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Are you a good worker? Do you work hard? Do you care so much about your job that you show up to work even when sick?

Well if your answer is yes, and you work in health care, you may be a public health hazard.

An important article in the Journal Of General Internal Medicine illustrates the potentially serious public health hazards of presenteeism, or showing up to work even when sickness compromises your ability to do your job. The lead author was Dr. Eric Widera, from the UCSF Division of Geriatrics(and GeriPal!). Co-authors included Drs. Anna Chang and Helen Chen.

Dr. Widera presents a compelling case of a nursing home gastroenteritis outbreak that lasted 24 days and was prolonged by staff members coming in to work sick. Gastroenteritis outbreaks, in which numerous patients develop an illness characterized by nauseau, vomiting, and diarrhea, are very common in nursing homes, or any setting in which people live closely together (such as cruise ships or college dorms). In healthy people, the symptoms can be highly distressing, but are usually self-limited. But in very frail nursing home residents, gastroenteritis can be dangerous.

Over the first 3 days of the outbreak, 10 nursing home residents and 5 staff members became sick with what proved to be norovirus—a form of gastroenteritis known to be supercontagious. Usual infection control procedures were instituted, and one would have expected the outbreak to run its course. However, by the end of the first week, despite recommendations to the contrary, it became clear that ill staff were coming to work. Often symptoms were not reported until employees had arrived for, and somtimes completed, their shifts. When it became clear that voluntary measures to prevent presenteeism had failed, the local health department stepped in to enforce “back to work” rules. By the end of the outbreak 35 residents and 24 staff had fallen ill with gastroenteritis.

Widera notes that nursing homes may be particularly susceptible to staff-resident-staff transmission of infectious diseases because the frailty of nursing home residents requires close physical contact between residents and staff. Unfortunately, in many nursing homes in the US, staff are not adequately paid, and may lack benefits including adequate sick leave. Financial difficulties may be make it hard to take time off from work.

However, physicians may be the worst presenteeism abusers. Widera cites a survey of British physicans in which 87% of general practitioners and 58% of hospital consultants said they “definitely would not” stay home if they had a severe cold.

When I was a resident, the culture was such that you came to work unless you physically could not get out of bed. Virtually all my fellow houseofficers and I had stories of how we on some occasion did just that. I hope that culture has changed.

Widera and colleagues have made an important contibution by telling the story of this outbreak. I strongly suspect similar episodes occur daily throughout the US, but we won’t be able to prevent these occurences if we don’t share these stories and learn from them.

by: [ken covinsky]

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