Wednesday, May 30, 2007

Pandemic Preparedness: Will Healthcare Workers Show Up?

Here's a story from Reuters that sounds troubling:

A survey of U.S. healthcare workers suggests that not all will be willing to be on the frontlines if there should be an outbreak of bird flu or other infectious disease. Some will opt to play it safe and stay home, according to the survey.

Doctors (73 percent) were more likely than nurses (44 percent) or other hospital personnel (33 percent) to indicate that they would report to work in the event of bird flu pandemic.

Results are based on surveys completed by 169 nurses, doctors and other hospital workers regarding their willingness to report to work in the event of bird flu pandemic.

It's worth recalling that, according to estimates, about 40 percent of the U.S. workforce would become ill and unable to work in the event of a pandemic. (See this earlier post.) As a result, the numbers of absent workers could actually be greater. You'd have 40 percent who are sick, plus others who call in sick but aren't.

Irwin suggests that planners take an honest approach with healthcare workers:
"Open and honest discussion may turn out to be the most important feature" of a pandemic influenza plan, Irvin predicted. "No workers means no plan, so no matter what you have on paper, and stored in the closet (masks, gowns, gloves), the plan won't work if no workers show up."

This advice may stem from the finding that:

For the "maybe" responders, the factor making the biggest difference (83 percent) was their level of confidence that the hospital would protect them.
As a result, Irvin argues that planners need to build confidence by educating workers about the risk:
"Clearly, we have work we need to do to educate healthcare personnel about the realistic risk given the infection control measures we would be using," Irvin said. "The SARS outbreak can be used as a close template for what to expect; once strict infection control measures were followed, the infection rate in healthcare personnel plummeted."
And yet, an epidemiologist at Effect Measure takes a skeptical view:
Surveys like this, done before an actual event, no matter how representative (and there are questions about this one given the tiny sample size and no description of methods) are probably a poor measure of behavior during a pandemic. Behavior will depend on many things, most of which aren't specified in this survey. And people react differently than they think they will ahead of time. Some rise to the occasion. Others find their fear is greater than they imagined. My guess is that [healthcare workers] will behave much better than these numbers suggest.

Still, it's a good idea to educate employees about the risk. That's a good way to build confidence, right? Only if you have an accurate understanding of the risk:

Educating [healthcare workers] to an appreciation of the risk is difficult when no one knows what the risk is. The current CFR may or may not sink to "only" the level of the 1918 flu. No one knows and there is no way to predict. To say otherwise is incorrect and doesn't inspire confidence about other claims -- for example, that the hospital's infection control practices would be effective -- especially as most hospitals are not remotely prepared for a pandemic. Even if masks and other measures work, and there is controversy about that, most institutions have only a fraction of what they would need.

So then ... what else could work? Making sure that you are prepared for the things that you can predict and control.

As an example, Effect Measure quotes a separate study that examined potential ways to dispense antiviral medicine to healthcare workers. A "ticket strategy," modeled on the way customers take numbers at a delicatessen, proved the most efficient. Under this scheme, each worker would be scheduled to receive medicine at a predetermined time and location. Lines and wait times were shorter under this model.

Concrete measures properly done will do more to improve [healthcare worker] turnout during a pandemic than attempts to educate the worker about a realistic appreciation of the risk.
I'm probably less skeptical of the efficacy of education. Assuming that some people will rise to the occasion, and I agree they probably will, they may be more inclined to do so if they have an accurate view of the risk - even if it's something as as, "No one can predict the mortality rate for any future pandemic, but we can tell you what we've experienced in past pandemics."

It may not sound like much, but it has the virtue of being true. And more importantly, it can change the grounds on which the worker decides whether to work. In the absence of information, workers' motivation to avoid a threat may be basic self-defense. But providing information about the threat, even the barest information, allows the worker to make a conscious choice. It's empowering. The worker is able to base his/her decision on an estimation of risk rather than on simple self-preservation.

Providing information about risk is even more likely to be effective if it is accompanied by other confidence-building measures.


Anonymous said...

While the medical response to pandemic flu will be important to controlling its spread and limiting its toll, there are considerable non-medical issues related to flu preparedness that are essential for ensuring the continued well-being of the nation's economy. Planning for Continuity of Operations (COOP) and Continuity of Government (COG) is critical to maintaining
the overall viability of society. Thus, while we rightly prepare for the flu, we must be equally prepared to function during the flu.

The Center for Technology and National Security Policy of the DOD's National Defense University has prepared a number of freely-available items which can help civilians be prepared both before and during the flu. "Bird Flu and You" is a poster available in 9 languages with basic information about influenza preparedness. "Weathering the Storm" is a report with
information about planning for COOP, including instructions for carrying out "tabletop excercises" with a COOP plan.

Electronic copies of the poster are available at Electronic copies of the report are
available at, and to request hard copies of the report, contact the Life Sciences group at

Robert E. Armstrong, Ph.D.
Mark D. Drapeau, Ph.D.

Center for Technology and National Security Policy
National Defense University
Washington, DC

John Bowen said...

Thanks very much for contributing this.