Flu in hospital workers

The AMA just took over a journal called Disaster Medicine and Public Health Preparedness. In fact they proudly announced they were the exclusive publisher and distributor of the journal, formerly published by Lippincott, Williams and Wilkins. I wouldn't even know about it except it was in connection with a press release of an article likely to be of interest any health care worker: ":Which Health Care Workers Were Most Affected During the Spring 2009 H1N1 Pandemic?" by Santos, Bristow and Vorenkamp of Weill-Cornell Medical School in New York. And the AMA even said it was redesigning the website to improve the journal's visibility and engagement by publishing important studies that can help emergency response health care professionals. Oh, and one more thing.It's behind a subscription firewall! If the article is so important and journal visibility so crucial, then why not make it available for free, the way many subscription journals are now doing for articles of public health importance? You would think that an article about risks to emergency response health care professionals would be made available as a public health service. It would even be good for the journal, bringing it to the attention of a lot of people (lke ourselves) who never heard of it before. They don't have to go entirely Open Access to do this. They can do it selectively when the situation warrants it. Anyway, I don't have access so all I can tell you is what is in the abstract.

The study took place in five hospitals during the first wave of the 2009 pandemic (spring), before any vaccine was available. Santos et al. looked at lab confirmed diagnoses and employee sick hours records for various departments:

Records of 123 confirmed reports of laboratory-confirmed influenza A or novel H1N1 infections in hospital employees were also analyzed. Two thirds of the H1N1 cases occurred during June (infection rates in parentheses): 34 in physicians and medical personnel (6.7%), 36 in nurses and clinical technicians (2.2%), 39 in Administrative & Support Personnel (infection rate = 1.2%), 3 in Social Workers & Counselors (infection rate = 1.0%), 8 in Housekeeping & Food Services (infection rate = 2.7%), and 3 in Security & Transportation (infection rate=3.9%). When analyzed according to department, the adult emergency department (infection rate = 28.8%) and the pediatric emergency department (infection rate = 25.0%) had the highest infection rates per department. (Santos et al.,Which Health Care Workers Were Most Affected During the Spring 2009 H1N1 Pandemic?, Disaster Medicine And Public Health Preparedness, 2010 4: 47-54; abstract)

No surprises but nothing comforting if you work in the ER, either. Half of the cases were in departments that had only 20% of the employees. Their risk was more than double that of other hospital workers, clearly a direct matter of exposure and not from just being another member of a general population experiencing a flu pandemic. Whatever precautions they were taking to protect themselves, they weren't working very well. Maybe interesting and useful information like that is actually in the article.

I don't know. I couldn't read it because I don't subscribe to this journal I never heard of. AAARRRGGGHHHH!


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thank you revere..

I am with you on making important , or high medical interest articles free for all. I would love to send my work to free access journals but they charge over $3K to the author. This equates to needing to pay for the privilege of publishing out of personal funds for those of us who are primarily clinically based with no--or very limited active grant funding. Journals make good money off of authors and give little to nothing in return. I have written several reviews for both the NEJM and Lancet and the number of downloads off of each respective journals site for my reviews were in the hundreds of thousands at at $/ £ 15-30 a download I may add.

By BostonERdoc (not verified) on 01 Apr 2010 #permalink

It seems to me that even without reading the whole article, there is enough information in the abstract to indicate that ER and pediatric facilities need a major reworking.

The funny thing about the research papers hidden behind subscription pay walls, is that the research may very well have been funded with your tax dollars.

That an infectious disease should prove infective to ER workers is hardly surprising. Especially among those working 36 hr shifts, their immune systems must be shot.
If this was a deadly pandemic of the 1918 variety, you wonder how many doctors and nurses would show up for work anyways,

On the other side of the coin, how many non-influenza patients in the ER were infected by influenza admissions, and how many were infected by the ER staff working through symptoms, or who are asymptomatic but infectious. The most dangerous setting during the SARS outbreak was in a hospital.

This is why it is important, should a real pandemic ever strike, to have some hospitals or designated areas which are for influenza patients only, and other for non-influenza cases only (might result in some patients w/o influenza but with flu-like symptoms being denied treatment at the right place). All patients and staff would be screened before entering non-influenza hospitals for fever or other symptoms. This at least helps minimize the disruption to health care for non-influenza patients due to infected patients and staff.

During a real pandemic (on a scale with 1918), those infected with influenza will overwhelm the system (respirators, lab tests, etc) and the best that can be offered will be food, nourishment, rest, nursing, perhaps not even in a hospital setting but in school gyms/auditoriums, etc. Thats a reality. You can't fund a system to handle an event that might happen once in a century (actually, you can but that would force me to discuss money creation and economics w/o convincing anyone given the collective ignorance and misinformation of such matters).

But at least, by facing the reality forced upon us, you can try to keep up with treating non-influenza cases, with doctors and nurses protected somewhat against infection as well (not 100% of course, there will be some impact). Those cases will not just disappear, so a heart attack victim can be treated w/o having to expose themselves to an influenza infested hospital where care will be delayed due to the large number of cases.

In the end, Darwins natural selection rules will rule in terms of who survives a pandemic and who does not. As they say, what doesn't kill you makes you stronger. This applies to the human race as well as individuals (when the premise applies, and it doesn't always, but herd immunity does make the race stronger to a given influenza pandemic strain). The tragedy will be compounded by non-influenza cases who normally would be saved, but were lost because of improper planning.

@pft - This is/was a real pandemic, just not as deadly as 1918. And I fully agree with you about keeping the flu infected out of the hospitals. Most people do. My choice for an alternative care site isn't a school gym or community center, but in a hotel that would likely be mostly empty anyway, since people wouldn't be traveling. They already have individual rooms and beds with linens, bathrooms and, at least in some cases, food service facilities. Only problem is that the high school gym is free and Marriott would probably want to be paid (even if they would be empty otherwise).

Is the ER is a perfect place to continue the chain of transmission? You betcha. We are always at full capacity morning, noon and night. Many times during the peak of the outbreak in May and Oct 2009, we had individuals who tested positive by rapid flu requiring admission (we typically have an admit rate of 30-40% at my shop since we cater to the complex medical patient) separated by others by only a curtain--or in many cases just lying in a bed in one of the hallways waiting for a bed upstairs to open up (typically 6 hrs). Then you have the multiple family members who gum up the areas and my anecdotal experience is they don't carryout good cough and hand hygiene. This overcapacity is worrisome. We do not have the infrastructure to handle the onslaught of patients during major public health emergencies. And BTW, nor do we have the capacity to handle the expected increases of routine health care or typical ED presentations (estimated at 10% by American College of Emergency Physicians) anticipated when the new health care reform goes into effect (how many new hospitals are anticipated to be constructed in your area within the next 3 years?--that's right none.)

As for showing up for work. Most ED docs will do so provided they are given the proper protective equipment and have adequate resources. We like everyone else have a self preservation mechanism and as we cynically say in the ER: The waiting room will be full when you (the health care worker) are 6 feet under so don't worry about the patients waiting or not getting treated--you cant save the world.

By BostonERdoc (not verified) on 02 Apr 2010 #permalink

So what is the point of the post? That the ED personnel are at risk? Already well known and understood.

Or that you (as a self-proclaimed public health "professional") cannot figure out how to pay for access to an academic article?

Seriously. Get credible please!

Although the numbers are small, and their infection rates are far lower than MDs and RNs, the infection rate among Housekeeping & Food Services and Security & Transportation personel look rather high. Could it be that those involved in direct provision of medical services are too self-absorbed to think about the safety of, and potential for infection via worker-bees?

By frank_grupt (not verified) on 05 Apr 2010 #permalink

re 9---Nice point, Frank Grupt, and in this regard, does anyone think that bundling and/or other reductions in Medicare pay rates to hospitals is going to lessen readmissions/tests/etc. rather than to shrinking janitorial staff? with the results one might expect.