Infectious Disease Incidents in the Workplace

7/27/2019 Infectious Disease Incidents in the Workplace

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White Paper

Infectious Disease Incidentsand the Workplace: Cases and Key Lessons

Learned for a Global Organization


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DISCLAIMER

The content of this paper is for general informational purposes and should not be relied on as legal advice.

International SOS White Paper Series

Infectious Disease Incidents and the Workplace is published by International SOS

and written by Myles Druckman MD, Vice President, Medical Services and Dr. Irene Lai MBBS, Deputy Medical Director,

Medical Information and Analysis, International SOS

DISCLAIMER

The content of this paper is for general informational purposes and should not be relied on as legal advice.


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Infectious Disease Incidents

and the Workplace

Table of Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

Selected Published Health Incidents in the Workplace . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

USA, June 2010: News reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

German measles at International Shareholders Meeting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

Measles in an employee in Boston . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

United Kingdom, 2007: Investigation of Workplace Contacts of Bird Flu Cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

Workplace Contacts of Bird Flu Cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

USA, 2006: Measles Outbreak Boston . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

New Zealand, 2002: Community and Workplace Outbreak of Tuberculosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

USA,1999: Large German Measles Outbreak, Spread From the Workplace . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

France, 1995-96: Winter Epidemic of Diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

USA, 1987: Mumps in Chicago . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

Selected International and National Guidance on Workplace Infectious Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

World Health Organization (WHO) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

International Labour Organization (ILO) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

Guidelines for Workplace TB Control Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

SARS: Practical and Administrative Responses to an Infectious Disease in the Workplace, March 2004 . . . . . . . . . . . . . . . . . .9

International Labour Standard HIV/AIDS and the World of Work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

US Department of Labor, Occupational Safety & Health Administration (OSHA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

US National Institute for Occupational Safety and Health (NIOSH) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

Case Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

Pandemic Preparedness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

www.osha.gov . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

www.ilo.org . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

The Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18

Dr. Irene Lai MMBS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18

Myles Druckman MD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18

About International SOS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19


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Introduction

The last decade has seen a significant increase in the

globalization of many organizations, with their international

operations increasingly becoming a critical component to their

overall business growth and potential for success. Global

workforce populations are changing and employees from vastly

different regions of the world are now interacting and working

together as never before. With this business evolution comes new

challenges, including the increasing risk of infectious disease

incidents in the workplace.

If employees, through the course of their workday, meet or workwith other people, then there is the potential for their workplace to

become the site of the spread of an infectious disease. An

infectious disease outbreak involving the workplace can

significantly disrupt business activities, leading to financial and

reputational losses.

Although some infections come from animals and insects, many

are spread from person-to-person, either directly or perhaps

through inanimate everyday items such as computer keyboards

or telephones. Infection control in the workplace begins by

assuming that everyone is potentially infectious1. Workers who

become infected in the workplace may go on to spread disease

to other co-workers, their families and their communities.

Occupational health and safety regulations and guidance related

to infectious disease are generally aimed at occupations where

the exposure to infection is higher than during the course of daily

living outside of the workplace. Such occupations put workers in

contact with infectious people or body fluids, or animals and their

by-products. At-risk industries include healthcare, sewage

treatment, childcare/school, correctional facilities, slaughter

houses and farms. The one area where published guidance is

often available for organizations outside these higher risk fields is

in influenza pandemic planning.

The term workplace is referenced in this paper to define officesand workplaces that are not higher-risk environments. This paper

examines the landscape of infectious diseases which spread

from person-to-person in workplaces where the risk is not

enhanced by the nature of the job itself.

As organizations seek new

opportunities for growth, they are

expanding operations to all corners

of the globe. This expansion

brings employees from various

regions of the world together in

unprecedented ways. This

business evolution has highlighted

the increasing risk of infectious

disease outbreaks, and their

impact on both employee health

and business productivity.

These incidents are not

uncommon, and cases will be

reviewed, along with the key

lessons learned.


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In this paper, selected published incidents are outlined andInternational SOS internal polls are reviewed. Selected

international and national guidelines on workplace infectious

diseases are presented. Three examples of corporate infectious

disease incidents are offered, with specific lessons learned. This

paper does not explore workplace food-borne infectious

outbreaks, nor workplace biological emergency preparedness.

Overview

The impact of infectious disease in the workplace can be

significant. Even when just a few employees are affected, the

incident can ripple throughout an organization, damaging the

companys external reputation. One case of meningococcal

meningitis, regardless of the source of infection, will cause

concern in anyone who had any contact with the infected person.

The United Kingdoms Meningitis Trust states, Our research

indicates that for every person who contracts meningitis, it

actually affects up to 20 people around them, including family,

friends and work colleagues. If there is a case of meningitis in

your workplace, it may cause a high level of anxiety and fear

amongst employees, so it is extremely important that accurate

information is given to employees. It continues to state that,

Employers face key business issues when an employee is

affected by meningitis, whether that employee contracts the

disease themself, or is affected because a close friend or family

member has the disease. Issues including staff response,

customer relations, and productivity can all have an impact on a

companys bottom line.

Health incidents in the workplace can shake employee

confidence, raise anxieties and ultimately affect their personal

health. Some infectious disease outbreaks typically affect only a

small number of individuals. Some, like the pandemic influenza

(H1N1) outbreak of 2009, demonstrate the potential to rapidly

affect a large segment of the employee population.

Data regarding infectious disease incidents and outbreaks in the

workplace is scarce and corporations are typically cautious in

discussing or documenting such cases in a public forum. Where

data is available, it typically analyzes the incident from a public

health standpoint and the impact on business operations is

overlooked. Nevertheless, it is clear that such incidents do occur

in the office setting and appear to be becoming more common.

Dr. Michael Osterholm, the director of the Center for Infectious

Disease Research and Policy at the University of Minnesota,

advised that they are receiving requests from more and moreorganizations seeking assistance in managing tuberculosis,

measles and other infectious disease outbreaks in the USA, with

many of these cases originating from employees or contacts from

developing nations.2 Many organizations work in remote and

The impact of an infectious

disease in the workplace can be

significant, even when few

employees are affected.

for every person who contracts

meningitis, it actually affects up to

20 people around them, including

family, friends and work

colleagues

Planning for such events is a

recommended corporate best

practice. Outside of pandemic

planning, little guidance on

infectious disease health and

safety for the non-higher risk

industries is available.


and the Workplace

Sidebar 1

Consistent among corporate best practices inhealth incident planning and response are:

I a systematic process for global health risk assessment;

I proactive planning of anticipated and potential health incidents;I well-oriented and educated management teams;

I pre-arranged emergency responders external providers; and

I strong internal and external integrated communication processes.

5

medically underserviced locations where outbreaks of vaccine-preventable and other diseases are not unusual. Global

workforces are merging, and employees regularly travel abroad

for work. As employees move, so will infectious diseases,

including illnesses which are now uncommon in some societies.


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Selected Published HealthIncidents in the Workplace

Although public health organizations investigate workplace

infectious disease incidents, official statistics often do not

distinguish outbreaks in the general community from work place-

based transmissions. The London Hazards Centre states for the

United Kingdom that, Government sources reported 1,100

cases of work-related infections in 2003. They accept this is

probably a gross under-representation of the real situation.3 In

the United States, of the 14 rubella [German Measles] outbreaks

reported to the Centers for Disease Control and Prevention (CDC)

in 1996-1998, seven were workplace-associated.4

A number of reports in public health and medical journals are

available, as well as anecdotal reports from news services. These

serve as evidence that the potential for outbreaks in the

workplace is real.

USA, June 2010: News Reports

German measles at international shareholders meeting

An international Walmart shareholders meeting was held at the

University of Arkansas in early June of 2010. An attendeebecame ill with a rash and was hospitalized, which was

confirmed as rubella (German Measles). The Department of

Public Health investigated and vaccinated over 140 persons who

were potentially exposed.5 At the time of writing, no secondary

cases had been identified. While the meeting proceeded, the

incident created significant concern in the wider community.

Measles in an employee in Boston

An employee of Reebok was diagnosed with measles in June

2010 and had apparently traveled abroad.6 The organization is

working with the public health department and "requiring all

employees to show proof of their immunity to measles or be

vaccinated.7 Throughout the community, more than 500 peoplewere vaccinated to prevent further spread.

While publications of infectious

disease outbreaks in the

workplace (outside of healthcare)

are limited and data is scarce,

some government authorities

accept that what data is available

is a gross under-representation of

the real situation.

Atleast in the United States,

outbreaks of diseases are often

newsworthy, with popular media

naming the organizations involved.

Many workplace outbreaks,

though, do not see the light of day

as organizations typically seek to

limit any external visibility to the

incident.


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and the Workplace

United Kingdom, 2007: Investigation of Workplace Contacts ofBird Flu Cases

In May of 2007, an outbreak of low pathogenic bird flu H7N2

occurred in a poultry farm in North Wales. Investigators found

birds infected in three poultry premises, linked to a market in

north-west England. Four people were confirmed infected.8

At the time, an extensive investigation and contact tracing were

performed. Over 200 contacts were identified and more than 80

people received antiviral medication, either as treatment or

preventative. Of those contacts, more than ten had flu-like

symptoms or conjunctivitis thought to be possibly due to H7N2

bird flu.9 Subsequent analysis of the data showed that home and

workplace encounters were more likely to result in transmissionthan encounters in other settings.10 Workplace settings included

the general office environment.11

Follow up testing results in January of 2008 of those who had

symptoms at the time did not confirm H7 bird flu as the cause of

their symptoms.12 Nevertheless, this clearly demonstrates the

workplace to be a potential primary site for an outbreak of novel

influenza. The disruption to business is not documented.

USA, 2006: Measles Outbreak in Boston

An international employee of a financial services firm was the

index (first) case in an outbreak that eventually infected 18

people in May. The primary exposure setting for this outbreakwas a large office building and nearby businesses.13 A detailed

case presentation is given later in this document (see Case

Studies), from International SOS internal operational records.

New Zealand, 2002: Community and Workplace Outbreak of

Tuberculosis

The index case was a general floor cleaner in a meat

processing factory who was hospitalized in June. While it could

not be conclusively proven, it was thought that the infected

worker had transmitted the disease to possibly as many as 39

co-workers14 (ten with active disease and 29 with a latent

infection). The impact on the workplace affected is not

documented, however, under public health guidelines, highlyinfectious cases of tuberculosis are kept in isolation, sometimes

in the hospital, for at least two weeks after the start of treatment.

USA, 1999: Large German Measles Outbreak, Spread From the

Workplace

In March of 1999, an employee with a meatpacking plant in

Nebraska was diagnosed with rubella. The outbreak lasted four

months, and spread from the workplace to the wider community

and other counties within the state. Over 120 cases were

confirmed.4

France, 1995-96:Winter Epidemic of Diarrhea

The French Sentinelles Network tracks several healthindicators, including acute diarrhea.15 Their data shows annual

winter outbreaks of acute diarrhea are common in France.

During the epidemic of January of 1996, it was estimated that

over 600,000 people with diarrhea throughout France consulted a

doctor.16 Analysis of the data found that infections were not

related to consumption of shellfish (oysters) or tap water as had

been thought. The greatest risk factor was exposure to a

household member with diarrhea, followed by contact with a sick

person in the workplace.

USA, 1987: Mumps in Chicago

This was apparently the first documented outbreak of mumps in

the workplace.17 The incident resulted in over 100 confirmed

cases in employees of three future exchange houses in Chicago

and their household members. 21 cases developed medical

complications, including some pregnant women, and nine werehospitalized. Unlike other reports of workplace health incidents,

the economic cost in this case was determined - based on

average costs for physician visits, hospital charges, medications,

vaccination, average hourly wage for those involved in

investigations, and average daily wage for ill employees. Total

direct and indirect economic costs associated with the outbreak

were $120,738; the cost-per-case was $1,473. The impact to the

organizations involved was not analyzed.

Transmission of infection does

occur in the workplace, although

the degree to which is not

quantified. The workplace may

even be the site of an outbreak of

a novel human infection. If

incidents are recognized early and

actions taken, the number ofpeople infected and the duration of

the outbreak can be minimized.

Sidebar 2

International SOS Poll

Date: 5 February, 2008

Fifty large US-based corporations took part in a poll asking about

preparedness and experience with workplace infectious disease

outbreaks. Industries represented included automotive, clothing,

financial, IT, manufacturing, mining, oil and gas, and pharmaceutical.

I 52% had pandemic plans which extended to include other

infectious diseases.

I 46% had described a workplace infectious disease incident that

significantly affected business operations with some loss of

productivity.

I The diseases which caused most concern were tuberculosis and

MRSA, followed by norovirus.


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Selected International andNational Guidance on

Workplace Infectious

Diseases

World Health Organization (WHO)

In 2004, WHO held an inter-country consultation on tuberculosis

(TB) in the workplace. The objective of the communication was

to establish a common consensus on approaches to introduce

TB control practices in the workplace, both as a means of

widening access to quality TB control services to TB patients atwork, as well as to address the challenge posed by TB to growth-

oriented employers in the corporate sector.18

The report highlights that organizations play a crucial part in

promoting and implementing TB control activities. A number of

benefits flow to employers, such as higher productivity and

morale amongst workers, and an improved corporate image

through the demonstration of corporate social responsibility.

The three elements of a framework for TB control in the workplace

are:

I A policy statement that includes an expression of

commitment;

I A communications strategy, and

I A strategy for implementation.

In 2003, the World Health Organization and International Labour

Organization published joint guidelines on TB control programs

in the workplace. (see next page)

International Labour Organization (ILO)

ILO has published two documents (excluding pandemic

guidance) relevant to organizations on infection control in a non-healthcare setting. These relate to tuberculosis and Severe Acute

Respiratory Syndrome (SARS). The ILO also sets an international

standard on Human Immunodeficiency Virus/Acquired Immune

Deficiency Syndrome (HIV/AIDS) prevention, treatment and

support in the workplace.

More and more organizations are

seeking assistance in managing

infectious disease incidents in the

workplace. International SOS is

most often asked for guidance on

tuberculosis and measles. Other

diseases that result in requests for

assistance include meningococcal

meningitis, cholera, varicella

(chicken pox), legionella, pandemic

(H1N1) 2009 flu and

avian flu H5N1.


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and the Workplace

to ensure sick people are prevented from coming into theworkplace. Both WHO and ILO implemented such screening

during international conferences during the SARS outbreak, and

they noted that screening practices may have done much to

reduce the spread of SARS.

Of note, workplaces that involve contact with the general public,

such as shops and banks, are advised to encourage employers

to empower workers to take action if they feel that their right to a

safe and healthy workplace is being jeopardized by a member of

the general public.

During times of an outbreak of SARS in a community, suggested

additional actions to take to reduce the risk of SARS include:I Preventing close physical contact in the workplace;

I Preparing an area where sick workers can be isolated; and

I Storing personal protective equipment.

The document concludes by noting that a planned response to

SARS is relevant to other epidemic diseases, including

tuberculosis and cholera, and preparedness in the workplace

and community at large is necessary.

International Labour Standard HIV/AIDS and the World of Work

In June of 2010, the ILO released21 a new standard for HIV/AIDS

in the workplace.22 The standard is a recommendation andsupports the existing Code of Practice on HIV/AIDS from 2001.

National authorities must now discuss and implement this

through national policies and legislation.

The standard promotes non-discrimination and emphasizes HIV

and AIDS should be recognized and treated as a workplace

issue. Prevention is a priority and requires access to information

and education. The workplace plays a role in facilitating access

to treatment, care and support for those with HIV/ AIDS.

Sidebar 3

WORKPLACE SETTINGS WITH INCREASED RISK OF TB(adapted from table 2)

Oil and gas industries, and

plantations

Cramped living quarters and

potentially poor health conditions

Mining industry Silicosis and cramped living

quarters

Businesses with a large

migrant workforce

Poverty, poor sanitation and

living conditions, and birth in

countries with high TB

infection rates

SARS: Practical and Administrative Responses to an Infectious

Disease in the Workplace, March 2004

Following a meeting of senior labor officials of ASEAN countries

in 2003, where they shared experiences in dealing with thebusiness impact of SARS, the group called on the ILO to produce

an informal set of guidelines for SARS and the workplace. 20 While

the document is based on the SARS outbreak, the guidelines

pertain to any infectious disease that is spread from person to

person, and emphasizes the importance of preparation at all

levels to contain such epidemics.

For workplaces with no increased risk of SARS, hygiene

practices already supported, such as routine daily cleaning and

respiratory hygiene (covering coughs, washing hands) are

emphasized. In addition, measures to encourage sick workers to

stay out of the workplace until they are cleared are considered

particularly protective during a SARS outbreak. Indeed, if

SARS cases are occurring locally, or people are coming to the

workplace from SARS affected areas, employers may feel it

appropriate to institute active screening for fever and symptoms,

Guidelines for Workplace TB Control ActivitiesPublished in 2003 with WHO, the document states that these

guidelines represent the first comprehensive approach to

workplace TB control.19 Activities to improve control of TB

include linking to local public health, the education of employees,

referral of sick employees for diagnosis and treatment, and the

support of workers throughout their treatment. Outside healthcare

and correctional facilities, there are workplace settings

considered at increased risk of TB transmission See Sidebar 3.

For the workplace to be safe from TB, the guide advises:

I Education: Health education campaigns which de-stigmatize

the illness;

I Clear management policies: For sick leave, confidentiality,

and the prompt recognition of symptoms and referral for

medical care;

I Implementing environmental controls: To prevent or

reduce airborne transmission from unsuspected cases or from

diagnosed cases of TB to non-infected employees.


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US Department of Labor, Occupational Safety & Health

Administration (OSHA)

Infectious diseases beyond simple illnesses such as colds and

flu may need to be evaluated by an employer to determine the

relationship to the workplace. Common colds and flu are not

considered work-related even if contracted while the employee

was at work.23 However in the case of other infectious diseases

such as tuberculosis, brucellosis and hepatitis C, employers

must evaluate reports of such illnesses for work relationship, just

as they would for any other type of injury or illness.

If more than one employee is affected with the same infection

and those employees had contact with each other, then the

employer would consider the case work-related. OSHAbelieves that non-minor illnesses resulting from exposure in the

work environment are work-related and therefore recordable

unless a specific exemption to the presumption applies. Infection

from exposure to another employee at work is no different, in

terms of the geographic presumption, from infection resulting

from exposure to a client, patient or any other person who is

present in the workplace.

Evaluating whether an infection is work-related or not requires a

certain amount of knowledge of infections and how they are

transmitted. Organizations, especially those without access to

targeted medical advice, may find this challenging.

US National Institute for Occupational Safety and Health (NIOSH)

Apart from pandemic influenza,24 NIOSH singles out Methicillin-

Resistant Staph Aureus (MRSA) for guidance to general

workplaces (non-healthcare).25 Employers should prevent its

spread by encouraging good hygiene and maintaining routine

cleaning.

The United States Department

of Labor, Occupational Safety &

Health Administration (OSHA)

expects employers to evaluate

reports of infectious diseases,

other than colds and flu, for their

relationship to work.

The United States National

Institute for Occupational Safety

and Health (NIOSH) provides

limited guidance for

organizations on Methicillin-

Resistant Staph Aureus (MRSA)

and pandemic influenza.

Organizations must thus fill in

the gaps to ensure they have

actionable plans, including pre-

prepared communications.


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and the Workplace

Case Studies

CASE STUDY 1

NOROVIRUS - London, United Kingdom Winter, 2008

In the winter of 2008, the United Kingdom experienced a large epidemic of norovirus. In early January, it was reported that nearly 100,000

Britons were getting ill on a weekly basis, and that 100 hospitals had closed their wards to new patients due to the surge of medical cases.26

In less than three months, nearly a million Britons had fallen ill to this virus.

Norovirus causes gastroenteritis, with a sudden onset of nausea, violent vomiting, diarrhea, abdominal cramps, low-grade fever, headache

and muscle aches. The infection is typically self-limited and not dangerous, although the very young and very old are most at risk of

complications from dehydration. The virus is highly contagious, and outbreaks spread quickly. The virus is spread by contact with an infected

person, through contaminated food or water, or by contact with contaminated surfaces or objects. The virus can also survive on hard surfaces.Patients may remain contagious for at least three days and often longer, as well as up to three days after they recover, so limiting the

transmission is challenging. Proper hand hygiene is one of the key elements in controlling outbreaks.

The impact of norovirus was experienced at the International SOS London alarm (call) center. Over a period of one week, 12 employees

became temporarily incapacitated by the illness, with eight of them simultaneously unable to work. This level of absenteeism could have

caused up to a 25% degradation in service capacity and could have led to massive service failures if not for the infectious disease planning

that had been put in place.

International SOS activated a number of key interventions which limited the impact of this infectious disease outbreak. On first news of the

escalating norovirus epidemic in the general London community, we distributed pre-prepared frequently asked questions (FAQs) about

norovirus to our employees. Employees were informed how to protect themselves and also how, if they fell sick, to limit spreading the illness to

others, including colleagues and family members. Strict hand washing protocols were put in place upon entering the facility and after using

washrooms. Additional cleaning was put in place, focusing on shared and commonly touched objects, using special cleaning agents. A

Norovirus Awareness Questionnaire was instituted at the business entry so that anyone with symptoms would self-identify themselves and not

enter the facility. Close contact with ill personnel also could be self-identified by the questionnaire and their entry to the facility managed. Even

with these procedures rapidly implemented, two cases occurred and within 48 hours, six additional cases followed.

The business continuity plan included the ability to transfer incoming calls from the London alarm center to other International SOS alarm

centers around the world. Calls were re-routed to the United States and Singapore, and there was no disruption to our business operations

from our clients perspective.

Other important actions undertaken included the modification and implementation of travel restrictions for our staff traveling to, or returning

from, the UK. In this case, non-essential travel to London was postponed, and only business-critical travel to London could proceed after

seeking approval by management. Travelers returning from London were required to self-quarantine for the incubation period before they were

allowed entry to the workplace, to ensure they were not at risk of infecting their work colleagues.

Fortunately, norovirus is typically a self-limited illness that resolves in a few days without specific treatment. That being said, the illness remains

the most common cause of gastroenteritis in the UK. Winter outbreaks occur annually, with some years being more significant than others. 27

The fact that International SOS

identified the threat early,

before cases occurred in our

employees, and had a plan

ready to be put into action,

significantly reduced the impact

of the illness on our personnel

and business operations.


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12

CASE STUDY 2

MEASLES - Boston, MA, USA Spring, 2006

In the spring of 2006, an employee of a major financial firm developed severe fever and malaise while at work on a trading floor in Boston. The

employee, who recently arrived from India, sought medical attention and measles was diagnosed.28 The disease spread to 18 others, throughseveral other places of business, and into the general community over several weeks before being brought under control.

Measles is one of the leading causes of death among young children, with over 197,000 deaths globally in 2007. 29 While targeted vaccination

programs have made significant inroads in reducing measles cases and deaths a 74% drop in deaths from 2000 to 2007 globally, only

82% of children receive one dose of measles vaccine by their first birthday (two doses are recommended since 15% of vaccinated children

fail to develop immunity from just one dose).

The virus is highly contagious, and is spread through the air via coughing and sneezing. The virus remains active and contagious in the air or

on infected surfaces for up to two hours. It can be transmitted by an infected individual from four days prior to the onset of a rash, to four days

after the rash erupts. Measles is a notifiable disease in many nations, including the US, which means that once the disease has been

diagnosed, the doctor must report the case to local public health authorities. Local health authorities will then assess the situation and activate

diseases control measures, including contact tracing and mass vaccination as appropriate.

As expected, once the employee was diagnosed with measles, the local city public health authorities immediately contacted the company

and commenced contact tracing. Health authorities were planning to close the trading floor pending review of the immunity status of all

employees working at the facility. The employees were understandably concerned, as was the management of the company. It was clear thatthe objectives of the local public health authority did not include maintaining and supporting the business needs and obligations of the

company.

With the office closed and millions of dollars of portioning revenue disappearing every hour, the company aggressively negotiated with the

public health authorities to agree on a solution to meet both the public health obligations while, at the same time, allowing the company to

reopen their business operation. While the public health authorities wanted documented clinical evidence of appropriate vaccination status (or

immunity to measles), the company regarded this as very time consuming. The company planned an in-house mass measles vaccination

program through a local medical provider willing to perform a mass measles vaccination program for the affected employee population.

Finally, the solution agreed upon was for each employee to either have documented evidence of their immunity from their family physician

(documentation of previous infection or two doses of vaccine), or to participate in the mass measles vaccination program. The company was

finally able to resolve the situation and have their employees return to work, but not before a number of days were lost with business disruption

costs estimated in millions of dollars.

Case Studies (Continued)


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13


and the Workplace

CASE STUDY 3

TUBERCULOSIS USA 2007

Two major corporations based in the same city in the USA became aware of a single case of tuberculosis in one of their respective

employees. As with the measles incident previously mentioned, one company did not have a corporate medical director. The other company

had a full-time, dedicated physician. In both cases, the patients developed symptoms of active tuberculosis while at work, and both patients

were residents of developing countries where they initially contracted the illness.

While the clinical condition was managed by the local medical providers in coordination with the local public health authorities, the challenges

the companies faced related to both communication and business disruption. Public health authorities performed contact tracing, which

caused increased employee anxiety and increased demands on the companies to provide guidance and direction. Risk communications

were the key challenge. Within hours, executive management wanted a formal update and assessment of the situation and the plan of action.

The company without a medical director scrambled to try to find a local infectious disease expert who could be available within a few hours to

speak to their CEO and board, and brief them on the issue and a plan of action. They were unsuccessful. The public health authorities were

also unable to speak to management. This left non-medical middle managers to attempt to rapidly understand this complex issue and explaina plan of action to their bosses. The next challenge was to present a clear communication plan for the employees. A town hall meeting was

set up, but again, the company was unable to find a local doctor to discuss the issues, nor were the local public health experts available. It

also became clear to the company that a doctor off the street would potentially be a liability, as the presenting physician would need to know

not only the clinical issues, but also the corporate culture and business strategies of the organization. The lack of medical leadership and

expertise led to a disruptive and unsatisfactory resolution of the incident. The outcome of this incident highlighted the need for a corporate

medical resource, and the company ultimately did retain the services of a corporate medical physician.

On the other hand, the organization which had a corporate medical director was able to more effectively communicate the risks and develop

plans for management and to present to the employee base. As well, the medical director interfaced with the local public health authorities,

and made their contact tracing efforts more efficient and less disruptive to the organization. The incident required the services of the medical

director for three full days, and then on-going monitoring of the outcomes over next few weeks and months. The overall management of the

event resulted in less business disruption and employee anxiety.

The organization which had a

corporate medical director was

able to more effectively

communicate the risks and

develop plans for management

and to present to the employee

base.


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Pandemic Preparedness

Corporate influenza pandemic planning began in earnest in

2004, shortly after the global outbreak of severe acute respiratory

syndrome (SARS) was brought under control, and following the

appearance of human cases of influenza A/H5N1 (bird flu), in

Vietnam and Thailand.

Influenza A/H5N1 is a novel influenza virus with pandemic

potential. Although it continues to infect birds and is occasionally

transmitted to humans, it does not spread easily from person to

person. If it should mutate to gain the ability to readily pass from

one person to the other, it could cause a pandemic.

Initially, there was little guidance, other than for the healthcare

sector, on the risks of pandemic influenza and the actions to be

taken to mitigate those risks. As the threat of bird flu H5N1

increased, authorities recognized that pandemic influenza could

potentially affect every aspect of the globally connected just-in-

time economy. There is now a significant amount of guidance for

organizations on pandemic influenza planning, including the

International Labour Organization,30 US Federal Government,31

OSHA,32 and the United Kingdom Cabinet Office33 to name a few.

Financial institutions were some of the earliest to adopt pandemic

planning, as their financial risk management teams assessed thepotential financial threat of a pandemic, and their results drove

them to aggressively develop plans to mitigate these risks. At the

same time, organizations with major assets in Asia began to

consider pandemic planning, driven by local management

concerns from early outbreaks of H5N1 in their area.

For those companies affected by SARS, lessons learned

included the need for:

I Pre-arranged internal communications to combat mis-

information in the media and local communities;

I Clear travel management programs to ensure personnel are

oriented and aware of infectious outbreaks; and

I Identifying travelers at risk and interacting with them on a real

time basis.

Unlike other infectious disease risks,

there is now a significant amount of

guidance for organizations on pandemic

influenza planning.

During the early stages of pandemic

H1N1 in 2009, the most common

causes of calls for assistance to

International SOS included:

People placed in mandatory quarantine upon

arrival in a foreign country, unaware of the risk

when they departed;

Guidance on the management of H1N1 in an

employee;

Access to antiviral medications; and

Access to pandemic vaccines.


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15

Important work and research from World Health Organization(WHO) and the Centers for Disease Control (CDC) in Atlanta

provided the basis for many corporate pandemic plans. The

concepts of Non-Pharmacological Interventions (NPI), Targeted

Layered Containment (TLC) and antiviral medication stockpiling

were key strategies utilized by many organizations to build their

internal corporate pandemic plans.

The WHO defined six discrete pandemic phases,34 each phase

linked to the evolution of a novel influenza virus ability to cause

illness in humans, its ability to spread readily from human to

human and its global spread. Many national and corporate

pandemic plans linked their pandemic interventions to the

escalating WHO pandemic phases.

In April of 2009, Mexican health authorities became aware of an

outbreak of an unknown respiratory illness that was rapidly

spreading through communities, causing hospitalization of

hundreds of people, and resulting in a number of fatalities. By

late April, it became clear that this was a novel influenza virus,

initially termed swine flu, and it had already spread to Canada

and the USA at the least.

Over the next five weeks, this new flu spread widely and rapidly

around the world, with most cases initially transmitted by

travelers from Mexico and the USA. On June 11, 2009, WHO

finally declared a pandemic. The virus was officially termed apandemic (H1N1) 2009 influenza.

The pandemic flu (H1N1) of 2009 tested many assumptions in

corporate pandemic plans. Plans had been written with avian flu

H5N1 in mind, a severe virus that is fatal in about 60% of all who

are infected. Pandemic (H1N1) 2009 is a mild illness in the vast

majority of cases. It became clear that more than WHO phases

were needed to inform the most appropriate corporate pandemic

interventions, and many plans required re-tooling.

Most corporate pandemic plans included Phase 6 actions that

were the most aggressive and invasive of pandemic

interventions such as working from home, point-of-entry

screening, the use of personal protective equipment, antiviral

distribution, and in some cases, facility closure. WHO phases did

not differentiate severity.

In addition, WHO phases did not differentiate between locations.

Once a phase escalation was declared, the whole world was

then in that phase. While aggressive interventions were

appropriate in Mexico City at the height of the outbreak, when

schools were closed and public gatherings cancelled, such

measures would have been inappropriate in places with no, or

very few, cases. From WHOs perspective, each location was at

the same Phase 6, though the actions companies took varied

widely, based on the impact of the influenza virus on the localcommunity.

Lessons learned from the first wave of H1N1 influenza revealed agap in the timing of pandemic interventions. While the actual

interventions themselves employee education, hygiene, travel

restrictions, door screening, etc., still remained appropriate it

was the timing mechanism of the activation that needed

modification.

Thus, a new generation of corporate pandemic plans evolved in

the late summer and fall of 2009 and came into action. These

plans included trigger points based on the number and trajectory

of H1N1 cases, and the assessed level of severity of the virus.

This gave organizations the flexibility to activate interventions

which were proportional to the local pandemic situation.

Pandemic plans became local; it was no longer a single plan buta tactical plan that was customized for the local site and

managed locally.

Anticipating the wave of infection in the local community

became an important component of a pandemic plan.

Surveillance relevant for a local plan required not only information

from the WHO and CDC, but also required state and county

public health data. Some companies collected information from

multiple local sources including news, school absenteeism

reports, hospital capacity spreadsheets and community

sentiment to gauge where they were in the wave.

Need higher resolution image/text/chart; currently unreadable.


and the Workplace


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16

Conclusion

Corporate health incident planning, whether it is for a known

infectious disease or an emerging illness, requires appropriate

planning and resources. Assessment of an organizations global

health exposure is a critical first step in plan development.

Corporations are expected to be able to manage foreseeableincidents. Common illnesses such as measles, norovirus,

tuberculosis, cholera and malaria must be addressed with an

appropriate plan. Relatively uncommon illnesses with potentially

severe impacts (such as meningococcal disease) should also be

included in plans.

The good news in planning for known illnesses is that information

is available today to address most incident management issues

in advance. Pre-prepared responses, including the notification of

public health authorities, enhanced hygiene and cleaning,

implementation of employee screening, quarantine, contact

tracing and the distribution of pre-scripted frequently asked

questions (FAQs) to employees will rapidly reduce anxiety anddemonstrate an efficient and professional response.

Another important resource in managing an infectious disease

incident is a corporate medical resource. A corporate physician

understands both the corporate culture and expectations, and

the health needs of the employee. Corporate medical directors

and their departments reduce confidentiality and privacy issues

and can act as an efficient bridge between management and

staff, and the local community. Corporate medical departments

have been shown to play a critical role in health incident

management, and more companies are realizing the importance

of this expertise.

Influenza pandemic may be considered one of the most

challenging known global health threats. Because it can impact

significant portions of a population over a short period of time, a

severe influenza pandemic can shake the foundation of any

Infectious disease in the workplace

is a corporate responsibility, and

plans and corporate medical

resources are critical components

in ensuring adequate duty of care

is provided.


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17

organization. A comprehensive pandemic plan includescorporate level policies that guide local units, pre-scripted

communications in multiple languages if appropriate, a local

pandemic plan of escalating pandemic interventions based on

community-based surveillance of influenza activity and severity,

and business continuity plans to manage absenteeism, sales

degradation and supply chain disruption.

As the human population grows and there is more global travel,

emerging diseases are likely to not only continue to occur, but

also affect more communities more rapidly. In these cases,

effective surveillance, corporate medical resources and health

incident plans will be crucial in ensuring that an organization is

best prepared to meet any new health challenge that maysuddenly arise.

Related Websites

www.osha.gov

United States Department of Labor, Occupational Safety and

Health Administration. The US body for ensuring safe working

conditions through setting and enforcing standards, and

providing training. The Website includes published standards,

regulations, data and statistics, fact sheets and guidance

documents.

www.ilo.orgInternational Labour Organization. The tripartite body of the

United Nations, representing government, employers and

workers for member states. The Website includes published

labor standards, statistics and databases on recommendations,

and occupational health and safety.

Acknowledgments

The author is grateful for the assistance and feedback received

on the content of this paper from the following individuals at

International SOS:

Leigh Burns, Group Product Director, Medical Consulting and

Training Services

Nicolau Chamma, MD, MPH, Regional Medical Director, Medical

Services - Americas Region

Ana Mensua, MPH, Public Health Advisor

Doug Quarry, MBBS MSc (Community Health), Medical Director,

Medical Information and Analysis

Francesca Viliani, MPH, MSc (Humanitarian Affairs), Director,

Public Health Services


and the Workplace


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18

Myles Druckman, MD

Dr. Druckman is Vice President,

Medical Services for International

SOS, where he leads the

development of customized

corporate health solutions for

multinational organizations that

support the health of their personnel

wherever they may live or work

globally.

Considered a leading pandemic expert and thought leader in

international corporate health, Dr. Druckman has served as a

resource for international and national media such as CNN,CNBC and Consumer Reports on topics such as the global

management of emerging diseases, pandemic preparedness,

and medical crisis management. In addition, Dr. Druckman

lectures widely and regularly publishes articles on international

healthcare issues.

Previously, Dr. Druckman held the position of Vice President,

Medical Assistance for International SOS in the Americas region.

Prior to this role, Dr. Druckman was Regional Medical Director for

International SOS in North Asia where he was based in Beijing,

China for five years. He developed and managed four

International SOS clinics, three International SOS alarm centers

and 26 remote operations. Prior to joining International SOS, Dr.Druckman spent five years in Moscow, where he founded the first

Western medical facilities in the former Soviet Union, in Moscow,

St. Petersburg and Kiev.

Dr. Druckman holds a Bachelor of Science degree from McGill

University and a Medical Degree from McMaster University

Medical School. He presently holds medical licenses in the

United States and Canada.

The Authors

Dr. Irene Lai, MBBS

Dr. Lai is the Deputy Director of

Medical Information and Analysis at

International SOS. She is one of the

companys lead pandemic

preparedness experts, and provides

technical and practical guidance to

the group on a global basis. She

oversees the medical input for

medical consultancies worldwide,

including numerous Fortune 500 Companies, as well as

consulting directly with a number of clients. She was

instrumental in developing the Pandemic Preparedness suite of

products and continues to enhance these.

Irene joined International SOS in 1997 as a Coordinating Doctor

in the Singapore office. Since then, she has held different roles

within the group during postings in Sydney, Australia and Jakarta,Indonesia.

Irenes Medical Degree is from the University of Sydney

(Australia). She trained primarily in internal medicine and clinical

research. She worked as a Medical Registrar in a number of

tertiary teaching hospitals in Sydney before practicing at

Northwestern Memorial Hospital, Chicago and then New York

University Medical Center. She holds current medical licenses in

Australia and Hong Kong.


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and the Workplace

15 Sentinelleshttp://websenti.u707.jussieu.fr/sentiweb/?page=presentation

16 Risk factors for winter outbreak of acute diarrhoea in France:

case-control study, Letrilliart, Desenclos and Flahualt, British

Medical Journal, 1997;315:1645-1649

http://www.bmj.com/cgi/content/full/315/7123/1645/a

17 Mumps in the Workplace, Further Evidence of the Changing

Epidemiology of a Childhood Vaccine-Preventable Disease,

Kaplan, Marder et al, Journal of the American Association,

1988;260(10):1434-1438 http://jama.ama-

assn.org/cgi/reprint/260/10/1434

18 TB Control in the Workplace, Report of an Inter-CountryConsultation New Delhi, February 19-20, 2004, World Health

Organization, Regional Office for South-East Asia,

http://www.searo.who.int/LinkFiles/Reports_TB-269.pdf

19 Guidelines for workplace TB control activities, World Health

Organization and International Labour Organization, Geneva,

Switzerland, 2003.

http://whqlibdoc.who.int/publications/2003/9241546042.pdf

20 Working Paper: SARS - Practical and administrative responses

to an infectious disease in the workplace, International Labour

Organization Sub-regional Office for East Asia, March 2004

http://www.ilo.org/wcmsp5/groups/public/---ed_emp/documents/publication/wcms_115129.pdf

21 International Labour Organization, Press Release, June 17,

2010: ILO conference adopts unprecedented new international

labour standard on HIV and AIDS

http://www.ilo.org/global/About_the_ILO/Media_and_public_infor

mation/Press_releases/lang--en/WCMS_141928/index.htm

22 International Labour Organization, Text of the Recommendation

Concerning HIV and AIDS and the World of Work, June 2010

http://www.ilo.org/wcmsp5/groups/public/---ed_norm/---

relconf/documents/meetingdocument/wcms_141906.pdf

23 US Department of Labor, Occupational Safety & HealthAdministration, OSHA Recordkeeping Handbook. The Regulation

and Related Interpretations for Recording and Reporting

Occupational Injuries and Illnesses

http://www.osha.gov/recordkeeping/handbook/index.html

24 US National Institute for Occupational Safety and Health,

Employer Guidance: Reducing All Workers Exposures to the

2009 H1N1 Flu, accessed June 15, 2010

http://www.osha.gov/h1n1/nonhealthcare.html

25 US National Institute for Occupational Safety and Health, MRSA

and the Workplace, accessed June 15, 2010

http://www.cdc.gov/niosh/topics/mrsa/26 BBC News Channel. "Stomach bug sweeping the country".

2008 [cited; Available from:

http://news.bbc.co.uk/1/hi/health/7169347.stm]

References

1 Work Issues - Infection Control, Better Health Channel, Victorian

State Government

http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/W

ork_issues_infection_control?OpenDocument

2 M. Osterholm, CIDRAP Summit 2009, Center for Infectious

Disease Research and Policy (CIDRAP), University of Minnesota,

Editor. 2009

3 London Hazards Centre Fact Sheet

http://www.lhc.org.uk/members/pubs/factsht/85fact.pdf

4 A Large Rubella Outbreak With Spread From the Workplace to

the Community, Danovaro-Holliday, LeBaron et al, Journal of the

American Medical Association. 2000; 284:2733-2739

http://jama.ama-assn.org/cgi/content/full/284/21/2733

5 Arkansas Department of Health, Press Release,June 9, 2010

http://www.arkansas.gov/health/newsroom/index.php?do:newsDe

tail=1&news_id=263

6 Boston Globe, June 16, 2010

http://www.boston.com/news/health/blog/2010/06/measles_confir

m.html

7 CBS Local News WBZ TV, June 15, 2010

http://wbztv.com/local/measles.reebok.headquarters.2.1753505.h

tml

8 World Health Organization, Disease Outbreak News, June 4,

2007 http://www.who.int/csr/don/2007_06_04/en/index.html

9 Wales Health Board, News, June 1, 2007

http://www.wales.nhs.uk/sitesplus/862/news/6831

10 Assessing the role of contact tracing in a suspected H7N2

influenza A outbreak in humans in Wales. Eames, Webb et al.

BMC Infectious Diseases 2010, 10:141

http://www.biomedcentral.com/content/pdf/1471-2334-10-141.pdfaccessed June 15, 2010

11 Intl. SOS personal correspondence from Dr Ken Eames,

London School of Hygiene and Tropical Medicine, June 16, 2010

and Dr Mark Temple, Public Health Wales, Health Protection,

June 17, 2010

12 Wales Health Board, News, January 24, 2008

http://www.wales.nhs.uk/sitesplus/862/news/8453

13 US Centers for Disease Control and Prevention, Summary of

Notifiable Diseases: Measles USA 2006

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5553a1.htm

14 A community and workplace outbreak of tuberculosis in

Hawkes Bay in 2002, McElnay, Thornley, and Armstrong, New

Zealand Medical Journal, August 20, 2004, vol 117 No 1200

http://www.nzma.org.nz/journal/117-1200/1019/


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27 Health Protection Agency England & Wales. Topics: Infectious

diseases, Norovirus. 2009 [cited; Available from:

http://www.hpa.org.uk/HPA/Topics/InfectiousDiseases/InfectionsA

Z/1191942172966/]

28 International SOS Medical Alert Measles cases in Boston,

Massachusetts, June-July 2006

29 WHO, Fact sheet no.286: Measles 2008

30 International Labour Organization, Guidance on Preparing

Workplaces for an Influenza Pandemic

http://www.ilo.org/employment/Whatwedo/Publications/lang--

en/docName--WCMS_115803/index.htm

31 United States Federal Government: Business Planning

Information http://www.flu.gov/professional/business

32 US Department Of Labor, Occupational Safety & Health

Administration (OSHA), Guidance on Preparing Workplaces for

an Influenza Pandemic

http://www.osha.gov/Publications/influenza_pandemic.html

33 United Kingdom Cabinet Office: Pandemic Flu Guidance for

Work place/ Business

http://www.cabinetoffice.gov.uk/ukresilience/pandemicflu/guidanc

e/business.aspx

34 WHO current phase of pandemic alert

http://www.who.int/csr/disease/avian_influenza/phase/en/


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About International SOS

International SOS (http://www.internationalsos.com) is the

worlds leading international healthcare, medical assistance,

and security services company. Operating in over 70 countries,

International SOS provides integrated medical, clinical, and

security solutions to organizations with international operations.

Services include planning and preventative programs, in-

country expertise, and emergency response. A global team of

7,000 employees led by 970 full-time physicians and 200

security specialists provides health and security support to

enable its members to operate wherever they work or travel.Members include 69 percent of the Fortune Global 500

companies.

2011 All copyrights in this material are reserved to AEA International Holdings

Pte. Ltd. No text contained in this material may be reproduced, duplicated or copied

by any means or in any form, in whole or in part, without the prior written permission

of AEA International Holdings Pte. Ltd.


22/22

For more information on Infectious Disease Incidents

and the Workplace, please contact International SOS

www.internationalsos.com/pandemicpreparedness

Documents

Infectious Disease Incidents in the Workplace