When the H1N1 virus known as swine flu hit Texas on April 23, local, state and federal health officials could not predict how the virus would spread, how lethal it would be or how easily transferable it would be from human to human.
According to Bruce Barr, an analyst for the Texas Association of Counties’ County Information Project who worked with state and local health authorities to monitor outbreaks and responses during the initial swine flu wave in April and May, communities affected by the virus were well-prepared for the threat they faced. They are now looking at lessons learned during the outbreak, diligently preparing for the forecasted second wave.
According to the World Health Organization and other expert agencies, pandemics strike in cycles, and they often evolve with each strike or wave. Though the first H1N1 outbreak had a spotty impact in different regions around the United States and mostly non-lethal, pandemic experts cannot predict how the virus would behave during its second wave, if there is one. It could hit different geographical regions with different severity, as it did the first time around, or it could be a more forceful virus overall.
Lisa Koonin, the senior advisor of the Center for Disease Control’s Influenza Coordination U nit, said communities and employers wanting to prepare for the second H1N1 wave should watch for similar swine flu symptoms appearing among the workforce: high fever, cough, runny nose, body aches and pains. While those are all symptoms of a normal flu, humans have less immunity to swine flu because it’s a new virus that most people have not been previously exposed to.
If H1N1 does strike Texas again, probably during the fall flu season, Koonin said she expects the advice to be the same as before: Stay home and take care. But, she added, that may change, and employers, government agencies and health organizations must be prepared for a more severe H1N1 attack or other pandemic.
“This is what we expect, we don’t know for sure what the severity level will be,” Koonin said, adding that in terms of severity, the first H1N1 outbreak has so far only been a “Category 2,” so employers who believe they got through the first outbreak fine may be surprised by a Category 3 or 4 or 5.
One lesson that can hopefully serve counties well in the future: While state and local authorities have worked on their community responses and emergency preparedness should a pandemic hit their regions, it’s also important to consider internal county policies and operations so that county services aren’t impacted by affected employees. During and following the first H1N1 outbreak, TAC’s Information Resources Department and department heads sent out instructions to staff on how to gain remote access to TAC servers, should the need arise for some employees to work from home.
But Koonin said it’s important that employers not only have a plan in place for increased absenteeism, but test the plan with staff. Employees who have the ability to work from home but have never done so should be allowed to do so at least once — before the next pandemic or H1N1 wave strikes.
“Reduce the number of people who are working on a given day and see how you deal with that absenteeism,” Koonin said, adding that now is the time to cross-train employees so that multiple people can perform at least the central functions of a position. “It’s really important to plan for redundancy and back up for every person in the work place.”
It’s also important to realize that anybody can get sick from a new virus, such as swine flu. There is nothing in the DNA of county judges, emergency managers, deputies or clerks that would keep any group from getting sick during a public health emergency. “Plan for the one person who has the key getting sick,” Koonin said.
Now is also the time for employers to look at and possibly revise sick policies.
“In many counties, there wasn’t an established protocol for dealing with collateral damage, such as what to do about parents who are taking care of children who cannot go to school because schools are closed,” Barr said. “How do you count all those lost days? … The issues that come into play are going to depend on a county’s size, budget, and all sorts of other factors.”
When the virus first began affecting Texas regions, the Centers for Disease Control and Department of State Health Services recommended closing some schools and day cares. The agencies also recommended that a person who suspected they had the virus or who probably had the virus stay home from work for at least seven days after exposure to the flu.
However, that recommendation could be inhibiting for some employees and county policies, for several reasons. Most county sick day policies place strict language on how a sick day may or may not be used; they can be used only if the employee or an immediate family member of the employee is sick and must be cared for. When a school is closed for several days due to a pandemic outbreak, an employee’s own child may not be sick; similarly, if an employee stays home from work because of expected exposure to a virus, he or she may not actually become ill. Employees may balk from using vacation days for such an event and come into work whether they’ve had contact with the virus or not, and could infect other employees as a result. Or, they may run out of vacation days and fear running out of sick days.
In Comal County, Human Resources Director Robert Grazioli knew that the outbreak called for flexibility. His first course of action was to send an email to department heads and elected officials that stressed the importance being “extra lenient” with employees who had to care for children during the school closures.
Grazioli also gave a variety of options for department heads and employees to consider, such as creating a temporary flexible work schedule for employees with young children, asking employees to alternate childcare responsibilities with their spouses so that both spouses could fulfill their professional duties, or discussing work-from- home options on a case-by-case basis.
He also closed some options that could have impacted employee health, such as bringing children to work. The county also made it clear that employees exhibiting any flu-like symptom would be sent home.
The immediate pandemic-leave policy was to require employees caring for their healthy but bored children to use vacation days, Grazioli said, but if an employee was new to the county or did not have any vacation days, they were allowed to use sick days. Employees who did not have sick days would be allowed excused unpaid leaves.
“We were very liberal in that regard, to try to make it as convenient and comfortable for employees as possible, and not hit the pocketbook,” he said.
Fortunately, less than a handful of employees had to make use of the on-the-fly pandemic policy. Grazioli credits the county’s employees for having school closure plans in place for their families. “There were only about three or four employees who had to use vacation because of their kids… most everyone had contingency plans built-in, which was kind of amazing,” he said.
The flexible approach to vacation and sick leave during a pandemic is in line with Center for Disease Control recommendations, said Lisa Koonin, the senior advisor of CDC’s Influenza Coordination Unit.
“It’s important to not let sick people come to work,” she said, “so the leave policy should be non-punitive.”
“The leave policy should say that employees that are sick with the pandemic influenza don’t have to have a doctor’s note and that any employee with a fever and cough or sore throat needs to stay home,” she added.
Diana Cecil, a human resources specialist with TAC, said that during the H1N1 pandemic outbreak, most county sick leave policies were narrowly tailored to allow for specific absences, such as caring for yourself when sick or a child who is sick, whereas vacation days can be taken for any reason. However, Cecil said a county commissioners court may choose to broaden the scope of its sick leave policy to include the use of sick days for precautions during a serious pandemic.
Doing so may encourage employees who have good reason to suspect they may have been in contact with the flu or may be “coming down with something” and could cause others to become sick to stay home, or may allow for leniency when parents must stay home to watch children during mandatory school closings.
“Sick leave is a benefit through county policy that can be changed by commissioners court at any time. They can determine its use, its availability, its purpose,” Cecil said, adding that the financial burden placed on employers for offering vacation and sick days is often the same. Both are regarded as a benefit to employees; the major difference is that many employers will pay out a person’s unused vacation days at the end of their employment, but not unused sick days.
TAC temporarily revised its sick day policy during the height of the H1N1 outbreak, when local health officials were concerned about possible school closures, to allow employees who had been in contact with the virus but were not yet showing symptoms access to sick days. The belief was that doing so would stop the possible spread of the flu among employees and ensure continuity of services to counties. The revision still specified certain conditions that must be met in order for the sick leave to be an option, and the policy became more narrowly tailored again when the threat and severity of the outbreak decreased.
“TAC employees living with school employees or who are primary care providers for children from schools that have been closed will be required to stay away from the office on sick leave for 72 hours,” the sick leave policy sent to employees during the height of the CDC warnings stated. “If the employee (or) child is not symptomatic following that period of time, the TAC employee is free to return to work unless child care needs prevent them from doing so. … Vacation time would then be charged.” As it turned out, TAC’s staff was largely unaffected by the outbreak, and the sick leave policy returned to normal several days later, when warnings diminished.
Koonin said it’s a good idea to have pandemic plans in place that are flexible according to the severity of the threat, which may rise or fall as time progresses. Threat levels are also different according to geography; H1N1 impacted different parts of the country differently. So while it’s important to have a comprehensive worksite plan in place, it’s also important for employers to choose which parts of the plan to implement at any time.
For instance, when state and local officials in Comal County considered the pandemic severity level in the region to be high, the county purchased thermometers and took employee temperatures to ensure that anyone who had a fever was aware and could rest at home. When the threat level decreased, the county suspended that practice. “Some response measures that may have been incorporated in previous responses may not need to be incorporated in a future response,” Koonin said.
No matter the severity, immediate and up-to-date communication to employees is a key element of a response, she added, especially because there may be some measure of confusion, panic and sensationalism in the media. Without clear communication from local leaders and employers, unnecessary stress may be placed on area emergency rooms. During the H1N1 outbreak, the New York Times reported that on May 1, 188 people visited the San Jaoquin Community Hospital in Bakersfield, Calif., fearing they had swine flu; not a single one had symptoms.
“That’s why employers have to develop a communication link with their employees now,” Koonin said, adding that the method should be promoted well ahead of time and that it should be utilized as early in the flu outbreak as possible. “The best response would be when (community health leaders) come out as soon as the outbreak starts with information, specific information about how to protect yourself from getting sick and how to care for sick people at home.”
During the process, TAC’s leadership addressed the need to communicate with T AC staff about what to do during a public health emergency, as well as a way to keep staff up-to-date about the current threat level of the outbreak. They developed a Web site geared toward employees at www.county.org/flu, and promoted it via an email sent to staff at the beginning of the pandemic response. The site contains the “Revised Guidelines for Swine Flu Response,” which were updated as the threat level rose and fell, as well as a county flu map, which shows which counties have had outbreaks. It also contains links to school district Web sites within or near Travis County and links to credible health services agencies, including the Texas Department of State Health Services, the Centers for Disease Control and the Texas Situation Reports from the Governor’s Division of Emergency Management.
The site, though geared toward TAC employees, is open to the public, so county officials can also go there to view which counties have been affected by a pandemic outbreak. In addition, TAC’s County Information Resources Agency have created a new disaster response Web site, www.recovertexas.org, which will have pandemic information should another new virus strike Texas.