White Paper

Infectious Disease Incidents and the Workplace: Cases and Key Lessons Learned for a Global Organization

International SOS White Paper Series Infectious Disease Incidents and the Workplace is published by International SOS and written by Myles Druckman MD, Vice President, Medical Services and Dr. Irene Lai MBBS, Deputy Medical Director, Medical Information and Analysis, International SOS

DISCLAIMER The content of this paper is for general informational purposes and should not be relied on as legal advice.
DISCLAIMER The content of this paper is for general informational purposes and should not be relied on as legal advice.

Infectious Disease Incidents and the Workplace

Table of Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 Selected Published Health Incidents in the Workplace . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 USA, June 2010: News reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 German measles at International Shareholders Meeting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 Measles in an employee in Boston . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 United Kingdom, 2007: Investigation of Workplace Contacts of Bird Flu Cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 Workplace Contacts of Bird Flu Cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 USA, 2006: Measles Outbreak Boston . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 New Zealand, 2002: Community and Workplace Outbreak of Tuberculosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 USA,1999: Large German Measles Outbreak, Spread From the Workplace . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 France, 1995-96: Winter Epidemic of Diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . USA, 1987: Mumps in Chicago . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 Selected International and National Guidance on Workplace Infectious Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 World Health Organization (WHO) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 International Labour Organization (ILO) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 Guidelines for Workplace TB Control Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 SARS: Practical and Administrative Responses to an Infectious Disease in the Workplace, March 2004 . . . . . . . . . . . . . . . . . .9 International Labour Standard HIV/AIDS and the World of Work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 US Department of Labor, Occupational Safety & Health Administration (OSHA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 US National Institute for Occupational Safety and Health (NIOSH) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 Case Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 Pandemic Preparedness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16 www.osha.gov . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17 www.ilo.org . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17 Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17 The Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18 Dr. Irene Lai MMBS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18 Myles Druckman MD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18 About International SOS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19

Introduction
The last decade has seen a significant increase in the globalization of many organizations, with their international operations increasingly becoming a critical component to their overall business growth and potential for success. Global workforce populations are changing and employees from vastly different regions of the world are now interacting and working together as never before. With this business evolution comes new challenges, including the increasing risk of infectious disease incidents in the workplace. If employees, through the course of their workday, meet or work with other people, then there is the potential for their workplace to become the site of the spread of an infectious disease. An infectious disease outbreak involving the workplace can significantly disrupt business activities, leading to financial and reputational losses. Although some infections come from animals and insects, many are spread from person-to-person, either directly or perhaps through inanimate everyday items such as computer keyboards or telephones. Infection control in the workplace begins by assuming that everyone is potentially infectious1. Workers who become infected in the workplace may go on to spread disease to other co-workers, their families and their communities. Occupational health and safety regulations and guidance related to infectious disease are generally aimed at occupations where the exposure to infection is higher than during the course of daily living outside of the workplace. Such occupations put workers in contact with infectious people or body fluids, or animals and their by-products. At-risk industries include healthcare, sewage treatment, childcare/school, correctional facilities, slaughter houses and farms. The one area where published guidance is often available for organizations outside these higher risk fields is in influenza pandemic planning. The term workplace is referenced in this paper to define offices and workplaces that are not higher-risk environments. This paper examines the landscape of infectious diseases which spread from person-to-person in workplaces where the risk is not enhanced by the nature of the job itself.

As organizations seek new opportunities for growth, they are expanding operations to all corners of the globe. This expansion brings employees from various regions of the world together in unprecedented ways. This business evolution has highlighted the increasing risk of infectious disease outbreaks, and their impact on both employee health and business productivity. These incidents are not uncommon, and cases will be reviewed, along with the key lessons learned.

Infectious Disease Incidents and the Workplace

In this paper, selected published incidents are outlined and International SOS internal polls are reviewed. Selected international and national guidelines on workplace infectious diseases are presented. Three examples of corporate infectious disease incidents are offered, with specific lessons learned. This paper does not explore workplace food-borne infectious outbreaks, nor workplace biological emergency preparedness.

medically underserviced locations where outbreaks of vaccinepreventable and other diseases are not unusual. Global workforces are merging, and employees regularly travel abroad for work. As employees move, so will infectious diseases, including illnesses which are now uncommon in some societies.

Sidebar 1 Consistent among corporate best practices in health incident planning and response are:

Overview
The impact of infectious disease in the workplace can be significant. Even when just a few employees are affected, the incident can ripple throughout an organization, damaging the companys external reputation. One case of meningococcal meningitis, regardless of the source of infection, will cause concern in anyone who had any contact with the infected person. The United Kingdoms Meningitis Trust states, Our research indicates that for every person who contracts meningitis, it actually affects up to 20 people around them, including family, friends and work colleagues. If there is a case of meningitis in your workplace, it may cause a high level of anxiety and fear amongst employees, so it is extremely important that accurate information is given to employees. It continues to state that, Employers face key business issues when an employee is affected by meningitis, whether that employee contracts the disease themself, or is affected because a close friend or family member has the disease. Issues including staff response, customer relations, and productivity can all have an impact on a companys bottom line. Health incidents in the workplace can shake employee confidence, raise anxieties and ultimately affect their personal health. Some infectious disease outbreaks typically affect only a small number of individuals. Some, like the pandemic influenza (H1N1) outbreak of 2009, demonstrate the potential to rapidly affect a large segment of the employee population. Data regarding infectious disease incidents and outbreaks in the workplace is scarce and corporations are typically cautious in discussing or documenting such cases in a public forum. Where data is available, it typically analyzes the incident from a public health standpoint and the impact on business operations is overlooked. Nevertheless, it is clear that such incidents do occur in the office setting and appear to be becoming more common. Dr. Michael Osterholm, the director of the Center for Infectious Disease Research and Policy at the University of Minnesota, advised that they are receiving requests from more and more organizations seeking assistance in managing tuberculosis, measles and other infectious disease outbreaks in the USA, with many of these cases originating from employees or contacts from developing nations.2 Many organizations work in remote and

I a systematic process for global health risk assessment; I proactive planning of anticipated and potential health incidents; I well-oriented and educated management teams; I pre-arranged emergency responders external providers; and I strong internal and external integrated communication processes.

The impact of an infectious disease in the workplace can be significant, even when few employees are affected. for every person who contracts meningitis, it actually affects up to 20 people around them, including family, friends and work colleagues Planning for such events is a recommended corporate best practice. Outside of pandemic planning, little guidance on infectious disease health and safety for the non-higher risk industries is available.

Selected Published Health Incidents in the Workplace

While publications of infectious disease outbreaks in the workplace (outside of healthcare) are limited and data is scarce, some government authorities accept that what data is available is a gross under-representation of the real situation. Atleast in the United States, outbreaks of diseases are often newsworthy, with popular media naming the organizations involved. Many workplace outbreaks, though, do not see the light of day as organizations typically seek to limit any external visibility to the incident.
Although public health organizations investigate workplace infectious disease incidents, official statistics often do not distinguish outbreaks in the general community from work placebased transmissions. The London Hazards Centre states for the United Kingdom that, Government sources reported 1,100 cases of work-related infections in 2003. They accept this is probably a gross under-representation of the real situation.3 In the United States, of the 14 rubella [German Measles] outbreaks reported to the Centers for Disease Control and Prevention (CDC) in 1996-1998, seven were workplace-associated.4 A number of reports in public health and medical journals are available, as well as anecdotal reports from news services. These serve as evidence that the potential for outbreaks in the workplace is real.

USA, June 2010: News Reports German measles at international shareholders meeting An international Walmart shareholders meeting was held at the University of Arkansas in early June of 2010. An attendee became ill with a rash and was hospitalized, which was confirmed as rubella (German Measles). The Department of Public Health investigated and vaccinated over 140 persons who were potentially exposed.5 At the time of writing, no secondary cases had been identified. While the meeting proceeded, the incident created significant concern in the wider community. Measles in an employee in Boston An employee of Reebok was diagnosed with measles in June 2010 and had apparently traveled abroad.6 The organization is working with the public health department and "requiring all employees to show proof of their immunity to measles or be vaccinated.7 Throughout the community, more than 500 people were vaccinated to prevent further spread.

Infectious Disease Incidents and the Workplace

United Kingdom, 2007: Investigation of Workplace Contacts of Bird Flu Cases In May of 2007, an outbreak of low pathogenic bird flu H7N2 occurred in a poultry farm in North Wales. Investigators found birds infected in three poultry premises, linked to a market in north-west England. Four people were confirmed infected.8 At the time, an extensive investigation and contact tracing were performed. Over 200 contacts were identified and more than 80 people received antiviral medication, either as treatment or preventative. Of those contacts, more than ten had flu-like symptoms or conjunctivitis thought to be possibly due to H7N2 bird flu.9 Subsequent analysis of the data showed that home and workplace encounters were more likely to result in transmission than encounters in other settings.10 Workplace settings included the general office environment.11 Follow up testing results in January of 2008 of those who had symptoms at the time did not confirm H7 bird flu as the cause of their symptoms.12 Nevertheless, this clearly demonstrates the workplace to be a potential primary site for an outbreak of novel influenza. The disruption to business is not documented. USA, 2006: Measles Outbreak in Boston An international employee of a financial services firm was the index (first) case in an outbreak that eventually infected 18 people in May. The primary exposure setting for this outbreak was a large office building and nearby businesses.13 A detailed case presentation is given later in this document (see Case Studies), from International SOS internal operational records. New Zealand, 2002: Community and Workplace Outbreak of Tuberculosis The index case was a general floor cleaner in a meat processing factory who was hospitalized in June. While it could not be conclusively proven, it was thought that the infected worker had transmitted the disease to possibly as many as 39 co-workers14 (ten with active disease and 29 with a latent infection). The impact on the workplace affected is not documented, however, under public health guidelines, highly infectious cases of tuberculosis are kept in isolation, sometimes in the hospital, for at least two weeks after the start of treatment. USA, 1999: Large German Measles Outbreak, Spread From the Workplace In March of 1999, an employee with a meatpacking plant in Nebraska was diagnosed with rubella. The outbreak lasted four months, and spread from the workplace to the wider community and other counties within the state. Over 120 cases were confirmed.4 France, 1995-96: Winter Epidemic of Diarrhea The French Sentinelles Network tracks several health indicators, including acute diarrhea.15 Their data shows annual winter outbreaks of acute diarrhea are common in France. During the epidemic of January of 1996, it was estimated that over 600,000 people with diarrhea throughout France consulted a doctor.16 Analysis of the data found that infections were not

Sidebar 2 International SOS Poll Date: 5 February, 2008

Fifty large US-based corporations took part in a poll asking about preparedness and experience with workplace infectious disease outbreaks. Industries represented included automotive, clothing, financial, IT, manufacturing, mining, oil and gas, and pharmaceutical.

I 52% had pandemic plans which extended to include other

infectious diseases.

I 46% had described a workplace infectious disease incident that

significantly affected business operations with some loss of productivity. I The diseases which caused most concern were tuberculosis and MRSA, followed by norovirus.

related to consumption of shellfish (oysters) or tap water as had been thought. The greatest risk factor was exposure to a household member with diarrhea, followed by contact with a sick person in the workplace. USA, 1987: Mumps in Chicago This was apparently the first documented outbreak of mumps in the workplace.17 The incident resulted in over 100 confirmed cases in employees of three future exchange houses in Chicago and their household members. 21 cases developed medical complications, including some pregnant women, and nine were hospitalized. Unlike other reports of workplace health incidents, the economic cost in this case was determined - based on average costs for physician visits, hospital charges, medications, vaccination, average hourly wage for those involved in investigations, and average daily wage for ill employees. Total direct and indirect economic costs associated with the outbreak were $120,738; the cost-per-case was $1,473. The impact to the organizations involved was not analyzed.

Transmission of infection does occur in the workplace, although the degree to which is not quantified. The workplace may even be the site of an outbreak of a novel human infection. If incidents are recognized early and actions taken, the number of people infected and the duration of the outbreak can be minimized.
7

More and more organizations are seeking assistance in managing infectious disease incidents in the workplace. International SOS is most often asked for guidance on tuberculosis and measles. Other diseases that result in requests for assistance include meningococcal meningitis, cholera, varicella (chicken pox), legionella, pandemic (H1N1) 2009 flu and avian flu H5N1.

Selected International and National Guidance on Workplace Infectious Diseases

World Health Organization (WHO) In 2004, WHO held an inter-country consultation on tuberculosis (TB) in the workplace. The objective of the communication was to establish a common consensus on approaches to introduce TB control practices in the workplace, both as a means of widening access to quality TB control services to TB patients at work, as well as to address the challenge posed by TB to growthoriented employers in the corporate sector.18 The report highlights that organizations play a crucial part in promoting and implementing TB control activities. A number of benefits flow to employers, such as higher productivity and morale amongst workers, and an improved corporate image through the demonstration of corporate social responsibility. The three elements of a framework for TB control in the workplace are: I A policy statement that includes an expression of commitment; I A communications strategy, and I A strategy for implementation. In 2003, the World Health Organization and International Labour Organization published joint guidelines on TB control programs in the workplace. (see next page)

International Labour Organization (ILO) ILO has published two documents (excluding pandemic guidance) relevant to organizations on infection control in a nonhealthcare setting. These relate to tuberculosis and Severe Acute Respiratory Syndrome (SARS). The ILO also sets an international standard on Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS) prevention, treatment and support in the workplace.

Infectious Disease Incidents and the Workplace

Guidelines for Workplace TB Control Activities Published in 2003 with WHO, the document states that these guidelines represent the first comprehensive approach to workplace TB control.19 Activities to improve control of TB include linking to local public health, the education of employees, referral of sick employees for diagnosis and treatment, and the support of workers throughout their treatment. Outside healthcare and correctional facilities, there are workplace settings considered at increased risk of TB transmission See Sidebar 3. For the workplace to be safe from TB, the guide advises: I Education: Health education campaigns which de-stigmatize the illness; I Clear management policies: For sick leave, confidentiality, and the prompt recognition of symptoms and referral for medical care; I Implementing environmental controls: To prevent or reduce airborne transmission from unsuspected cases or from diagnosed cases of TB to non-infected employees. Sidebar 3 WORKPLACE SETTINGS WITH INCREASED RISK OF TB (adapted from table 2)
Oil and gas industries, and plantations Cramped living quarters and potentially poor health conditions

to ensure sick people are prevented from coming into the workplace. Both WHO and ILO implemented such screening during international conferences during the SARS outbreak, and they noted that screening practices may have done much to reduce the spread of SARS. Of note, workplaces that involve contact with the general public, such as shops and banks, are advised to encourage employers to empower workers to take action if they feel that their right to a safe and healthy workplace is being jeopardized by a member of the general public. During times of an outbreak of SARS in a community, suggested additional actions to take to reduce the risk of SARS include: I Preventing close physical contact in the workplace; I Preparing an area where sick workers can be isolated; and I Storing personal protective equipment. The document concludes by noting that a planned response to SARS is relevant to other epidemic diseases, including tuberculosis and cholera, and preparedness in the workplace and community at large is necessary. International Labour Standard HIV/AIDS and the World of Work In June of 2010, the ILO released21 a new standard for HIV/AIDS in the workplace.22 The standard is a recommendation and supports the existing Code of Practice on HIV/AIDS from 2001. National authorities must now discuss and implement this through national policies and legislation. The standard promotes non-discrimination and emphasizes HIV and AIDS should be recognized and treated as a workplace issue. Prevention is a priority and requires access to information and education. The workplace plays a role in facilitating access to treatment, care and support for those with HIV/ AIDS.

Mining industry

Silicosis and cramped living quarters Poverty, poor sanitation and living conditions, and birth in countries with high TB infection rates

Businesses with a large migrant workforce

SARS: Practical and Administrative Responses to an Infectious Disease in the Workplace, March 2004 Following a meeting of senior labor officials of ASEAN countries in 2003, where they shared experiences in dealing with the business impact of SARS, the group called on the ILO to produce an informal set of guidelines for SARS and the workplace.20 While the document is based on the SARS outbreak, the guidelines pertain to any infectious disease that is spread from person to person, and emphasizes the importance of preparation at all levels to contain such epidemics. For workplaces with no increased risk of SARS, hygiene practices already supported, such as routine daily cleaning and respiratory hygiene (covering coughs, washing hands) are emphasized. In addition, measures to encourage sick workers to stay out of the workplace until they are cleared are considered particularly protective during a SARS outbreak. Indeed, if SARS cases are occurring locally, or people are coming to the workplace from SARS affected areas, employers may feel it appropriate to institute active screening for fever and symptoms,

The United States Department of Labor, Occupational Safety & Health Administration (OSHA) expects employers to evaluate reports of infectious diseases, other than colds and flu, for their relationship to work. The United States National Institute for Occupational Safety and Health (NIOSH) provides limited guidance for organizations on MethicillinResistant Staph Aureus (MRSA) and pandemic influenza. Organizations must thus fill in the gaps to ensure they have actionable plans, including preprepared communications.

US Department of Labor, Occupational Safety & Health Administration (OSHA) Infectious diseases beyond simple illnesses such as colds and flu may need to be evaluated by an employer to determine the relationship to the workplace. Common colds and flu are not considered work-related even if contracted while the employee was at work.23 However in the case of other infectious diseases such as tuberculosis, brucellosis and hepatitis C, employers must evaluate reports of such illnesses for work relationship, just as they would for any other type of injury or illness. If more than one employee is affected with the same infection and those employees had contact with each other, then the employer would consider the case work-related. OSHA believes that non-minor illnesses resulting from exposure in the work environment are work-related and therefore recordable unless a specific exemption to the presumption applies. Infection from exposure to another employee at work is no different, in terms of the geographic presumption, from infection resulting from exposure to a client, patient or any other person who is present in the workplace. Evaluating whether an infection is work-related or not requires a certain amount of knowledge of infections and how they are transmitted. Organizations, especially those without access to targeted medical advice, may find this challenging.

US National Institute for Occupational Safety and Health (NIOSH) Apart from pandemic influenza,24 NIOSH singles out MethicillinResistant Staph Aureus (MRSA) for guidance to general workplaces (non-healthcare).25 Employers should prevent its spread by encouraging good hygiene and maintaining routine cleaning.

10

Infectious Disease Incidents and the Workplace

Case Studies
CASE STUDY 1 NOROVIRUS - London, United Kingdom Winter, 2008
In the winter of 2008, the United Kingdom experienced a large epidemic of norovirus. In early January, it was reported that nearly 100,000 Britons were getting ill on a weekly basis, and that 100 hospitals had closed their wards to new patients due to the surge of medical cases.26 In less than three months, nearly a million Britons had fallen ill to this virus. Norovirus causes gastroenteritis, with a sudden onset of nausea, violent vomiting, diarrhea, abdominal cramps, low-grade fever, headache and muscle aches. The infection is typically self-limited and not dangerous, although the very young and very old are most at risk of complications from dehydration. The virus is highly contagious, and outbreaks spread quickly. The virus is spread by contact with an infected person, through contaminated food or water, or by contact with contaminated surfaces or objects. The virus can also survive on hard surfaces. Patients may remain contagious for at least three days and often longer, as well as up to three days after they recover, so limiting the transmission is challenging. Proper hand hygiene is one of the key elements in controlling outbreaks. The impact of norovirus was experienced at the International SOS London alarm (call) center. Over a period of one week, 12 employees became temporarily incapacitated by the illness, with eight of them simultaneously unable to work. This level of absenteeism could have caused up to a 25% degradation in service capacity and could have led to massive service failures if not for the infectious disease planning that had been put in place. International SOS activated a number of key interventions which limited the impact of this infectious disease outbreak. On first news of the escalating norovirus epidemic in the general London community, we distributed pre-prepared frequently asked questions (FAQs) about norovirus to our employees. Employees were informed how to protect themselves and also how, if they fell sick, to limit spreading the illness to others, including colleagues and family members. Strict hand washing protocols were put in place upon entering the facility and after using washrooms. Additional cleaning was put in place, focusing on shared and commonly touched objects, using special cleaning agents. A Norovirus Awareness Questionnaire was instituted at the business entry so that anyone with symptoms would self-identify themselves and not enter the facility. Close contact with ill personnel also could be self-identified by the questionnaire and their entry to the facility managed. Even with these procedures rapidly implemented, two cases occurred and within 48 hours, six additional cases followed. The business continuity plan included the ability to transfer incoming calls from the London alarm center to other International SOS alarm centers around the world. Calls were re-routed to the United States and Singapore, and there was no disruption to our business operations from our clients perspective. Other important actions undertaken included the modification and implementation of travel restrictions for our staff traveling to, or returning from, the UK. In this case, non-essential travel to London was postponed, and only business-critical travel to London could proceed after seeking approval by management. Travelers returning from London were required to self-quarantine for the incubation period before they were allowed entry to the workplace, to ensure they were not at risk of infecting their work colleagues. Fortunately, norovirus is typically a self-limited illness that resolves in a few days without specific treatment. That being said, the illness remains the most common cause of gastroenteritis in the UK. Winter outbreaks occur annually, with some years being more significant than others.27

The fact that International SOS identified the threat early, before cases occurred in our employees, and had a plan ready to be put into action, significantly reduced the impact of the illness on our personnel and business operations.
11

Case Studies (Continued)

CASE STUDY 2 MEASLES - Boston, MA, USA Spring, 2006
In the spring of 2006, an employee of a major financial firm developed severe fever and malaise while at work on a trading floor in Boston. The employee, who recently arrived from India, sought medical attention and measles was diagnosed.28 The disease spread to 18 others, through several other places of business, and into the general community over several weeks before being brought under control. Measles is one of the leading causes of death among young children, with over 197,000 deaths globally in 2007.29 While targeted vaccination programs have made significant inroads in reducing measles cases and deaths a 74% drop in deaths from 2000 to 2007 globally, only 82% of children receive one dose of measles vaccine by their first birthday (two doses are recommended since 15% of vaccinated children fail to develop immunity from just one dose). The virus is highly contagious, and is spread through the air via coughing and sneezing. The virus remains active and contagious in the air or on infected surfaces for up to two hours. It can be transmitted by an infected individual from four days prior to the onset of a rash, to four days after the rash erupts. Measles is a notifiable disease in many nations, including the US, which means that once the disease has been diagnosed, the doctor must report the case to local public health authorities. Local health authorities will then assess the situation and activate diseases control measures, including contact tracing and mass vaccination as appropriate. As expected, once the employee was diagnosed with measles, the local city public health authorities immediately contacted the company and commenced contact tracing. Health authorities were planning to close the trading floor pending review of the immunity status of all employees working at the facility. The employees were understandably concerned, as was the management of the company. It was clear that the objectives of the local public health authority did not include maintaining and supporting the business needs and obligations of the company. With the office closed and millions of dollars of portioning revenue disappearing every hour, the company aggressively negotiated with the public health authorities to agree on a solution to meet both the public health obligations while, at the same time, allowing the company to reopen their business operation. While the public health authorities wanted documented clinical evidence of appropriate vaccination status (or immunity to measles), the company regarded this as very time consuming. The company planned an in-house mass measles vaccination program through a local medical provider willing to perform a mass measles vaccination program for the affected employee population. Finally, the solution agreed upon was for each employee to either have documented evidence of their immunity from their family physician (documentation of previous infection or two doses of vaccine), or to participate in the mass measles vaccination program. The company was finally able to resolve the situation and have their employees return to work, but not before a number of days were lost with business disruption costs estimated in millions of dollars.

12

Infectious Disease Incidents and the Workplace

CASE STUDY 3 TUBERCULOSIS USA 2007

Two major corporations based in the same city in the USA became aware of a single case of tuberculosis in one of their respective employees. As with the measles incident previously mentioned, one company did not have a corporate medical director. The other company had a full-time, dedicated physician. In both cases, the patients developed symptoms of active tuberculosis while at work, and both patients were residents of developing countries where they initially contracted the illness. While the clinical condition was managed by the local medical providers in coordination with the local public health authorities, the challenges the companies faced related to both communication and business disruption. Public health authorities performed contact tracing, which caused increased employee anxiety and increased demands on the companies to provide guidance and direction. Risk communications were the key challenge. Within hours, executive management wanted a formal update and assessment of the situation and the plan of action. The company without a medical director scrambled to try to find a local infectious disease expert who could be available within a few hours to speak to their CEO and board, and brief them on the issue and a plan of action. They were unsuccessful. The public health authorities were also unable to speak to management. This left non-medical middle managers to attempt to rapidly understand this complex issue and explain a plan of action to their bosses. The next challenge was to present a clear communication plan for the employees. A town hall meeting was set up, but again, the company was unable to find a local doctor to discuss the issues, nor were the local public health experts available. It also became clear to the company that a doctor off the street would potentially be a liability, as the presenting physician would need to know not only the clinical issues, but also the corporate culture and business strategies of the organization. The lack of medical leadership and expertise led to a disruptive and unsatisfactory resolution of the incident. The outcome of this incident highlighted the need for a corporate medical resource, and the company ultimately did retain the services of a corporate medical physician. On the other hand, the organization which had a corporate medical director was able to more effectively communicate the risks and develop plans for management and to present to the employee base. As well, the medical director interfaced with the local public health authorities, and made their contact tracing efforts more efficient and less disruptive to the organization. The incident required the services of the medical director for three full days, and then on-going monitoring of the outcomes over next few weeks and months. The overall management of the event resulted in less business disruption and employee anxiety.

The organization which had a corporate medical director was able to more effectively communicate the risks and develop plans for management and to present to the employee base.

13

Pandemic Preparedness
Corporate influenza pandemic planning began in earnest in 2004, shortly after the global outbreak of severe acute respiratory syndrome (SARS) was brought under control, and following the appearance of human cases of influenza A/H5N1 (bird flu), in Vietnam and Thailand. Influenza A/H5N1 is a novel influenza virus with pandemic potential. Although it continues to infect birds and is occasionally transmitted to humans, it does not spread easily from person to person. If it should mutate to gain the ability to readily pass from one person to the other, it could cause a pandemic. Initially, there was little guidance, other than for the healthcare sector, on the risks of pandemic influenza and the actions to be taken to mitigate those risks. As the threat of bird flu H5N1 increased, authorities recognized that pandemic influenza could potentially affect every aspect of the globally connected just-intime economy. There is now a significant amount of guidance for organizations on pandemic influenza planning, including the International Labour Organization,30 US Federal Government,31 OSHA,32 and the United Kingdom Cabinet Office33 to name a few. Financial institutions were some of the earliest to adopt pandemic planning, as their financial risk management teams assessed the potential financial threat of a pandemic, and their results drove them to aggressively develop plans to mitigate these risks. At the same time, organizations with major assets in Asia began to consider pandemic planning, driven by local management concerns from early outbreaks of H5N1 in their area. For those companies affected by SARS, lessons learned included the need for: I Pre-arranged internal communications to combat misinformation in the media and local communities; I Clear travel management programs to ensure personnel are oriented and aware of infectious outbreaks; and I Identifying travelers at risk and interacting with them on a real time basis.

Unlike other infectious disease risks, there is now a significant amount of guidance for organizations on pandemic influenza planning.

During the early stages of pandemic H1N1 in 2009, the most common causes of calls for assistance to International SOS included:
People placed in mandatory quarantine upon arrival in a foreign country, unaware of the risk when they departed; Guidance on the management of H1N1 in an employee; Access to antiviral medications; and Access to pandemic vaccines.

14

Infectious Disease Incidents and the Workplace

Important work and research from World Health Organization (WHO) and the Centers for Disease Control (CDC) in Atlanta provided the basis for many corporate pandemic plans. The concepts of Non-Pharmacological Interventions (NPI), Targeted Layered Containment (TLC) and antiviral medication stockpiling were key strategies utilized by many organizations to build their internal corporate pandemic plans. The WHO defined six discrete pandemic phases,34 each phase linked to the evolution of a novel influenza virus ability to cause illness in humans, its ability to spread readily from human to human and its global spread. Many national and corporate pandemic plans linked their pandemic interventions to the escalating WHO pandemic phases. In April of 2009, Mexican health authorities became aware of an outbreak of an unknown respiratory illness that was rapidly spreading through communities, causing hospitalization of hundreds of people, and resulting in a number of fatalities. By late April, it became clear that this was a novel influenza virus, initially termed swine flu, and it had already spread to Canada and the USA at the least. Over the next five weeks, this new flu spread widely and rapidly around the world, with most cases initially transmitted by travelers from Mexico and the USA. On June 11, 2009, WHO finally declared a pandemic. The virus was officially termed a pandemic (H1N1) 2009 influenza. The pandemic flu (H1N1) of 2009 tested many assumptions in corporate pandemic plans. Plans had been written with avian flu H5N1 in mind, a severe virus that is fatal in about 60% of all who are infected. Pandemic (H1N1) 2009 is a mild illness in the vast majority of cases. It became clear that more than WHO phases were needed to inform the most appropriate corporate pandemic interventions, and many plans required re-tooling. Most corporate pandemic plans included Phase 6 actions that were the most aggressive and invasive of pandemic interventions such as working from home, point-of-entry Need higher resolution image/text/chart; currently unreadable. screening, the use of personal protective equipment, antiviral distribution, and in some cases, facility closure. WHO phases did not differentiate severity. In addition, WHO phases did not differentiate between locations. Once a phase escalation was declared, the whole world was then in that phase. While aggressive interventions were appropriate in Mexico City at the height of the outbreak, when schools were closed and public gatherings cancelled, such measures would have been inappropriate in places with no, or very few, cases. From WHOs perspective, each location was at the same Phase 6, though the actions companies took varied widely, based on the impact of the influenza virus on the local community.

Lessons learned from the first wave of H1N1 influenza revealed a gap in the timing of pandemic interventions. While the actual interventions themselves employee education, hygiene, travel restrictions, door screening, etc., still remained appropriate it was the timing mechanism of the activation that needed modification. Thus, a new generation of corporate pandemic plans evolved in the late summer and fall of 2009 and came into action. These plans included trigger points based on the number and trajectory of H1N1 cases, and the assessed level of severity of the virus. This gave organizations the flexibility to activate interventions which were proportional to the local pandemic situation. Pandemic plans became local; it was no longer a single plan but a tactical plan that was customized for the local site and managed locally. Anticipating the wave of infection in the local community became an important component of a pandemic plan. Surveillance relevant for a local plan required not only information from the WHO and CDC, but also required state and county public health data. Some companies collected information from multiple local sources including news, school absenteeism reports, hospital capacity spreadsheets and community sentiment to gauge where they were in the wave.

15

Conclusion
Corporate health incident planning, whether it is for a known infectious disease or an emerging illness, requires appropriate planning and resources. Assessment of an organizations global health exposure is a critical first step in plan development. Corporations are expected to be able to manage foreseeable incidents. Common illnesses such as measles, norovirus, tuberculosis, cholera and malaria must be addressed with an appropriate plan. Relatively uncommon illnesses with potentially severe impacts (such as meningococcal disease) should also be included in plans. The good news in planning for known illnesses is that information is available today to address most incident management issues in advance. Pre-prepared responses, including the notification of public health authorities, enhanced hygiene and cleaning, implementation of employee screening, quarantine, contact tracing and the distribution of pre-scripted frequently asked questions (FAQs) to employees will rapidly reduce anxiety and demonstrate an efficient and professional response. Another important resource in managing an infectious disease incident is a corporate medical resource. A corporate physician understands both the corporate culture and expectations, and the health needs of the employee. Corporate medical directors and their departments reduce confidentiality and privacy issues and can act as an efficient bridge between management and staff, and the local community. Corporate medical departments have been shown to play a critical role in health incident management, and more companies are realizing the importance of this expertise. Influenza pandemic may be considered one of the most challenging known global health threats. Because it can impact significant portions of a population over a short period of time, a severe influenza pandemic can shake the foundation of any

Infectious disease in the workplace is a corporate responsibility, and plans and corporate medical resources are critical components in ensuring adequate duty of care is provided.

16

Infectious Disease Incidents and the Workplace

organization. A comprehensive pandemic plan includes corporate level policies that guide local units, pre-scripted communications in multiple languages if appropriate, a local pandemic plan of escalating pandemic interventions based on community-based surveillance of influenza activity and severity, and business continuity plans to manage absenteeism, sales degradation and supply chain disruption. As the human population grows and there is more global travel, emerging diseases are likely to not only continue to occur, but also affect more communities more rapidly. In these cases, effective surveillance, corporate medical resources and health incident plans will be crucial in ensuring that an organization is best prepared to meet any new health challenge that may suddenly arise.

Acknowledgments
The author is grateful for the assistance and feedback received on the content of this paper from the following individuals at International SOS: Leigh Burns, Group Product Director, Medical Consulting and Training Services Nicolau Chamma, MD, MPH, Regional Medical Director, Medical Services - Americas Region Ana Mensua, MPH, Public Health Advisor Doug Quarry, MBBS MSc (Community Health), Medical Director, Medical Information and Analysis Francesca Viliani, MPH, MSc (Humanitarian Affairs), Director, Public Health Services

Related Websites www.osha.gov United States Department of Labor, Occupational Safety and Health Administration. The US body for ensuring safe working conditions through setting and enforcing standards, and providing training. The Website includes published standards, regulations, data and statistics, fact sheets and guidance documents. www.ilo.org International Labour Organization. The tripartite body of the United Nations, representing government, employers and workers for member states. The Website includes published labor standards, statistics and databases on recommendations, and occupational health and safety.

17

The Authors
Dr. Irene Lai, MBBS Dr. Lai is the Deputy Director of Medical Information and Analysis at International SOS. She is one of the companys lead pandemic preparedness experts, and provides technical and practical guidance to the group on a global basis. She oversees the medical input for medical consultancies worldwide, including numerous Fortune 500 Companies, as well as consulting directly with a number of clients. She was instrumental in developing the Pandemic Preparedness suite of products and continues to enhance these. Irene joined International SOS in 1997 as a Coordinating Doctor in the Singapore office. Since then, she has held different roles within the group during postings in Sydney, Australia and Jakarta, Indonesia. Irenes Medical Degree is from the University of Sydney (Australia). She trained primarily in internal medicine and clinical research. She worked as a Medical Registrar in a number of tertiary teaching hospitals in Sydney before practicing at Northwestern Memorial Hospital, Chicago and then New York University Medical Center. She holds current medical licenses in Australia and Hong Kong.

Myles Druckman, MD Dr. Druckman is Vice President, Medical Services for International SOS, where he leads the development of customized corporate health solutions for multinational organizations that support the health of their personnel wherever they may live or work globally. Considered a leading pandemic expert and thought leader in international corporate health, Dr. Druckman has served as a resource for international and national media such as CNN, CNBC and Consumer Reports on topics such as the global management of emerging diseases, pandemic preparedness, and medical crisis management. In addition, Dr. Druckman lectures widely and regularly publishes articles on international healthcare issues. Previously, Dr. Druckman held the position of Vice President, Medical Assistance for International SOS in the Americas region. Prior to this role, Dr. Druckman was Regional Medical Director for International SOS in North Asia where he was based in Beijing, China for five years. He developed and managed four International SOS clinics, three International SOS alarm centers and 26 remote operations. Prior to joining International SOS, Dr. Druckman spent five years in Moscow, where he founded the first Western medical facilities in the former Soviet Union, in Moscow, St. Petersburg and Kiev. Dr. Druckman holds a Bachelor of Science degree from McGill University and a Medical Degree from McMaster University Medical School. He presently holds medical licenses in the United States and Canada.

18

Infectious Disease Incidents and the Workplace

References
1

15

Sentinelles http://websenti.u707.jussieu.fr/sentiweb/?page=presentation Risk factors for winter outbreak of acute diarrhoea in France: case-control study, Letrilliart, Desenclos and Flahualt, British Medical Journal, 1997;315:1645-1649 http://www.bmj.com/cgi/content/full/315/7123/1645/a

16

Work Issues - Infection Control, Better Health Channel, Victorian State Government http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/W ork_issues_infection_control?OpenDocument M. Osterholm, CIDRAP Summit 2009, Center for Infectious Disease Research and Policy (CIDRAP), University of Minnesota, Editor. 2009 London Hazards Centre Fact Sheet http://www.lhc.org.uk/members/pubs/factsht/85fact.pdf A Large Rubella Outbreak With Spread From the Workplace to the Community, Danovaro-Holliday, LeBaron et al, Journal of the American Medical Association. 2000; 284:2733-2739 http://jama.ama-assn.org/cgi/content/full/284/21/2733 Arkansas Department of Health, Press Release,June 9, 2010 http://www.arkansas.gov/health/newsroom/index.php?do:newsDe tail=1&news_id=263 Boston Globe, June 16, 2010 http://www.boston.com/news/health/blog/2010/06/measles_confir m.html CBS Local News WBZ TV, June 15, 2010 http://wbztv.com/local/measles.reebok.headquarters.2.1753505.h tml World Health Organization, Disease Outbreak News, June 4, 2007 http://www.who.int/csr/don/2007_06_04/en/index.html Wales Health Board, News, June 1, 2007 http://www.wales.nhs.uk/sitesplus/862/news/6831 Assessing the role of contact tracing in a suspected H7N2 influenza A outbreak in humans in Wales. Eames, Webb et al. BMC Infectious Diseases 2010, 10:141 http://www.biomedcentral.com/content/pdf/1471-2334-10-141.pdf accessed June 15, 2010 Intl. SOS personal correspondence from Dr Ken Eames, London School of Hygiene and Tropical Medicine, June 16, 2010 and Dr Mark Temple, Public Health Wales, Health Protection, June 17, 2010 Wales Health Board, News, January 24, 2008 http://www.wales.nhs.uk/sitesplus/862/news/8453 US Centers for Disease Control and Prevention, Summary of Notifiable Diseases: Measles USA 2006 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5553a1.htm A community and workplace outbreak of tuberculosis in Hawkes Bay in 2002, McElnay, Thornley, and Armstrong, New Zealand Medical Journal, August 20, 2004, vol 117 No 1200 http://www.nzma.org.nz/journal/117-1200/1019/

17 2

Mumps in the Workplace, Further Evidence of the Changing Epidemiology of a Childhood Vaccine-Preventable Disease, Kaplan, Marder et al, Journal of the American Association, 1988;260(10):1434-1438 http://jama.amaassn.org/cgi/reprint/260/10/1434 TB Control in the Workplace, Report of an Inter-Country Consultation New Delhi, February 19-20, 2004, World Health Organization, Regional Office for South-East Asia, http://www.searo.who.int/LinkFiles/Reports_TB-269.pdf Guidelines for workplace TB control activities, World Health Organization and International Labour Organization, Geneva, Switzerland, 2003. http://whqlibdoc.who.int/publications/2003/9241546042.pdf Working Paper: SARS - Practical and administrative responses to an infectious disease in the workplace, International Labour Organization Sub-regional Office for East Asia, March 2004 http://www.ilo.org/wcmsp5/groups/public/--ed_emp/documents/publication/wcms_115129.pdf International Labour Organization, Press Release, June 17, 2010: ILO conference adopts unprecedented new international labour standard on HIV and AIDS http://www.ilo.org/global/About_the_ILO/Media_and_public_infor mation/Press_releases/lang--en/WCMS_141928/index.htm International Labour Organization, Text of the Recommendation Concerning HIV and AIDS and the World of Work, June 2010 http://www.ilo.org/wcmsp5/groups/public/---ed_norm/--relconf/documents/meetingdocument/wcms_141906.pdf US Department of Labor, Occupational Safety & Health Administration, OSHA Recordkeeping Handbook. The Regulation and Related Interpretations for Recording and Reporting Occupational Injuries and Illnesses http://www.osha.gov/recordkeeping/handbook/index.html US National Institute for Occupational Safety and Health, Employer Guidance: Reducing All Workers Exposures to the 2009 H1N1 Flu, accessed June 15, 2010 http://www.osha.gov/h1n1/nonhealthcare.html US National Institute for Occupational Safety and Health, MRSA and the Workplace, accessed June 15, 2010 http://www.cdc.gov/niosh/topics/mrsa/ BBC News Channel. "Stomach bug sweeping the country". 2008 [cited; Available from: http://news.bbc.co.uk/1/hi/health/7169347.stm]

18

19

20

21

22

10

23

11

24

12

13

25

14

26

19

27

Health Protection Agency England & Wales. Topics: Infectious diseases, Norovirus. 2009 [cited; Available from: http://www.hpa.org.uk/HPA/Topics/InfectiousDiseases/InfectionsA Z/1191942172966/] International SOS Medical Alert Measles cases in Boston, Massachusetts, June-July 2006 WHO, Fact sheet no.286: Measles 2008

28

29

30

International Labour Organization, Guidance on Preparing Workplaces for an Influenza Pandemic http://www.ilo.org/employment/Whatwedo/Publications/lang-en/docName--WCMS_115803/index.htm United States Federal Government: Business Planning Information http://www.flu.gov/professional/business US Department Of Labor, Occupational Safety & Health Administration (OSHA), Guidance on Preparing Workplaces for an Influenza Pandemic http://www.osha.gov/Publications/influenza_pandemic.html United Kingdom Cabinet Office: Pandemic Flu Guidance for Work place/ Business http://www.cabinetoffice.gov.uk/ukresilience/pandemicflu/guidanc e/business.aspx WHO current phase of pandemic alert http://www.who.int/csr/disease/avian_influenza/phase/en/

31

32

33

34

20

About International SOS

International SOS (http://www.internationalsos.com) is the worlds leading international healthcare, medical assistance, and security services company. Operating in over 70 countries, International SOS provides integrated medical, clinical, and security solutions to organizations with international operations. Services include planning and preventative programs, incountry expertise, and emergency response. A global team of 7,000 employees led by 970 full-time physicians and 200 security specialists provides health and security support to enable its members to operate wherever they work or travel. Members include 69 percent of the Fortune Global 500 companies.

2011 All copyrights in this material are reserved to AEA International Holdings Pte. Ltd. No text contained in this material may be reproduced, duplicated or copied by any means or in any form, in whole or in part, without the prior written permission of AEA International Holdings Pte. Ltd.

21

For more information on Infectious Disease Incidents and the Workplace, please contact International SOS www.internationalsos.com/pandemicpreparedness