vaccination and maintenance programme for staff. Maintenance of a programme such as influenza vaccination may be difficult tosustain: all control systems deteriorate over time. A structured campaign wouldneed to be implemented and an auditing and review process put into place. Thiswould provide a “feedback loop” to enable the organisation toreinforce, maintain and develop, and ensure continued effectiveness. Planned prevention Legislation requires that healthcare workers be protected against hepatitisB. This infection may occur through contact with infected body fluids. Thelikelihood of infection occurring is about 30 per cent20. Successive governments have implemented appropriate screening programmes andprovided funding for vaccination, thereby saving lives. No funding was madeavailable for a vaccination programme against influenza. In the UK, Departmentof Health guidelines do not recommend immunisation of healthy adults. Atpresent they advise vaccination only for those persons most at risk of seriousillness or death if they contract influenza. Cost v benefit analysis – Government data In 1997 the Government issued a multiphase contingency plan for a pandemicof influenza. This was revised in February 1999. Its aims and objectives are toassist organisations in the health care sector, including OH departments, toprepare contingency arrangements. In inter-pandemic years the virus can take 18months to spread from the Far East via transportation routes thus allowing thenew strain to be incorporated into the UK’s annual vaccines. Sadly, newpandemics can travel worldwide in six months. In a milder pandemic phase in 1957, 30,000 deaths occurred in England andWales of which 6,716 were ascribed to influenza. An estimate from 29 GPpractices was 2.3 deaths per 1000 cases attended. Two-thirds of the deaths werein patients aged 55 years and over. Since these statistics were published, advances have been made in thedevelopment of influenza vaccines. In the 1994-95 season six million doses ofvaccine were given at a cost to the NHS of over £3m. None of these vaccines wasavailable to staff. During the 1999-2000 season Glaxo-Wellcome introduced Relenza – an oralspray to be used for influenza treatment. The new NHS body with responsibilityfor quality and standards, NICE (the National Institute for ClinicalExcellence) had been investigating the drug. The Government has followed itsadvice. The cost per patient is £24. The Health Secretary instructed GPs not toprescribe Relenza on the NHS, as a financially strained NHS would buckle underthe 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 standardvaccines21. The Department of Health circular for September 1999 did not advocate usingGovernment funds for vaccinating staff. Although it acknowledged that the NHSwas under severe strain it did not offer financial help. The HSC, a governmentauthority, with legislation in place for OH departments to provide, maintainand 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 offervaccination to staff. It was the opinion of the trust that healthy staff whocame into contact with influenza would be better protected in the future bybuilding up their own antibodies. The view was also taken that immunised staffwho still contracted influenza could be considered malingerers, both by themselvesand by others. This could counter the goodwill created by vaccination and workagainst a speedy recovery. Using a benchmarking service – the Post Office22, which carried out thefirst large study of the cost-effectiveness of the influenza vaccination in1979, it was shown that there was no consistent benefit to those staff who werevaccinated. The five-year study did show an overall saving of 4 per cent in sicknessabsence, although this could not be directly attributed to the vaccinationprogramme. NHS Requirements Referred costs The number of new general practice consultations for influenza-like illnesscan be expected to exceed 500 per 100,000 population per week. A practice of10,000 would therefore expect 50 new patients a week. As the influenza virus spread across the UK, health professionals, OHdepartments and politicians were once again examining the options for dealingwith what the Government claimed to be the worst outbreak in 10 years. Influenza was a concern also across North America and Europe. Health serviceprofessionals in these countries felt that crises in their health services weredue to chronic funding shortages, lack of nurses and lack of emergencyservices, for example intensive care unit beds23. In Canada the Ontario Nurses Association claimed “there are just notenough nurses – period”. One explanation for the ability of continental Europe to respond better thanthe UK to an influenza epidemic is because more is spent on health and OHservices. France spends 9.7 per cent of GDP and Germany 10.7 per cent. An increase in acute admissions of patients presenting with influenza andrespiratory illness causes a backlog of routine admissions. Not only aremedical beds taken up but also surgical beds are used causing cancellation ofroutine operating. This leads to an increase in waiting lists and preventscompliance with government guidelines for those waiting over 18 months underthe Patients Charter. OH departments also bear the strain of referred costs – in my trust this wasnot the added cost of vaccination for which we had conducted a risk assessmentbut an increase in the numbers of staff with stress-related symptoms andmusculoskeletal disorders due to a combination of overtime, shift working andunder-staffing. During the period November 1999 to January 2000 the Government wasrepeatedly issuing statements regarding the “flu epidemic”. RoyalCollege of General Practitioner consultation rates, however, show that anepidemic 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 EssexHospital Trust, the OH department is investigating whether vaccination ofhealth care workers in geriatric wards would be an advantage. Potter says,”vaccination of health care workers has been suggested as an additionalstrategy that might reduce the transmission of influenza”24. Work environments where health care workers are regularly in contact withthe general public may benefit from a routine immunisation programme. OHdepartments will need to consider the following factors: In such an environment the decline in patient care resulting in absenteeismcaused by influenza may be a significant factor. This should be weighed upagainst the limited evidence of the cost-effectiveness of vaccination in theworkplace. Vaccination will only provide cover for one year. The Post Office study of 1996found uptake rate fell from 42 per cent in the first year to 24 per cent in thefifth year. Participants in this study were asked to describe their use of OH servicesfrom the onset of influenza to the end of the episode. Only those who presented to the OH department within five days of the firstsymptom were asked to provide a baseline blood sample for serology testing. Asecond sample was taken 21 days later. Both samples were tested for thepresence of antibodies to Influenza A and B. Predefined criteria was used toassess the data25. Immunising the community Although the uptake in influenza vaccine has increased, reports suggest thatit is under-used. GPs can improve this by compiling lists of patients in atrisk groups. Sufficient vaccines could be ordered in advance and structuredimmunisation clinics organised. Vaccination could also take place away from theGP surgery. Strategies for vaccination are shown in Table 2. Audit is an important part of clinical practice and it is essential thatagreed standards are met. Results of these audits could be discussed at PrimaryCare Group (PCG) meetings with a view to improving coverage the following year.Such activities would not only improve the health of the nation but alsoprovide important visibility of health promotion. Legal issues The HASAWA Act, 1974, and MHASAW Regulations, 1999, both placeresponsibility on employers to take care of their employees’ health, andconduct health surveillance. Both of these pieces of legislation recommend arisk 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. Allof this legislation requires that staff are able to make an informed choicewith regard to health surveillance. The trust’s approach in deciding not to adopt a vaccination programme meantthat clear evidence would have needed to have been produced if the decision hadbeen challenged. The DOH circular suggested only that NHS trusts considered vaccination. Noclear directive was issued. Conclusion This study presents an evaluation of the influenza virus and its impact onhealth care workers. The report found that: – When the general population gets influenza, a large percentage ofhealthcare workers become infected – There is a shortage of medical and ancillary staff – There are implications surrounding bed availability, overloading andclosure 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 finesof £2,000 per patient per week are imposed on NHS trusts for exceeding waitinglist targets. The report highlights the complexity of managing this issue. The basis forall management of Health and Safety is HSG65. OH departments cannot prevent staff from contracting influenza and althoughthere are DOH guidelines for staff to be vaccinated there are moral andfinancial implications to this The literature research highlighted that vaccination of staff can preventdeaths 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 fromduties. This will balance out any “feel-good” factors brought aboutby immunisation. It will not improve health or produce a more efficientworkforce. Immunisation lasts for one year as the virus in its mutated formkeeps changing. My own trust decided against vaccination of its workforce after discussionwith the OH service; it concluded that it was not necessary to vaccinateotherwise healthy staff and no vaccination programme was adopted. The Government confirmed an epidemic in January 2000. But from datacollected from the eastern region there was no evidence of this. The number ofnew cases per week required for such status was never reached. Action plan The Government is investigating the possibility of extending vaccination ofthe elderly and their carers and those with chronic disease in future years My own trust will continue with health surveillance and management ofinfluenza in medical and ancillary staff. Risk assessments will be undertakeneach autumn to determine if new strategies need to be adopted. Meanwhile the influenza virus still continues to claim lives and have thepotential 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, RoyalCollege of Physicians: London, UK. 3. Oldstone MBA (1998) Viruses, plagues and history, Oxford UniversityPress: Oxford, UK. 4. International Influenza Education Panel. (2000) www.influenzanews.com. 5. Webster A, Monto AS, Keene O. (1999) Journal of Anti-Microbiology, TopicB; 44:23-29 6. Oldstone MBA. (1998) Viruses, plagues and history, Oxford UniversityPress:Oxford, UK. 7. Influenza News (2000) Press Release, Influenza News; 29 January www.influenzanews.com8. Ashley J. (1990) Deaths in Great Britain associated with influenzaepidemic, Population Trends; 65:16-20. 9. Fielding JE. (1990) Work site health promotion, Health PromotionInternational; 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, AAOHNJournal; 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-yearstudy 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-yearstudy 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 workersreduces 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 promotionSetting objectives – specific, measurable, realisticControlling health risks – by risk assessmentImplementation – control measuresMeasuring performance – benchmarking, periodic inspectionsReviewing performance – to improve systemsAuditing – independent and verifiedTable 2: Strategies for vaccination– GPs could vaccinate chronically ill patients while on rounds– GPs should give the initial vaccination because of the limited risk ofanaphylactic 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 GPsurgery– Dedicated clinics could be set up– Public awareness campaigns could be implemented each September, alertscould be broadcast on television, targeting at risk groups– Hospitals could assess the risk status of their admissionslast_img

Leave a Reply

Leave a Reply

Your email address will not be published. Required fields are marked *