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As the influenza season begins, EIN members are dealing with novel H1N1 influenza in health care settings and concerns about staffing. The Centers for Disease Control and Prevention (CDC) currently recommends reassignment of high-risk health care workers (HCWs) who could be exposed to the virus. Several groups, including IDSA and the Society for Healthcare Epidemiology (SHEA), have raised concerns and recommended against this approach (see “From the President”).
A comment from an EIN member in New York started a recent discussion on the subject. “We have a few allogenic bone marrow transplant patients on the ventilator with H1N1 flu pneumonia,” the member wrote. “Some ICU RNs are refusing to care for them and requesting reassignment for fear of contracting the virus. We plan on coming up with a strong policy that mandates they care for these patients” unless HCWs are pregnant; have a chronic lung condition, such as asthma or chronic obstructive pulmonary disease (COPD); or are taking immunosuppressant medication. “If they still refuse, then they will face disciplinary action,” the member continued. “Does anyone else have a similar issue or policy?”
“We have not instituted reassignment for any of our workers at this point,” a Wisconsin member replied, although reassigning pregnant workers was being considered. “Beyond that, we expect them to adhere to the ‘duty to care policy.’”
Identifying and isolating patients with H1N1 will protect HCWs more effectively than trying to figure out what individual workers can and can’t do, “and it sends a better message about our protective measures and our responsibilities to our patients,” another member responded. “The point may quickly become moot when our staff becomes more likely to contract this virus in the supermarket or library than at work. I wonder how many of the staff refusing to care for these patients also refuse the vaccine?”
The member, from California, also referenced CDC’s H1N1 guidance regarding pregnant HCWs (additional CDC guidance on reassignment is available here) and summarized the joint position statement issued by SHEA, IDSA, and several others groups arguing against this approach: “They cite a number of concerns, including the potential impact on the workforce, HCW privacy, the issue of where to ‘draw the line’ (such as HCWs who have a compromised family member at home), and implications for care of patients with seasonal influenza.” Effective protective measures are available, the member noted, and HCW infection typically results from failure to use these measures or occurs outside of work.
A respondent from Massachusetts also cited the groups’ position statement and described a similar approach. “If we believe our infection control procedures are highly effective, unless we are dealing with an extraordinarily high-risk situation (which would be relatively unusual in someone well enough to work) we are not prepared to change work assignments.”
The ICU nurses’ behavior was “simply unethical,” according to a member from Missouri. Pregnant nurses are not excused from caring for patients with other infections, such as cytomegalovirus (CMV), because there is not at an increased risk if proper precautions are followed. “The same logic applies with H1N1. They should not be excused as they have no increased risk if they take appropriate precautions—mask[s] and good hand washing.”
With the exception of pregnancy, “once you start exempting people, it’s a tough cascade to stop,” a member from Connecticut warned. Other HCWs should not be exempted and should take other precautions, such as wearing personal protective equipment (PPE) for all patient exposure and considering neuraminidase prophylaxis for unprotected exposure until a vaccine is available, he added.
A member from Ohio shared the experience of a colleague from the initial H1N1 outbreak earlier this year, when HCWs first encountered the new influenza strain: “Pregnant women were not allowed to care for the patients,” the member wrote. “Our detailed explanations of the risks and our calm professionalism kept the doubts at bay. The fact that nobody contracted the disease in the face of the most ill patients bears testament to good preparation and follow through with precautions, protocols, and hand washing.”
Drawing on several decades of experience as an ID clinician, a respondent from New York highlighted the responsibility HCWs bear to care for those with “communicable, potentially life-threatening diseases.” The member continued: “Risks of disease acquired during the performance of health care are not new. What seems new is the perception that performing health care should be zero risk.”
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The Emerging Infections Network (EIN) is a provider-based sentinel network designed to help the public-health community detect trends in emerging infectious diseases.
A joint project of IDSA and the Pediatric Infectious Diseases Society (PIDS) and supported by funding from the Centers for Disease Control and Prevention (CDC), EIN tracks emerging infectious diseases and keeps the public-health community up to date with issues that are currently affecting or may soon affect members’ clinical practices. The Network provides a great opportunity for members to share knowledge quickly across large geographical distances. Both IDSA and PIDS members are eligible to join. The EIN listserve allows members to discuss new disease trends and difficult cases. Click here for more information or to join EIN.
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