We surveyed public health co-workers regarding attitudes toward a physician who returned to New Hampshire after volunteering in the West African Ebola outbreak. An unexpectedly large (18.0%) proportion of staff expressed discomfort with the Ebola responder returning to work. Employers should take proactive steps to address employee fears and concerns

Chan, Benjamin P

Daly, Elizabeth R

Talbot, Elizabeth A

English

Dartmouth Digital Commons (Dartmouth College)

Dartmouth CollegeDartmouth Digital CommonsOpen Dartmouth: Faculty Open Access Articles10-19-2015Workplace Safety Concerns among Co-workers ofResponder Returning from Ebola-AffectedCountryBenjamin P. ChanNew Hampshire Department of Health and Human ServicesElizabeth R. DalyNew Hampshire Department of Health and Human ServicesElizabeth A. TalbotDartmouth CollegeFollow this and additional works at: https://digitalcommons.dartmouth.edu/facoaPart of the Immunology and Infectious Disease CommonsThis Article is brought to you for free and open access by Dartmouth Digital Commons. It has been accepted for inclusion in Open Dartmouth: FacultyOpen Access Articles by an authorized administrator of Dartmouth Digital Commons. For more information, please contactdartmouthdigitalcommons@groups.dartmouth.edu.Recommended CitationChan, Benjamin P.; Daly, Elizabeth R.; and Talbot, Elizabeth A., "Workplace Safety Concerns among Co-workers of ResponderReturning from Ebola-Affected Country" (2015). Open Dartmouth: Faculty Open Access Articles. 3879.https://digitalcommons.dartmouth.edu/facoa/3879	 Emerging	Infectious	Diseases	•	www.cdc.gov/eid	•	Vol.	21,	No.	11,	November	2015	 2077Benjamin P. Chan, Elizabeth R. Daly,  Elizabeth A. TalbotWe	surveyed	public	health	co-workers	 regarding	attitudes	toward	a	physician	who	 returned	 to	New	Hampshire	after	volunteering	 in	 the	 West	African	 Ebola	 outbreak.	An	 un-expectedly	 large	 (18.0%)	 proportion	 of	 staff	 expressed	discomfort	 with	 the	 Ebola	 responder	 returning	 to	 work.	 Employers	should	take	proactive	steps	to	address	employ-ee	fears	and	concerns.The largest Zaire ebolavirus epidemic reported began in West Africa in December 2013 (1) and spread to at least 10 countries, resulting in >27,000 suspected, prob-able, or confirmed cases of Ebola virus disease (EVD) as of June 2015 (2). Arrival of the first case of EVD in the United States resulted in intense public fear and concern, exacerbated by continuous news coverage and misinfor-mation (3). A New Hampshire physician, who worked at the New Hampshire Division of Public Health Services (DPHS), volunteered in West Africa; she provided EVD case management training for health care workers in Ebola treatment centers in Sierra Leone but did not provide di-rect patient care. When she returned to New Hampshire, in accordance with guidelines of the Centers for Disease Control and Prevention and DPHS, she was considered low risk for EVD development and instructed to self-monitor with daily phone checks from DPHS; home quarantine and movement restrictions were not required (4,5). Given the heightened fear surrounding Ebola, we conducted an as-sessment of attitudes and intended practices in presumably EVD-educated state public health employees in relation to their Ebola responder co-worker.The StudyWe developed a Web-based questionnaire (online Technical Appendix, http://wwwnc.cdc.gov/EID/article/ 21/11/15-0780-Techapp1.pdf) and distributed it through workplace email prior to the Ebola responder’s return. The questionnaire provided background information about the returning Ebola responder and asked 26 ques-tions related to 13 hypothetical scenarios and 5 demo-graphic questions. Respondents were asked to predict their reaction, depending on whether the Ebola responder had direct contact with Ebola patients while using appro-priate personal protective equipment. We grouped responses into dichotomous categories of “comfortable” and “uncomfortable” on the basis of the reported level of comfort or anticipated actions to avoid contact; data were analyzed with SAS v. 9.3 (SAS Institute Inc., Cary, NC, USA). We performed a univariate analy-sis using the Mantel-Haenszel χ2 and McNemar tests to evaluate response comparisons for demographic groups and paired response proportions, respectively. Two-tailed Fisher exact p values were used to assess statistical signifi-cance with p<0.05 considered significant. We performed multivariate analyses using logistic regression to assess for associations between the multiple demographic variables and reported comfort level; odds ratios (ORs) were evalu-ated and considered significant if p<0.05.A total of 178 (71.2%) of 250 staff members completed the questionnaire. Respondent characteristics are shown in Table 1; scenarios are listed in the first column of Table 2.Even when the Ebola responder had had no contact with an EVD patient, 18.0% of respondents were uncom-fortable with the person returning to the workplace; 7.9% reported that they might not come to work if the Ebola responder was present. The proportion of respondents in-dicating discomfort generally increased in scenarios that described closer and/or more prolonged contact, from walking in the same hallway (14.7%) to attending a holiday party at the Ebola responder’s home (46.9%). When the Ebola responder had direct contact with an EVD patient, the proportion of respondents uncomfortable with each sce-nario was significantly higher (Table 2), and the percentage of persons who were uncomfortable with a particular sce-nario increased by an average of 18.3%.In a univariate analysis, staff members who report-ed being uncomfortable with the return of an Ebola re-sponder co-worker who had had no contact to EVD pa-tients were 11 times more likely to work in noninfectious disease program areas (OR = 10.7, p = 0.003). No staff person working in the infectious disease program reported discomfort with the Ebola responder returning to work, despite the fact that these employees would have the most contact with the Ebola responder. Because of this strong Workplace Safety Concerns among  Co-workers of Responder Returning  from Ebola-Affected CountryAuthor	affiliations:	New	Hampshire	Department	of	Health	and	Human	Services,	Concord,	New	Hampshire,	USA	(B.P.	Chan,	E.R.	Daly,	E.A.	Talbot);	Geisel	School	of	Medicine	at	Dartmouth,	Lebanon,	New	Hampshire,	USA	(E.A.	Talbot)DOI:	http://dx.doi.org/10.3201/eid2111.150780DISPATCHES2078	 Emerging	Infectious	Diseases	•	www.cdc.gov/eid	•	Vol.	21,	No.	11,	November	2015association, we conducted a subgroup analysis of per-sonnel working outside the infectious disease program, which showed that staff who reported being uncomfort-able around the Ebola responder were 3 times more likely to have education below a bachelor’s degree (OR = 2.7, p = 0.039). In univariate or multivariate analyses, no other respondent characteristics were significantly associated with comfort or discomfort.ConclusionsWithout a doubt, Ebola virus is transmitted through direct contact with infectious body fluids from a symptomatic person (6–10), but this study suggests that even health de-partment staff may not fully understand this concept. A substantial number of public health staff—with presumably excellent access to accurate EVD information—were un-comfortable with having an asymptomatic Ebola responder return to the workplace. Almost 15% of surveyed staff re-ported discomfort even walking in the same hallway as an Ebola responder who had had no contact with any EVD pa-tients. Discomfort increased to 35.6% in scenarios describ-ing closer proximity to or physical contact with the returning Ebola responder. Duration of contact also appeared to be a critical factor in perceived risk; more staff reported being uncomfortable sitting in a chair next to the Ebola responder (35.6%) than with shaking the person’s hand (29.6%). This finding may reflect a residual, albeit incorrect, concern over airborne transmission.Our survey did find that infectious disease staff demon-strated less discomfort. We surmise that these persons had better knowledge of EVD than noninfectious disease staff because they were directly involved in EVD response activi-ties. When we excluded infectious disease staff, having an education level below a bachelor’s degree was the only char-acteristic significantly associated with increased discomfort. These results are consistent with findings of several public polls: up to two thirds of persons believed that EVD spreads “easily” by multiple routes of transmission, with more than a third concerned that they or a family member could be ex-posed and get sick from Ebola virus; these beliefs were more common among those with less education (11–13).The fear and concern expressed by public health staff are not unique to the United States. Fear and stigmatization in West Africa EVD-epidemic countries, fueled by lack of information and deeply engrained misperceptions, have hindered efforts to control the epidemic and have led to survivor discrimination. Likewise, although state policy al-lowed this Ebola responder to return to the workplace, the concern expressed by staff created an environment in which she felt she could not work, and she opted to telework.    Table 1. Respondent	characteristics	for	survey	assessing	workplace	comfort	levels	with	co-worker	travel	to	an	Ebola-affected	country Characteristic No.	(%)	respondents,	n	=	178* Sex   F 133	(78.7)  M 34	(20.1)  Other 2	(1.2) Age,	y;	range	23–68,	median	51  20–49 67	(40.6)  50–69 98	(59.4) Education	level   High	school 15	(8.9)  Some	college 19	(11.2)  Bachelor’s degree 60	(35.5)  Graduate	degree 75	(44.4) Program	area   Infectious	disease 38	(22.8)  Other 129	(77.2) Clinician 26	(15.1) *Nonresponders for	each	demographic	question	were	excluded	from	the	respective	proportion	calculations.	Reponses	were	missing	for	program	area	(n	=	11),	sex	(n	=	9),	age	(n	=	13),	education	level	(n	=	9),	and	clinical	background	(n	=	6).     Table 2. Respondent	comfort	level	with	co-worker	travel	to	an	Ebola-affected	country	and	co-worker	contact	with	Ebola	patients Scenario No.	paired	responses,	n	=	178 No.	(%)	respondents %	Change	(ratio) p	value* Travel	with	contact	with	Ebola	patients Travel	with	no	contact	with	Ebola	patients Uncomfortable	with       Co-worker	return	to	work 178 76	(42.7) 32	(18.0) --24.7	(2.4) <0.001  Walking	in	same	hallway	as	co-worker 177 57	(32.2) 26	(14.7) 17.5	(2.2) <0.001  Being	in	same	room	as	co-worker	for	  meeting 176 65	(36.7) 30	(17.1) 19.6	(2.1) <0.001  Sitting	in	chair	next	to	co-worker 177 88	(49.7) 63	(35.6) 14.1	(1.4) <0.001  Standing	in	line	next	to	co-worker 177 78	(44.1) 47	(26.6) 17.5	(1.7) <0.001  Using	same	restroom	as	co-worker 176 77	(43.8) 40	(22.7) 21.1	(1.9) <0.001  Shaking	hands	with	co-worker 176 85	(48.3) 52	(29.6) 18.7	(1.6) <0.001  Hugging	co-worker 175 87	(49.7) 59	(33.7) 16.0	(1.5) <0.001  Riding	in	co-worker's	car 177 81	(45.5) 51	(28.8) 16.7	(1.6) <0.001  Assisting	co-worker	if	he/she	fainted 177 95	(53.7) 62	(35.0) 18.7	(1.5) <0.001  Eating	homemade	food	made	by	co-worker 176 95	(54.0) 67	(37.9) 16.1	(1.4) <0.001 Would	consider	not	coming	to	work	if	co-worker	returned 178 37	(20.8) 14	(7.9) 12.9	(2.6) <0.001 Would	not	attend	party	at	co-worker’s home 176 125	(70.6) 82	(46.9) 23.7	(1.5) <0.001 *McNemar’s test for paired proportions.  	Safety	Concerns	among	Co-workers	of	Ebola	Responder		 Emerging	Infectious	Diseases	•	www.cdc.gov/eid	•	Vol.	21,	No.	11,	November	2015	 2079During this period, we conducted outreach to staff through staff meeting presentations, a small group question-and-answer session, and individual meetings to allow persons to ask questions and express concerns. When the monitor-ing period was over, the Ebola responder returned to work without incident.Our survey has several limitations. First, scenarios cannot assess the source of discomfort evoked by interact-ing with a returning traveler; baseline discomfort from a handshake is predictably less than is assisting a co-worker who fainted, regardless of EVD risk. In addition, some re-sponses appear inconsistent. Although riding in a car with an Ebola responder and sitting in an adjacent chair are not different in terms of proximity and contact, the responses differed substantially. Finally, the survey may have drawn attention to the Ebola responder and created concern that would not naturally have occurred if the Ebola responder had returned unannounced to the workplace.Travelers returning from countries with widespread Ebola virus transmission can elicit strong reactions within their communities. Employers should consider taking ac-tive steps to address fears and concerns because workplace reactions and discrimination may have substantial effects on returning Ebola responders. Staff education remains the best approach to alleviating concerns and maintaining a functional workplace, while facilitating the needed hu-manitarian response to the historic EVD disaster.Dr. Chan is a board-certified infectious disease and preventive medicine physician currently serving as state epidemiologist for the New Hampshire Department of Health and Human Services, Division of Public Health Services, Concord. His primary re-search interests include health care epidemiology, antimicrobial stewardship, and health care quality improvement.References  1. Baize S, Pannetier D, Oestereich L, Rieger T, Koivogui L,  Magassouba N, et al. Emergence of Zaire Ebola virus disease in Guinea. N Engl J Med. 2014;371:1418–25. http://dx.doi.org/ 10.1056/NEJMoa1404505  2. World Health Organization. Ebola response roadmap—situation report. 2015 Jun 24 [cited 2015 Jun 24]. http://www.who.int/csr/disease/ebola/situation-reports/en/  3. Merino JG. Response to Ebola in the US: misinformation, fear, and new opportunities. BMJ. 2014;349:g6712. http://dx.doi.org/ 10.1136/bmj.g6712  4. Centers for Disease Control and Prevention. Interim U.S. guidance for monitoring and movement of persons with potential Ebola virus exposure. 2014 Dec 24 [cited 2015 Apr 23]. http://www.cdc.gov/vhf/ebola/pdf/monitoring-and-movement.pdf  5. New Hampshire Division of Public Health Services. Interim policy summary for isolation of suspect Ebola patients and quarantine of persons potentially-exposed to Ebola virus. 2014 Nov 10 [cited 2015 Apr 23]. http://www.dhhs.state.nh.us/dphs/cdcs/ebola/ documents/isolationquarantine-interim.pdf  6. Baron RC, McCormick JB, Zubeir OA. Ebola virus disease in southern Sudan: hospital dissemination and intrafamilial spread. Bull World Health Organ. 1983;61:997–1003.  7. Dowell SF, Mukunu R, Ksiazek TG, Khan AS, Rollin PE,  Peters CJ. Transmission of Ebola hemorrhagic fever: a study of  risk factors in family members, Kikwit, Democratic Republic of  the Congo, 1995. J Infect Dis. 1999;179(suppl 1):S87–91.  http://dx.doi.org/10.1086/514284  8. Francesconi P, Yoti Z, Declich S, Onek PA, Fabiani M, Olango J,  et al. Ebola hemorrhagic fever transmission and risk factors  of contacts, Uganda. Emerg Infect Dis. 2003;9:1430–7.  http://dx.doi.org/10.3201/eid0911.030339  9. Richards GA, Murphy S, Jobson R, Mer M, Zinman C, Taylor R,  et al. Unexpected Ebola virus in a tertiary setting: clinical and  epidemiologic aspects. Crit Care Med. 2000;28:240–4.  http://dx.doi.org/10.1097/00003246-200001000-0004110. Bausch DG, Towner JS, Dowell SF, Kaducu F, Lukwiya M,  Sanchez A, et al. Assessment of the risk of Ebola virus  transmission from bodily fluids and fomites. J Infect Dis. 2007;196:S142–7. http://dx.doi.org/10.1086/52054511. Harvard School of Public Health. Poll finds many in U.S.  lack knowledge about Ebola and its transmission [press release].  21 Aug 2014 [cited 2015 Apr 23]. http://www.hsph.harvard.edu/news/press-releases/poll-finds-many-in-us-lack-knowledge- about-ebola/12. Pew Research Center. Ebola worries rise, but most are ‘fairly’  confident in government, hospitals to deal with disease. 21 Oct 2014 [cited 2015 Apr 23]. http://www.people-press.org/files/2014/10/10-21-14-Ebola-Release.pdf13. Harvard School of Public Health. Poll: most believe Ebola  likely spread by multiple routes, including sneezing,  coughing [press release]. 15 Oct 2014 [cited 2015 Apr 23].  http://www.hsph.harvard.edu/news/press-releases/ poll-finds-most-believe-ebola-spread-by-multiple-routes/Author for correspondence: Benjamin P. Chan, Division of Public  Health Services, New Hampshire Department of Health and Human Services, 29 Hazen Dr, Concord, NH 03301-6504, USA;  email: benjamin.chan@dhhs.state.nh.usGovDeliveryManage	your	email	alerts	so	you	only	receive	content	of	interest	to	you.Sign	up	for	an	Online	Subscription:wwwnc.cdc.gov/eid/subscribe.htmTable of ContentsEmailed to you

Workplace Safety Concerns among Co-workers of Responder Returning from Ebola-Affected Country

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Workplace Safety Concerns among Co-workers of Responder Returning from Ebola-Affected Country

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