William Bunn III, MD, JD, MPH, receives inquiries about Severe Acute Respiratory Syndrome (SARS) almost daily. As vice president of Health, Safety, Security and Productivity for International Truck and Engine Corp., Chicago, Bunn has employees traveling frequently to and from Asia, as well as visitors coming to U.S. facilities from other countries.
"Callers typically ask, 'Should we have people traveling?' 'Should we allow people to come to our facility?' 'Should we postpone meetings and classes?'" says Bunn. "Our approach is to make human resources personnel, managers and employees aware of the Centers for Disease Control and Prevention (CDC) guidelines and to give them a place to go with questions. Our company has a policy regarding infectious diseases. If an employee has a question about whether or not to come to work, I want them to know they have a number to call for an answer."
SARS, say experts, is an ongoing challenge for occupational health professionals and safety managers. In fact, Dr. Julie Gerberding, director of the CDC, admitted in late May that her agency was preparing for the possibility "that we'll see a resurgence or even expansion of SARS next fall," in the United States, because SARS is a respiratory illness, and rates of respiratory illnesses rise in the fall and winter.
"Despite the rapid and effective response from partners around the world, SARS exposes fundamental weaknesses in the global health infrastructure," said Dr Jong-Wook Lee, director-general elect of the World Health Organization (WHO). "The epidemic highlights the need for local and national surveillance and response mechanisms."
To date, there have been approximately 400 potential SARS cases reported in the United States, with over 70 confirmed cases. Many employers do not know how to respond if an employee is stricken by an infectious disease such as SARS. Who do they call, and what do they tell other employees who might have come into contact with that employee?
With new information about the virus and outbreaks occurring almost daily, Bunn says he refers to the CDC Web site (www.cdc.gov) to stay knowledgeable. "Information about SARS changes rapidly, and I don't want to see inconsistent information going out to our employees," says Bunn. "By referring to the information provided by CDC, all of our facilities are on the same, updated page."
According to CDC, SARS "is an infectious illness that appears to spread primarily by close person-to-person contact." Potential ways in which SARS can be transmitted by close contact include touching the skin of other people or objects that are contaminated with infectious droplets and then touching the eyes, nose or mouth.
CDC advises that workers who traveled to a known SARS area in the last 10 days, or who had close contact with a co-worker or family member with suspected or probable SARS, could be at increased risk of developing SARS. Symptoms include a fever (greater than 100.4 F) and may include headache, an overall feeling of discomfort and body aches. After two to seven days, people infected with SARS may develop a dry cough and have trouble breathing.
"If these symptoms develop, you should not go to work, school or other public areas, but should seek evaluation by a health-care provider and practice infection control precautions recommended for the home or residential setting," CDC advises on its Web page.
Dr. Richard Ehrenberg, a senior scientist with the National Institute for Occupational Safety and Health (NIOSH), is working with the CDC team investigating SARS. His job on the team is to offer guidance for protecting workers primarily in the healthcare and airline industries, the only two industries in the United States where there were suspected work-related cases of SARS.
"In this country, early on, there were two or three healthcare workers who were suspected SARS cases because they had compatible symptoms and had treated an individual with compatible symptoms. This was prior to recognition of the outbreak and prior to the issuance of guidelines," says Ehrenberg. The patient did not have SARS, he adds, so it is unlikely the healthcare workers had it.
In a somewhat similar case, says Ehrenberg, there was a concern that members of airline flight crews who had layovers in Asian countries where SARS outbreaks have occurred might have been exposed to the virus. Ehrenberg says he's not aware of any documented cases of SARS among U.S.-based flight crews, however.
Fortunately, he adds, there are not many suspected or confirmed SARS cases in the United States and no major outbreaks like those experienced in parts of China, Taiwan, Hong Kong and Toronto. However, he advises, "There are still issues" of which employers need to be aware, such as precautions to prevent the spread of SARS. Some of these include travel advisories and alerts; quarantining SARS patients and, possibly, the facilities where the patient works, lives or was treated; and appropriate preventative measures.
When Employees Travel
CDC issues two types of notices to travelers: advisories and alerts. A travel advisory recommends that nonessential travel be deferred; a travel alert does not advise against travel, but informs travelers of a health concern and provides advice about specific precautions. CDC updates information on its Web site on a travel alert page that can be accessed at www.cdc.gov/ncidod/sars/travel.htm.
Bunn says his company takes CDC travel alerts and advisories very seriously, not only for SARS, but also for other infectious and deadly diseases, such as yellow fever, Ebola and malaria.
The word "international" in its name is no coincidence; International Truck and Engine Corp. has about 300 workers enrolled in its Travelers Remote Destination Program. Those employees, who travel frequently or who are posted to facilities in other countries, are:
- Asked to supply an extensive medical history;
- Given complete physicals;
- Administered appropriate and updated vaccines;
- Issued a travel kit containing approximately 50 items including a manual about emergency medical care, bandages and ointment, non-prescription medications such as aspirin and prescription medicines such as malaria medication, when appropriate;
- Given an S.O.S. card with important healthcare information and telephone numbers; and
- Told to call a toll-free in-company telephone number if they have questions or concerns about medical care.
"Bioterrorism, anthrax, sensitivity to SARS; there is a heightened sense of awareness of risk, especially in travel to and from other countries," says Bunn.
That sentiment is shared by CDC's Gerberding. "We live in a world of emerging infectious diseases and emerging threats," she said at a meeting on a campus of Kent State University in Ohio. Citing the importance of educating and protecting healthcare workers, Gerberding added, "The weakest link in the system can lead to an outbreak."
When Outbreaks Occur
Shoreland Inc., based in Milwaukee, offers travel and risk-related information to the highest levels of government in the United States and Canada, Fortune 500 companies, public health departments, military units, hospitals and universities. As part of the services it offers, Shoreland tracks virus outbreaks around the world.
Company president Donald Cook says that with his clients, he's working to "eliminate some of the fear" associated with SARS, but also to make them aware of the importance of vigilance.
"From a company perspective, the risk of an employee getting SARS is small," Cook admits. "We're really lucky so few people in this country have it. If this was really infectious, we'd be down the toilet."
However, he adds, "SARS is hard to catch but bad if you get it." He points out that fear of SARS and the quarantines and facility closures related to SARS "haven't just impacted tourism. China lost a significant amount of its clothing business. That business has gone to India and other countries that don't have SARS."
In this age of global commerce, "Business needs to learn how to handle the risk" of health concerns such as SARS, says Cook. Some U.S. companies with overseas facilities (Cook is loath to name names, saying they're clients) have had to shut down their operations and disinfect their facilities.
And SARS isn't an isolated issue, Cook warns. SARS is just the latest in a long list of nasty viruses and illnesses of which employers and employees need to be aware.
He rattles off a list of potential health threats for traveling employees and notes many of these illnesses have already made their way into the United States: malaria, West Nile virus, Ebola, dengue fever, yellow fever, hepatitis. "And that doesn't even include accidents and accidental injury," he adds. "Anyone who has ever driven in India after dark knows how dangerous the roads can be."
Precautions and Prevention
Shoreland counsels clients with facilities in SARS-affected areas to:
- Provide daily medical screenings outside work locations for employees returning from SARS-affected areas but who did not have contact with a suspected SARS case for a 10-day monitoring period;
- Deny access to facilities for 10 days to employees and visitors from SARS-affected areas who have had contact with a suspected SARS case;
- Communicate a SARS Infection Control Plan to local authorities;
- Instruct employees not to come to work if they have a fever or respiratory symptoms and give employees a card detailing the steps they should take if they become symptomatic;
- Regularly clean common areas and surfaces, including hand railings, counters, bathrooms, light and equipment switches, printer and copier buttons and other shared furniture, fixtures and equipment;
- Stagger break periods and lunches to reduce overcrowded conditions;
- Increase space per employee for crowded work areas; and
- Reroute or restrict access to business-critical areas.
Cook said one client asks all employees traveling to Asia to complete a daily log that includes twice-daily temperature readings (morning and night), and any planes, trains or other public transportation they've taken. Should their temperatures rise, or they realize they've been on a plane that had a SARS carrier, they can receive appropriate care.
"If you let down your guard for a second, then the case that should have been diagnosed at day five isn't caught until day 12. Then that patient has been shedding the virus for an additional seven days, potentially infecting anyone coming into contact with him who didn't use proper precautions," such as gloves and a N-95 respirator that is worn properly, says Cook.
As with other infectious illnesses, one of the most important preventive practices is careful and frequent hand washing. Cleaning the hands often using either soap and water or waterless, alcohol-based hand sanitizers removes potentially infectious materials from the skin and helps prevent disease transmission, according to the CDC guidelines.
Amber Hogan, an industrial hygienist with OSHA's Office of Health Enforcement, says that with SARS, "the most important issue is hand washing. Educate employees about good hand hygiene. It's hard for OSHA to say, 'Let's talk about hand washing,'" she jokes, but adds it is an important step in preventing the spread of viruses in the workplace.
OSHA has posted information about SARS on its Web site (www.osha.gov), including a PowerPoint presentation that employers may find useful in discussing the risks of SARS in the workplace, information about precautions to be taken in working with patients with SARS, and links to other agencies' fact sheets, guidance and information on SARS.
At this time, notes Melody Sands, director of the Office of Health Enforcement, OSHA does not perceive SARS to be a workplace issue. The agency is treating SARS as a public health issue and is deferring to CDC and its experts to control the spread of the virus in this country.
That could change, however. "OSHA has the ability to cite employers under the general duty clause if there was a case of blatant exposure of employees to SARS," she says, adding, "OSHA hasn't used it yet."
Shoreland's Cook urges employers to do whatever they need to do to keep SARS and other infectious diseases out of the workplace and not let outbreaks get to the point where they become an issue for OSHA. "We need to better prepare for these weird scenarios, for the unexpected," he adds. "We can't solve it all; we need to figure out how we can work together to prevent outbreaks like SARS," he says.
Sidebar: Links to SARS Information
Interim guidelines for the general work environment: www.cdc.gov/ncidod/sars/workplaceguidelines.htm
SARS infection control management guidelines, including infection control for health care employees: www.cdc.gov/ncidod/sars/ic.htm
NIOSH SARS Page: www.cdc.gov/niosh/topics/SARS
OSHA Web site with link to SARS PowerPoint presentation: www.osha.gov
Link to Shoreland Inc.'s Travel Health Online Web site: www.tripprep.com