SYDNEY LAW SCHOOL A day (nearly) like any other: health care work in a pandemic PhD candidate Caroline Saint

In 1893 “[w]hen they take up nursing they know they must meet infectious diseases and are prepared to nurse them...”. Matron McMaster, The Coast Hospital Little Bay (NSW) 2

PANDEMIC “prevalent throughout an entire country or continent, or the whole world” The Macquarie Dictionary Online 3

Influenza Pandemic 4

A closely watched virus … 5 But there are others …

Surveys – pre-2009 pandemic 6 AuthorsWho?Findings Damery et al (UK 2010) Survey of professional and ancillary staff across 3 NHS trusts (1032 responses) Most recognised a duty to work although nearly 30% nurses; 25% hospital medical staff and 18% GPs thought no duty to work if at risk Stuart and Gillespsie (Australia 2008) Cross sectional anon survey of professional and ancillary staff. Large Victorian metro health service (1440 responses) 10% HCW’s said they would refuse to work because of fear Ehrenstein (Germany 2006) Multi-choice survey medical (including 3 rd yr m/s), nursing staff and administrators (664 responses) 28% believed it would be “professionally acceptable” for a HCW to refuse to work to protect themselves and family

SARS vs INFLUENZA SARSINFLUENZA Long incubation period 4-5 daysShort incubation period 1-2 days Infectious when symptomaticInfectious before symptoms Contact tracing effectiveContact tracing ineffective No known asymptomatic carriersAsymptomatic carriers Containment possibleContainment NOT possible Mortality around 10%“worst known” mortality around 5% 7

SARS vs INFLUENZA SARSINFLUENZA Long incubation period 4-5 daysShort incubation period 1-2 days Infectious when symptomaticInfectious before symptoms appear Contact tracing effectiveContact tracing ineffective No known asymptomatic carriersAsymptomatic carriers Containment possibleContainment NOT possible Mortality around 10%“worst known” mortality around 5% Around 2-2.5% in Australia 8

RISK SARS low risk of getting the disease in the community (with a relatively high risk of dying if you did) As opposed to INFLUENZA a high risk of getting the disease in the community (with a relatively low risk of dying as a consequence) 9

Work during a pandemic An ‘express contractual’ obligation to work during “a pandemic or other societal medical emergency” be included in employment contracts Malm, Heidi et al, 'Ethics, Pandemics, and the Duty to Treat' (2008) 8(8) American Journal of Bioethics 4 10

Employment contract and pandemic influenza 11 Fundamental basis of the employment contract is to work in return for money Health care workers are employed to provide care to sick people

(the ‘worst ever’) Pandemic “most nurses and physicians continued to work safely – without patient isolation equipment; personal protective equipment or measures; antiviral or antibacterial medications; or vaccines against influenza or respiratory bacteria” Shanks, G. Dennis et al, 'Low but highly variable mortality among nurses and physicians during the influenza pandemic of 1918–1919' (2011) Influenza and Other Respiratory Viruses,

TORONTO Occupational group/volunteersNumbers of deaths Soldiers131 Clerks50 Students30 Housewives27 Retired persons22 Nurses18 Slonim, Karen, “Send only your serious cases." Delivering flu to Toronto: An anthropological analysis of the Influenza Epidemic in Toronto, Ontario, Canada. (Doctorate of Philosophy Thesis, University of Missouri-Columbia, 2010) 13

Pandemic (H1N1) 2009 Risk for Frontline Health Care Workers Clinical and non-clinical staff had similar levels of antibodies - small difference not significant Found rates of antibodies in staff similar to that found in the community - Risk at work didn’t seem any higher - Staff at risk at work – not only from patients - Workers with children at home had biggest risk 14 Marshall, Caroline et al, 2011, Emerging Infectious Diseases, 17(6),

Life has risks … 15