Key findings from the discussions were HCWs' views on risk factors for occupationally acquired infectious diseases, their perceptions of illness and sickness-related absence, their views on monitoring absence and the structured collection of symptom data, factors affecting the willingness to report symptoms, factors affecting the validity of self-reported symptom data and knowledge and structural barriers for early recognition of nosocomial outbreaks.
Healthcare workers' views on risk factors for occupationally acquired infections
All participants described experiences of nosocomial infectious disease transmission in terms of infections they had acquired or witnessed colleagues acquire, stating common infections to be gastrointestinal and respiratory viruses, and less common meningitis, hepatitis, TB and HIV. They identified risk factors for occupationally acquired infections to be (1) exposure to patients with undiagnosed infectious diseases, especially in accident and emergency wards, (2) break-down in infection control procedures due to lack of knowledge, resources and equipment, (3) immuno-naïvety and (4) symptomatic colleagues; all of which are likely to occur during an EID outbreak. In general, nosocomial disease transmission risk was perceived to be low, although UK participants considered healthy people to be more likely to contract infectious diseases in a hospital than in the community. A breakdown in infection control procedures was deemed acceptable in some situations as some participants in Hungary, who worked in intensive care departments, expressed the view that they have 'more pressing issues' than following infection control procedures, such as 'saving lives'. Other members of this group however felt that staff, in particular accident and emergency staff, needed to be 'more afraid of patients' and thought intensive care staff to be more at risk, but also more aware. It was generally accepted that it was the responsibility of the individual HCW to report suspicion of nosocomial transmission incidences, though they expressed the belief that there was a need for more policies to protect the most vulnerable, such as for accident and emergency and pregnant staff. Participants' statements on risk factors for occupationally acquired infectious diseases are presented in appendix 2.
Healthcare workers' perceptions of illness and sickness-related absence
Participants believed HCWs' health to be perceived of low importance by themselves, peers and employers, resulting in little sympathy towards their own health needs. It emerged that they often experienced anxiety when reporting absence from work with an illness and described common feelings of scepticism and distrust between themselves and line managers. Consequently, they were reluctant to stay at home with mild symptoms and even felt they were expected to come to work under such conditions to relieve managers from staffing pressures as, at times, managers were required to cover these shifts themselves. They felt they lacked understanding concerning the relationship between severity of symptoms and infectiousness and at which point they may pose a risk to others.
The participants commented on the varying illness behaviour patterns and absence reporting practices across professions with doctors being those most likely to attend work with infectious disease symptoms (appendix 3). They stated that only severe symptoms such as high fever and acute pain would encourage higher level staff to be absent and highlighted a lack of clear guidelines for symptomatic staff in the work place. In addition, in Hungary, staff sick leave entitlements amount to less than their actual pay, further motivating HCWs to come to work when unwell or take sick leave as annual leave. Participants' statements on their perceptions of illness and sickness-related absence are presented in appendix 3.
Healthcare workers' views on monitoring their absence and symptoms for the surveillance of emerging infections and their willingness to report
During the discussions, a framework for a syndromic surveillance system was described to participants whereby absent staff, who suspected themselves of having a contagious illness, would be encouraged to report symptoms for daily monitoring and identification of potential outbreaks . All felt they had experienced activities similar to those suggested, having been asked to report symptoms, stay away from work and in some cases provide specimens when unwell during the recent H1N1 outbreak.
Whilst all HCWs agreed colleagues habitually reported symptoms informally when notifying their absence, a number of benefits of frequent monitoring were highlighted such as the ability to 1.) identify staff absenteeism, 2.) improve infection control monitoring, and 3.) prevent spread of infections resulting in reduced rates of illness.
Willingness to disclose symptoms for routine surveillance however varied. UK participants were more open towards discussing symptoms and were of the view their colleagues would also be, in cases where the sickness was genuine and the rationale of the reporting system understood (appendix 4). They were nevertheless also concerned that detailed enquiries could be perceived as intrusive and provoke or increase feelings of anxiety and distrust. Further, they believed the sensitivities around disclosing this level of detail would vary depending on the individual, employer-employee relationships and the type of symptom, potentially undermining the validity of the data (appendix 4). Nevertheless, the concept was positively received as opportunities were identified for hospitals to give direction on how to manage symptomatic staff and, they in fact, anticipated reduced rates of absence.
In Hungary and Greece participants were also positive towards the concept of monitoring symptom reports and agreed this would lead to the earlier identification of outbreaks and improved management. However, they were sceptical as to how effective this would be for EIDs where the characteristics of the novel pathogen may be poorly understood.
In contrast, participants in Germany were less in favour of the suggestion that employers enquire about and formally record reported symptoms as part of absence data recording. They described the tight legislation around employer-employee relations, where currently it is unlawful for employers to request personal health details. They expressed the need for the protection of employee privacy and confidentiality and thought the risks associated with nosocomial transmission of EIDs were too small to compromise these rights. They were concerned about potential consequences for employment upon discovering an infectious HCW, and about the risk of victimisation, describing the existing controversy for hepatitis and HIV infected HCWs (appendix 4). However, they recognised a need for balancing staff and patient safety with confidentiality and the right to privacy, and identified situations where workers' councils needed to adopt a more proactive rather than reactive approach to identifying and preventing nosocomial transmission. HCWs' views on monitoring absence and symptom reports for surveillance of emerging infections are presented in appendix 4.
Knowledge and structural barriers for the timely recognition of outbreaks among hospital staff
Beyond aspects relating to monitoring absence and symptom reports to detect outbreaks, participants in all groups voiced their concerns regarding local knowledge and structural barriers for earlier identification of EIDs.
Firstly, HCWs were concerned the lack of experience and low perceived risks of exposure to new pathogens would minimise awareness among hospital staff, leading to reduced suspicion and increased delay to the recognition of a new pathogen. Specialist input would be required for the monitoring process, introducing further labour and financial burdens on hospitals. In addition, the need for HCWs to be discriminating as to which symptoms to report, could result in wide variation in reporting practice, again potentially undermining the validity of the system. With EIDs viewed as rare events, participants felt that if the detection of EIDs was the sole rationale for reporting, adherence could decline as HCWs might question the usefulness of such a system.
Secondly, participants queried the heterogeneity in absence reporting across professions and working groups within the hospital. Nurses often had independent reporting systems to higher level health professionals and described experiences where the absence of doctors had been noticed only hours after they were due to attend work, if at all. They stated that often, there was a complete lack of structure in absence reporting among senior staff. With regular use of bank, temporary and contract staff, an accurate overview of absentee levels and reasons for absence within the hospital was deemed challenging.
Thirdly, all participants discussed the current role of occupational health departments and opportunities for their involvement in a surveillance system of this kind. Participants criticised the lack of funding and resources supplied to these departments, which currently played a minor role in managing HCWs' health beyond initial employment screening. They felt occupational health departments would be well placed to manage symptom and personal health data and organise diagnostic testing, and were keen to see their function broaden, assisting with the management of acutely as well as chronically sick staff, and in particular those symptomatic in the work place. Further, they felt independent assessments of symptomatic staff by occupational health departments would make decisions to send staff home 'more valid' and minimise anxieties and scepticism (appendix 5). In all countries, participants described the current practice for sick HCWs to visit their own general practice doctors, highlighting the potential inability for these to identify unusual symptoms in the first instance and make time-spatial links with other possible cases. There was consensus on the need to expand standard management and control guidelines of infectious disease outbreaks in the work place beyond those for gastrointestinal infections. However, with occupational health departments struggling with current functions, such as promoting and providing seasonal influenza vaccinations, participants lacked confidence in the ability of these departments to manage staff with acute infections and perform epidemiological investigations. HCWs' perceptions of knowledge and structural barriers are presented in appendix 5.