The Presenteeism Problem: "It's My Allergies . . . Honestly!"

As we discuss HAI prevention, there are the "Big 6" HAIs (CLABSI, CAUTI, SSI, C. diff, MDROs, and VAP [although that one has been put on probation]) that get all the attention and resources.  However, other infections acquired in healthcare settings have less visibility but cause substantial harm.  One such HAI is healthcare-acquired respiratory viral infections (HARVI).  HARVI due to influenza has gotten increasing attention, especially in light of healthcare personnel (HCP) vaccination discussions (no worries, friends, I'm not stoking that debate again), but other viruses are increasingly recognized as causes of harm among our patients and colleagues (especially in light of better diagnostic tests).

In the current issue of ICHE, Len Mermel and Eric Chow provide an interesting perspective on one key aspect of HARVI transmission - HCP working while ill/symptomatic.  In their commentary, they argue that sick leave and work restriction policies that use fever as the parameter to keep HCP at home is too lenient, as infections due to many respiratory viruses may not cause fever but can still pose a substantial transmission risk.  They also call for a culture change surrounding presenteeism/working while ill, as too often the pressures to stay at work (limited sick leave especially with vacation days bundled into sick days in a single allocation, desire not to burden colleagues, importance of not handing over care to patients and maintaining the doctor-patient relationship) outweigh the push to stay home.  Policies, they appropriately argue, should be non-punitive with redundancy to allow coverage more readily.  Thanks to them both for raising some very important and provocative questions.

As I read their commentary, however, I kept going down various rabbit holes focused on implementation: 

• How do you assess HCP with resp. symptoms for infection vs. non-infectious entities like allergies (there's no POC test to rule out allergic rhinitis)?  This would be a huge issue at my hospital, as we sit in the allergy belt of the country where spring leads to a chorus of runny noses.
• What are the untended consequences of broader "stay at home" policies?  In units with highly-specific patient populations, you may run out of the experienced, skilled HCP and rely on coverage HCP, who may not be as comfortable or familiar with protocols, treatment regimens (e.g. a non-trauma nurse covering in the trauma unit).  Does that lead to unintended harm (arguably yes, if HCP shortages occur)?
• What about the utility of masking those with respiratory symptoms and no fever (not mentioned in the paper)?  Does that reduce transmission as effectively?  As part of the broader culture change, should expectations for masking to improve acceptance be part of the conversation?

Finally, such discussions and debates highlight the need for more implementation guidance and research on HARVI prevention. Hey, SHEA, time for a new Compendium chapter?