During a bioterror attack, who would help?

Increased awareness of the potential for attacks using nuclear, biological or chemical agents has instigated a fair amount of specialized training since the 9/11 attacks. But surveys of healthcare workers around the United States have suggested the possibility that some healthcare workers might not show up for work in the event of an attack.

"They're willing to come out for explosions, but less willing to come out for biological and contagious epidemics," says Salvatore Lanzilotti, who until last December was head of the Honolulu Emergency Services Department.

Competence and willingness  
Earlier this year, Dr. Jeffrey Crane published a study of Florida community healthcare providers that looked at not just willingness, but also knowledge about dealing with nbc events. He found that when you add competence to the equation, only 32% of the physicians, nurses and pharmacists surveyed were both willing and able to respond. (Read here.)

A 2004 study of workers at four Chicago-area hospitals showed that while 98% of the emergency department personnel would be willing to work additional hours in the event of an airplane crash, only 76% would work extra hours to care for victims of a radioactive bomb, and just 61% would do so in the event of a biological attack.

A survey of school nurses in one Texas county, published in 2004 in the journal Biosecurity and Bioterrorism, asked how willing the nurses would be "to care for patients in the event of an outbreak of an unknown, but potentially deadly, illness." Out of 111 completed surveys, 33% of the school nurses said they were only moderately willing to care for such patients, 35% were only a little willing and 7% were not at all willing. The numbers were even worse when the survey asked about sars or pneumonic plague, with 24% moderately willing, 40% a little willing and 20% not at all willing. ­www.biosecurityjournal.com

In 2004, Drs. Christina Hantsch and Katherine Martens, of Loyola University Medical Center in Chicago, followed up their 2003 survey of hospital healthcare workers with a survey of prehospital healthcare workers, such as emts and paramedics, and found that they were unwilling to show up in the event of a nuclear or biological attack at roughly the same rate as the hospital workers. (Annals of Emergency Medicine 2004; 44: s95, and 2003; 42: s105–s106.)

However, they also differentiated between the attack happening when the worker was already at work and if the attack happened when the worker was at home. Hantsch and Martens found that 71% of workers would be willing to stay at work, but only 56% were willing to come in, if they were at home.

"So it did drop off a bit," Hantsch says, "which would be a concern if the event occurred on a night shift or on a holiday."

Both are times when emergency department staffing is typically lower.

Finally, a recent issue of the Journal of Urban Health reported on a survey of workers at 47 healthcare facilities in metro New York City. (Read here.) The researchers, several of them from Columbia University's Mailman School of Public Health, found that healthcare workers' ability and willingness to report to duty varied considerably depending on the type of disaster.

The highest abilities to report for work were for a mass-casualty incident, (83%), environmental disaster (81%) or chemical event (71%), and least for a smallpox epidemic (69%), radiological event (64%), sars outbreak (64%) or severe snowstorm (49%).

In terms of willingness, the healthcare personnel surveyed were most willing to report during a snowstorm (80%), mci (86%) or environmental disaster (84%), and least willing during a sars outbreak (48%), radiological event (57%), smallpox epidemic (61%) or chemical event (68%).

Mixed results about fear  
The basic reason behind the lack of willingness to show up is fear, although the workers' concerns for their personal safety varied greatly among the studies. A Japanese study showed personal safety to be relatively high among the concerns. In the survey, which was based on treating patients with sars, 92% of the healthcare workers surveyed said they would prefer to avoid the patient, and more than half said they were afraid of sars. <www.CDC.gov/ncidod/eid/vol11no03/04-0631.htm>

But Lanzilotti's and Hantsch and Martens' studies showed less concern among the workers for their personal safety and more for their families. The Hantsch and Martens survey notes that only three of 446 respondents cited fears for their personal safety.

(Interestingly, Hantsch and Martens note that in their survey, personnel were more afraid of a radiological attack, such as a dirty bomb, than they were of a biological attack.)

In the Columbia/Mailman study, "More than half of the respondents reported moderate or high levels of concern about a terrorist-related workplace exposure to a chemical or bioterrorist agent."

The study report continues, "… ability and willingness were reported to be lowest for those types of events in which employees are more likely to perceive the highest degree of risk to themselves or their family (smallpox, chemical, radiation, and SARS)."

"The most frequently cited reason for employees' unwillingness to report to duty during a disaster," the Columbia/Mailman study says. "was fear and concern for the safety of their families and themselves. During a catastrophic event, employers must recognize that their hcws [healthcare workers] are likely to be as (or even more) concerned than the average citizen, because they might have a greater understanding of the associated risks."

Healthcare workers' fears of what are technically referred to as nosocomial infections aren't entirely unfounded. Lanzi­lotti cites an incident during the sars epidemic in 2003, when a nurse in Toronto brought the disease home and her child caught it and died. "People were afraid to come to work after that," he says.

And an article in the July issue of Emerging Infectious Diseases estimates that between nine and 42 healthcare workers per million die each year from an infection picked up on the job. ­(Read here.) The Japanese study found that during the sars epidemic, 21% of the cases involved healthcare workers.

Effects on readiness 
Understanding the level of willingness is crucial for emergency planning. The school nurse survey was undertaken because the Denton County Health Department realized that if they had to conduct emergency smallpox vaccinations on the local population, they wouldn't have enough public health nurses to do the job. School nurses were considered simply because they were the most available.

However, after looking at the high level of risk that nurses in Toronto and Taiwan faced during the sars epidemic, not to mention the reports of fatigue, dehydration and separation from families, the Texas researchers determined that willingness to work could be an issue, particularly since the school nurses would be asked to volunteer.

Determining actual readiness isn't easy, either. "Things have come a long way with planning and preparedness since 2001," says Hantsch, "but, really, we don't know. We don't know what would actually happen. And there's certainly some areas that have spent more time and effort on training, so it's hard to know across the nation how it is."

Part of the problem with the surveys is that they're speculative. They asked the workers to self-report what they thought they would do, which could easily turn out to be very different from what they actually do.

"We had 22% that said they were unable to answer the question," says Hantsch, noting that that number is very high. "Without having had a disaster, we have no way to compare the numbers."

Better training helps
Training came up continually as one of the best antidotes to workers' fears. The Japan study notes that workers' perception of risk was directly related to institutional polices and training. Basically, if the workers had a clear sense of procedures and protocols for reducing the spread of infection and a sense that the institution would support their needs, they were less afraid to work.

Hantsch and Martens' surveys asked why workers would be unwilling and found that there was a strong desire for training, though they did not specify what kinds.

Lanzilotti cautions that relying on knowledge alone would not be enough to bring in the workers in an infectious disease emergency. While his study noted that willingness to work was related to knowledge and skill, knowledge and skill didn't necessarily translate into an overall increase in willingness to work.

"There's a lot of things that have to happen," Lanzilotti says. "You have to make sure that … people are working in a safe environment because if they're not, they may not come to work."

"People talked about training," along with other concerns, Hantsch says. "It was security at work, and then health care and security for their families."

Reassuring measures 
Specifically, in the Hantsch and Mar­tens ems survey, the eight most important support factors, in descending order of priority, were:

• shelter for family and training,
• medical care,
• security at home,
• security at work and shelter for self, and
• clarification of role and food.
  

The most common limitation given for an inability to work was family commitments.

Hantsch adds that while training is critical, support for healthcare workers' needs, including prophylactic medicines and care for children and elderly family members, must also be part of any hospital's plan.

The Columbia/Mailman study detailed various ways healthcare agencies could help keep their workers' families safe. "Health care facilities can also provide support to employees with childcare and eldercare obligations that might affect their ability to report to work in a number of ways. Preplanning for the formation of emergency childcare or eldercare centers that are either on or off-site can help address this.

"Another, less costly strategy might involve facilitating the formation of emergency childcare/eldercare pools, with staff scheduled in such a way that sharing these responsibilities is possible. This method might be preferable to some employees, as hcws may be more likely to leave their children or elders in custody with people that they already know and trust. Additionally, some employees might be reluctant to leave children or elders in a facility that is in proximity to an event, and care provided by coworkers in a home setting could address this."

Lanzilotti goes further, stressing that hospitals must start looking at their sops and infrastructure, to the point of making it mandatory to hand everyone a mask on entering the emergency room and building rooms that prevent the spread of infection to other parts of the hospital.

Hantsch also says that based on the research, planners need to assume that a minimum of 16% of their emergency department work force won't show up in the event of a biological attack.

As Martens says, in any attack, a hospital's key resource is its personnel, and if they're going to be expected to show up, it's up to the institution to make it safe for them to do so.