Working while sick

A few days ago, I learned about visual abstracts, a great way to encapsulate the essence of a paper. You can read more about visual abstracts here. Here's my first attempt using a recent paper in the American Journal of Infection Control.

This paper tells us that hospitals can't just mandate influenza vaccine for their workers and think that they have done their job. Preventing the transmission of respiratory illnesses requires a more comprehensive approach that makes a real attempt at keeping sick healthcare workers at home. Of note, the rate of vaccination in the survey participants was 45%, and vaccine effectiveness that season was only 19%.

Bottom line: Influenza like illness (ILI) has many causes, influenza vaccine is modestly to moderately effective against three of those, and healthcare workers continue to place patients at risk by coming to work when sick with ILI.

Fear the "freely evolving turbulent puff cloud"!

It’s well worth your time to check out a great video recently published in NEJM by Dr. Lydia Bourouiba (from the MIT Fluid Dynamics of Disease Transmission Laboratory). Simply entitled “A Sneeze”, the images and videos graphically demonstrate the biological plausibility of the findings Eli describes in his recent post on presenteeism.

In her description, Dr. Bourouiba writes:

"[The video]…shows a turbulent cloud that consists of hot and moist exhaled air, mucosalivary filaments and drops, and residues from droplet evaporation (nuclei). The ejection lasts up to 150 msec and then transitions into a freely evolving turbulent puff cloud. The largest droplets rapidly settle within 1 to 2 m away from the person. The smaller and evaporating droplets are trapped in the turbulent puff cloud, remain suspended, and, over the course of seconds to a few minutes, can travel the dimensions of a room and land up to 6 to 8 m away.”

Thanks to John Boyce for pointing this out on the SHEA Open Forum (join SHEA to sign up!).

Paid Sick Leave: Avoiding Contagious Presenteeism and Preventing Influenza

The US of A is the ONLY industrialized country without nationwide access to paid sick leave. Reread that sentence several times to let it sink in, it's OK, I'll wait for you. Opponents of paid sick leave say that mandatory sick leave increases the cost of labor and hurts job creation. In addition, they suggest  that paid leaving increases shirking behavior and "noncontagious absenteeism". However, there are potential economic benefits for paid leave, particularly in regards to encouraging workers to not work when they've acquired an infectious disease - "contagious presenteeism."

Before wider adoption of mandatory paid sick leave in the US, it is likely that the health and economic value of such mandates will need to be estimated. To that end, economists Stefan Pichler and Nicolas Ziebarth have just published an unreviewed working paper in the National Bureau of Economic Research, that sought to estimate the impact of paid sick leave on labor supply and avoiding presenteeism as manifest through reduced influenza cases. They were able to take advantage of the staggered implementation of several city (San Francisco, Washington DC, Seattle, Philly, Portland and New York City) and state (CT, CA, MA, OR) sick leave mandates in order to determine the reduction in population-level influenza-like illness (ILI) cases using Google Flu data (2003-2015). Other cities, and states not covered by the mandates served as controls. 

When they examined the impact of the mandates using city-level data and difference-in-differences models, they found that gaining access to paid sick leave resulted in a 5.5% reduction in ILI per 100,000 doctors visits. When analyzed using state-level data, they found a 2.5% reduction in ILI after adoption of mandatory sick pay. Importantly, the authors state that "infections rates may further decrease in the medium to long-run when employees have accrued larger amounts of paid sick days." The paper then takes a deep dive into the underlying behavioral mechanisms of these programs (contagious presenteeism and noncontagious absenteeism) and the positive and negative aspects of mandatory sick leave using US and German data, which makes for interesting reading if you have time. 

The findings of this paper suggest an important population-level benefit for mandatory sick leave policies, which suggests the US should consider passing a bill to make such a policy nationwide. In fact, President Obama said this during his 2015 State of the Union Address: “Send me a bill that gives every worker in America the opportunity to earn seven days of paid sick leave. It’s the right thing to do. It’s the right thing to do.” I'm thinking more mandatory sick leave and less influenza would make America a wee bit greater.

Image Source: nyc.gov

A Living Wage and Paid Sick Leave are Infection Control Issues

We've written often about presenteeism, workers staying on the job while they are sick, and have mentioned paid sick leave as a mechanism for keeping sick healthcare workers at home. A few years ago, New York City mandated a minimum of 5 days paid sick leave for all companies with over 20 workers, yet few other cities or states have similar regulations. While most presenteeism discussions focus on workers in specific workplaces, little attention has been paid to home healthcare providers. These individuals face significant time and financial pressures to work while sick, as evidenced by a recent Guardian article examining issues facing working mothers in Denver.

In the first of an election year series of discussion groups, The Guardian asked five working mothers, including three home healthcare workers, about the many barriers they face caring and providing for their families. Several quotes from the article are particularly relevant to discussions of presenteeism and infection prevention:

"As the women discussed, they’re paid less than male colleagues, they often struggle to find reliable childcare, they lack medical leave and they rarely even get paid time off"

"I mean, I cannot miss a day of work, because I have to pay rent."

"they [home healthcare companies] don’t give you benefits, they don’t give gas [money], they don’t pay for my mileage, and you take care of all these sick people in their homes. And then when you get home with this low paycheck, again, you’re struggling. The money’s not enough for us to take care of our family. No vacation, no sick pay, no benefits."

"All the women who were home healthcare aides lacked paid medical leave, which can leave both them and their clients vulnerable." 

"When I go into people’s homes, I need to be well. I take care of people with Aids, I take care of people with cancer. They don’t need to get pneumonia from me. So it’s not just about me as a home care worker, it’s about raising the standard of home care not only for myself, but for the people I take care of."

"I was sick last year with Type A flu virus. I couldn’t take one day, and they told me to wear a mask on my face to go to my client. She’s 84."

Much attention has been paid to social determinants of health and how social and economics factors are associated with poor individual and community health. What is clear from this discussion group is that social determinants of health impact infection control through presenteeism and that no one, not even the wealthy, are protected from infections (e.g. influenza) transmitted in the community by home healthcare workers who have to work while sick to provide for their families.  A living wage and paid sick leave for all workers are critically needed for infection prevention and for many other reasons, as outlined in this excellent, well-timed, discussion group.

Influenza Vaccine Mandate Math

Last week, I described five steps individual hospitals, systems and society should take when implementing compulsory influenza vaccination of healthcare workers. One component of many influenza vaccine policies is mandatory surgical masks for healthcare workers who refuse or otherwise cannot receive the vaccine. Does masking unvaccinated healthcare workers even make sense? Or rather, who is more likely to spread influenza in hospitals - an unmasked, vaccinated healthcare worker or an unvaccinated, masked healthcare worker? Let's look at the numbers.

Let's assume influenza vaccine is 50% effective. In 2014-15, overall effectiveness was 19% while in 2012-13 and 2013-14 it was 49% and 51%, respectively. I'll give the vaccine a mulligan last year since during the prior decade, vaccines were far more effective. Let's further assume with vaccine mandates, 90% of healthcare workers receive the vaccine and 10% do not.

If 90% receive a vaccine that is 50% effective, we will have 45% of healthcare workers in our hospital protected and 45% unprotected. The tricky thing is that we won't know who is protected or unprotected. And what if the 45% vaccinated but non-immune healthcare workers assume they are immune and work while sick? You can imagine them saying - "I'm sick, but it's not influenza because I was vaccinated, so I'll do my ICU shift." Any mandatory vaccination policy should consider that scenario or it's possible that the mandate could make hospitals less safe. But what of the 10% required to wear masks? I suspect they'd be more likely to stay home if sick, but even if they don't they'll be wearing a mask!

Finally, if I had a choice between being cared for by a vaccinated, unmasked healthcare worker or a masked, unvaccinated healthcare worker, I'd chose the mask. That is, until we implement influenza prevention bundles that focus on presenteeism.

Note: Mike wrote a fantastic quantitative post (in 2010!!) comparing a vaccine mandate to a presenteeism reduction policy. His conclusion: "Reducing presenteeism by 1 percentage point (from 70% to 69%) would have the same impact as increasing vaccination from 70% to 98%." It's too bad not many read the blog back in 2010...

Bacteria and Viruses to Humans -> I Am Invisible

Last week, in typical Controversies Blog fashion, we had a bit of a dust up discussing white coats and presenteeism. It occurred to me that in each instance, the primary barrier to infection prevention remains our inability to recognize that our adversaries are invisible. How else can we explain doctors insisting that washing white coats every three days is adequate and that they've never personally transmitted pathogens while caring for patients? So for those of us that still think hand hygiene compliance of 40% is satisfactory, contact precautions are bogus and that coming to work sick is cool, I have a three word reminder: pathogens are invisible. ciao

We need to rethink professionalism

A new study in JAMA Pediatrics (free full text here) should make hospital epidemiologists and infection preventionists cringe. All physicians and advanced practice providers at Children's Hospital of Philadelphia were sent a survey on presenteeism. Of the 929 providers surveyed, 58% responded.

The big findings were as follows:

• 95% felt that working while sick puts patients at risk
• 16% would come to work with fever 
• 30% would come to work with diarrhea
• 5% would come to work with vomiting
• 56% would come to work with acute onset of respiratory tract symptoms
• Asked several ways, >90% stated they would come to work while sick out of a sense of professional obligation

What I find most interesting about this paper is not how often sick healthcare workers come to work (though it's a big problem), but why they do so. And once again, professionalism rears its ugly head. Professionalism revolves around expectations and norms set by the profession. It seems to me that if we viewed this more through the lens of humanism rather than professionalism, we'd be better off. From a humanistic standpoint, which holds a universal rather than parochial view, all would agree that individuals who are ill with potentially contagious diseases should not come to work (doesn't matter whether you're a doctor, a teacher or a plumber). Similarly, in the white coat debate, professionalism drives the argument that physicians should wear a white coat. Humanism would dictate that attire should be practical, comfortable, safe, and personally desirable. Several years ago, Judah Goldberg wrote a great essay in Academic Medicine that I often quote and recently re-read on the conflict between humanism and professionalism. It really crystallized for me the differences between the two philosophies, which are often in conflict, and once the differences are made clear, it's easy to see the corrupting influence of professionalism. It's worth a read.

Presenteeism makes the Sunday NY Times

As regular readers know, “presenteeism” (coming to work while sick and potentially infectious) is a frequent topic on this blog. It’s nice to see the issue getting wider attention, this weekend in the pages of the New York Times. Go ahead and read Danielle Ofri’s excellent piece on the topic, from which I’ve pasted a couple quotes below:

“This, of course, is ridiculous behavior on the part of medical professionals who would never recommend such nonsense to their patients. Medical workers with respiratory infections are contagious. Caregivers with gastrointestinal infections — as I had — can easily infect their patients. ….  

What we can do, however, is examine the existential qualms that doctors have about illness. From the beginning of medical school it is important to advance the idea that illness is a part of all of us — doctors and patients alike; that there is very little that separates us from our patients, other than the circumstance of the moment; and, for goodness’ sake, that we need to call in sick when we are sick.”

Here come the maskers

Recently, the New York State Health Department mandated that all healthcare workers either be vaccinated against influenza or wear a mask. This week’s JAMA has a commentary by the ethicist Art Caplan and New York’s Commissioner of Health, Dr. Nirav Shah. In the JAMA piece they argue the ethical imperative underlying the mask ruling. You can read about the ruling here and the JAMA commentary here (free full text). Unvaccinated HCWs will be required to wear the mask during periods of widespread influenza activity. It’s important to note that over the past 6 years, the period of widespread activity in New York varied from 11 to 22 weeks. That’s a long time to wear a mask, which is required in any area where patients are typically present. The document notes that this includes the cafeteria, though the unvaccinated worker is allowed to be mask-free when eating.

For many reasons, I dislike mandatory influenza vaccination. But I despise the mask regulation. I have to question the rationale. It seems to me to be less about ethics and more about being coercive and punitive. It’s wasteful. There have been periods of time when masks were in short supply with the shortage being made worse by the maskers. Most importantly, wearing a mask for prolonged periods of time is impractical—it’s uncomfortable and distracting. If we are going to argue for masking on an ethical basis, since influenza vaccination is only 60% effective at best, wouldn’t it be consistent to argue that all healthcare workers, vaccinated and unvaccinated, should wear a mask? It's also laughable that the ethicist doesn't mention that it's unethical to come to work while sick with influenza, which studies tell us is quite common. Presenteeism remains the elephant in the middle of the room, and reducing it is likely far more important than mandating influenza vaccine or masks to prevent transmission of infectious diseases in the healthcare setting.

Photo: REUTERS/Yuri Maltsev

Infection control rule #1: if you're sick, stay home.

A new study from the University of Pittsburgh Graduate School of Public Health uses epidemic modelling to determine the impact of reducing presenteeism on workplace transmission of influenza during a pandemic, such as the one we experienced with H1N1 in 2009.

The investigators compared the status quo (72% of employees with paid sick days stay home with flu, while 52% of those without sick days do not) to three other scenarios: (1) all employees have access to paid sick days, (2) all also have access to 1 flu day, or (3) all also have access to 2 flu days. The concept here is that employees are specifically paid to stay home when ill with influenza.

The findings:

• Universal paid sick days resulted in a 6% reduction in workplace transmission (applied to Allegheny County, PA [population 1.2 million] that is equivalent to nearly 4,000 fewer infections).
• Adding 1 flu day resulted in a 25% decrease in workplace transmission (15,000 infections averted)
• Adding 2 flu days resulted in a 39% decrease in workplace transmission (26,000 infections averted)

Bottom line:  Efforts to reduce presenteeism (a horizontal infection prevention strategy) can have significant impact. 

Implication:  If we're really serious about reducing infections transmitted to patients in hospitals from staff, we must start thinking about how to reduce presenteeism. And that's a lot harder than firing healthcare workers who refuse to take their flu shot. 

Photo:  Man by Virgil Cantini, 1965, bronze and steel sculpture on Parran Hall at the University of Pittsburgh Graduate School of Public Health.

A little public health victory

Like hand hygiene, getting workers to stay home when sick is an example of a horizontal infection prevention strategy. Horizontal strategies are multipotent (not aimed at a single pathogen), generally simple methods. While most humans inherently know that it's not a good idea to come to work with fever or diarrhea, many either can't or won't stay home and risk infecting co-workers, customers, or patients.

One major reason for presenteeism is lack of sick time, a particular problem for food service workers and other low wage earners. But the healthcare industry has its problems too, as many hospitals provide workers with paid time off (PTO) as opposed to sick leave. PTO is time that can be used for vacation, personal days or sick time. While this has some advantages, it also presents problems. For example, time off for illness reduces vacation time, so a sick worker may have to choose between working with the flu or going to Disney World. A worker that has used all of his PTO, may also feel compelled to work while ill.

New York City took a step in the right direction yesterday when it mandated five days of sick leave with pay for employees who work in companies with 20 or more workers. Smaller businesses will be forced to allow workers to have sick leave without pay with no threat of job loss.

From a public health perspective, the first step to reducing presenteeism is ensuring that workers have sick leave. However, for doctors and nurses, we'll need other solutions to keep them home. Perhaps denormalization of presenteeism would be a start. Maybe someday coming to the hospital while sick will be viewed like smoking on rounds. While I bet that sounds implausible to many, I remember attending physicians smoking during morning report when I was a medical student in the mid-1980s.   

So kudos to New York, the only city in the world with a mayor who has a school of public health named after him!

Presenteeism - Don't Come to Work Sick!

Mike has posted numerous times on the problem of presenteeism in healthcare workers. The Wall Street Journal has a nice article/video on "the art of calling in sick" and why it's important to stay home to protect your co-workers. The post includes sage advice from Iowa's own Loreen Herwaldt, who advises influenza and pertussis vaccines and good hand hygiene. She says that "the 24-hour rule pediatricians preach to parents—that a child with the flu should stay home from school or day care at least 24 hours after the fever and symptoms go away—usually holds true for adults too." Importantly, she also mentions that the rules would differ for healthcare workers who are sick.

Remember primum non nocere? Ok, then stay home

A new study in the Archives of Internal Medicine reports the results of a survey of 150 Internal Medicine residents from 20 residency programs on presenteeism. 51% reported they had worked at least once in the last year with flulike symptoms, and 16% reported working at least three times. The two top reasons cited for working while ill were not wanting to force colleagues to cover and feeling responsible for patient care.

Tomorrow I give my annual infection prevention talk to all new incoming residents at our medical center. And again I'll make a plea for the young doctors to stay home if they are ill. But when will SHEA and other organizations begin to tackle this issue? It's much easier and cheaper for hospitals to mandate influenza vaccination than reduce presenteeism. While mandating flu vaccine allows hospitals to look tough, reducing presenteeism is likely to be more effective at protecting patients.  

Photo: Zazzle

Some norovirus with your entree?

We've blogged before about the problem of presenteeism in healthcare workers. We've all seen coworkers come to work sick and maybe have even done that ourselves. But from a public health perspective, presenteeism isn't just a problem for doctors and nurses. Those who work in the food service industry can spread gastrointestinal and other infections when they come to work sick. And they are very likely to work while sick. An article in the latest issue of The Progressive points out that 80% of food servers in the US lack paid sick leave. The Restaurant Opportunities Center United (ROC) in a survey (below) of 4,300 food service workers found that nearly 2/3 of these workers prepared or served food while sick.



ROC has also published a diners' guide (full text here), which includes information on which restaurants do and do not provide paid sick leave for their employees.

One more time: If you're sick, stay home!

In the June issue of Infection Control and Hospital Epidemiology there's a report on an outbreak of H1N1 influenza among healthcare workers in a Chicago hospital in May 2009. This was prior to the availability of the vaccine for this influenza strain. It should come as no surprise that 55% of the HCWs who developed swine flu worked for at least one day while symptomatic. Another example of presenteeism.

On a more positive note, the Connecticut legislature has passed a bill that mandates sick pay, which should help to reduce presenteeism, though lack of sick pay was likely not the problem at the Chicago hospital. Nonetheless, I don't think that most hospitals are making a sincere effort to keep sick workers at home.

The surgical mask for the non-surgeon



Photo: LesterHo

My favorite section of GQ magazine is the column, The Style Guy, in which Glenn O'Brien solves sartorial conundrums. The June issue has a question from a reader asking whether it's ok to wear a surgical mask with a suit when you're recovering from the flu and want to get back to work. Here's his response:

In Japan the surgical mask is more normal than a hat. Ths is sometimes because of Japanese courtesy, keeping their germs to themselves; sometimes because of their fear of germs; and sometimes in homage to Michael Jackson. In America you can't pull the mask off with anything but scrubs. My position is, if you're sick enough to be contagious, stay the hell home.

There you have it. Even the Style Guy is down on presenteeism.

Stay home!

Mike has posted several times recently on presenteeism, a problem that is long overdue for increased attention. At a time when more and more healthcare workers are at risk for termination should they not get their flu shots, why are we not taking presenteeism more seriously? It seems like a much greater threat to our patients than is an 86% influenza vaccination rate (the rate we achieved here without a mandate). Today’s NY Times has an excellent piece by Dr. Pauline Chen, describing her personal experience and discussing the Journal of General Internal Medicine paper that Mike blogged about previously. I’ll end with this quote from Dr. Chen’s article:

“......when doctors come into work so sick they need intravenous fluids, it’s considered a badge of courage,” said Dr. Eric Widera, the study’s lead author and an assistant professor of geriatrics at the University of California, San Francisco. “No one is standing up for the patient and saying, ‘This is wrong.’ ”

Mike's previous posts on presenteeism
The JGIM paper (pdf)
Dr. Chen's NY Times article

More on presenteeism

This week's JAMA has a short report on presenteeism in medical residents across 4 specialties in 12 hospitals. The survey was sent to 744 residents and had a 72% response. Overall, 58% of residents reported that they had worked while sick at least once in the past year, and 31% reported doing so more than once. A higher proportion of presenteeism was found in 2nd year vs. 1st year trainees. This is directly related to my posting yesterday on control of nosocomial influenza and provides some food for thought as we begin to plan for the upcoming flu season.

Presenteeism: It plagues us

The August edition of the Journal of General Internal Medicine has a paper and editorial on presenteeism that are important for the infection prevention community. Presenteeism is the situation that occurs when workers report to work ill. In the case of communicable diseases in the healthcare setting, presenteeism has the potential to spark outbreaks of illness such as norovirus gastroenteritis, influenza, and other respiratory infections.

As I mentioned in a previous posting, our influenza control plan for the upcoming season is to encourage (but not mandate) vaccination of healthcare workers, coupled with a greater emphasis on avoiding presenteeism. Unlike vaccination, reducing presenteeism is a multipotent intervention, and a great example of the horizontal approach to infection control.