Strategies for seasonal influenza: spreading prevention across the worlforce

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Strategies for seasonal influenza: spreading prevention across the workforce is an Economist Intelligence Unit report, sponsored by Novartis. It analyses changing corporate perceptions in the US and western Europe about the impact of seasonal influenza and the prevention measures companies are putting in place.

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Strategies for seasonal influenza: spreading prevention across the worlforce

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  2. 2. Strategies for seasonal influenza Spreading prevention across the workforce Contents About the report 2 Executive summary 3 Introduction: Picking influenza out of a crowd 5 Chapter 1: Business perceptions of seasonal influenza 9 Chapter 2: Preventing seasonal influenza Chapter 3: Fighting mistrust, misunderstanding and misinformation 20 Conclusion 25 Appendix: Survey results 1 14 26 © The Economist Intelligence Unit Limited 2013
  3. 3. Strategies for seasonal influenza Spreading prevention across the workforce About the report Strategies for seasonal influenza: spreading prevention across the workforce is an Economist Intelligence Unit report, sponsored by Novartis. It analyses changing corporate perceptions in the US and western Europe about the impact of seasonal influenza and the prevention measures companies are putting in place. This report draws on two main sources for its research and findings: • Angus MacGregor, director of human resources, Eversheds (UK) • Al Smith, corporate director, safety, Greyhound Lines (US) • Doug Quarry, medical director, medical information and analysis, International SOS (UK) • Rod Ratsma, head of UK business continuity management practice, Marsh Risk Consulting • Jenny Hawker, health management consultant, Mercer UK  In June 2013, The Economist Intelligence Unit surveyed 418 senior business executives from the US, the UK, Germany, France, Italy and Spain—one-half of whom are from the board or C-level (CEO, CFO, CIO, etc). Twenty industries are represented in this sample, with just over one-quarter (28%) of companies coming from financial services or manufacturing. Around one-half of these companies have more than 500 employees or more than US$500m in annual revenue. • Helen Darling, president and chief executive, National Business Group on Health (US)  Alongside the survey, we conducted a series of in-depth interviews with senior executives, academics and other experts, supplemented by the desk research of relevant third party publications. Our thanks are due to the following for their time and insights (listed alphabetically by organisation): • Judy Harvey, manager, corporate industrial hygiene and workplace safety program, United Technologies (US) • William Fried, senior medical director, Aetna (US) • Janice Hartgens, global occupational health manager, UPS (US) • Frank Fox, head of occupational health, Anglo American • Stefan Lang, chief medical officer and head of occupational medicine and health protection department, BASF (Germany) • Graham Johnson, clinical lead, nursing, for Bupa Health Clinics (UK) • Andreas Tautz, chief medical officer, Deutsche Post DHL (Germany) 2 • Philippe Aeschlimann, spokesman, Nestle SA (Switzerland) • Gill Macleod, chief executive, RoonLane Medical (UK) • Amy Costello, senior benefits analyst, Staples (US) • Lisa Hamblet, vice president, Staples Facility Solutions, Staples (US) • Jonathan Van-Tam, School of Community Health Sciences, University of Nottingham (UK); consultant on pandemic influenza to the World Health Organization • Tim Stevenson, head of medical services, Virgin Atlantic Airways (UK) • Tom Sondergeld, director of team member health benefits and well-being, Walgreens (US) • Tim Brne, director of immunization services, Walgreens (US) The report was written by Andrea Chipman and edited by James Chambers © The Economist Intelligence Unit Limited 2013
  4. 4. Strategies for seasonal influenza Spreading prevention across the workforce Executive summary Seasonal influenza is a reliably regular blight on the working age populations of the US and western Europe. Employee absenteeism is generally perceived to be the biggest cost of flu to businesses in these regions. Yet for such a common and recurring adversary, there continue to be plenty of knowledge gaps among employers and employees, from understanding the virus to measuring and mitigating its impact. In order to better understand the perception of seasonal influenza among businesses in the US and western Europe, the Economist Intelligence Unit surveyed over 400 business leaders in those regions and conducted a series of in depth interviews with executives and experts, supplemented by extensive desk research. Difficulties in diagnosing seasonal influenza and distinguishing it from other common viruses— even for doctors—means it is challenging for managers to keep an accurate record on employee absences. Understandably therefore, many companies either fail to collect data on the impact of influenza or lack confidence in the data they do collect. As a result, it is tough for senior business leaders to assess adequately the success or failure of corporate influenza prevention initiatives. Such knowledge gaps are compounded by a paucity of third party literature on the economic impact of seasonal influenza. Few companies know the business impact of seasonal influenza: As most cases of suspected influenza are not officially diagnosed, many managers find it difficult to assess its frequency in their organisations. A sizeable minority of companies (47%) rate their data collection efforts “poor” or lower—with one in five (22%) collecting no data at all. There is also a distinct lack of third party information available on the business impact of seasonal influenza. This general lack of data is seen as one of the top three obstacles restricting the success of company initiatives around prevention. Being able to quantify the business cost of seasonal influenza would raise prevention as a business priority. While employers and employees tend to be more aware than they were several years ago about the threat posed by seasonal influenza, this has more to do with the “pandemic effect” created by regular warnings about potential global outbreaks, rather than any change in strategy. 3 © The Economist Intelligence Unit Limited 2013 The key findings of this research include the following: Southern European businesses are feeling fewer “symptoms” of the virus: Absenteeism is by far the biggest business cost associated with
  5. 5. Strategies for seasonal influenza Spreading prevention across the workforce influenza, but there is a split in how countries perceive trends in influenza-related absenteeism to be developing: Germany, the UK and the US all report double-digit increases in employee sick days in recent years, whereas businesses in Spain, Italy and France report either a negligible increase or a net decrease. Alongside this trend there has been an overall net increase in the business priority of seasonal influenza compared with three years ago, based largely in the UK, Germany and the US. This contributes to a higher risk profile for influenza overall in the US, the UK and particularly Germany than in the more southern European countries. Most companies conduct influenza mitigation, although some lack a coordinated approach: Three-quarters of companies communicate with employees about influenza, with poster campaigns and email newsletters being the favoured method. Fully 84% of companies conduct some form of seasonal influenza prevention activity, such as on-site vaccinations and an elevated focus on workplace hygiene during the influenza season. Yet only one-half (50%) of companies have a formal strategy in place to mitigate the virus. The gap between these figures suggests that a significant minority of influenza activities, such as vaccinations or messaging, do not form part of a structured prevention strategy, nor are they led from the top. Pandemic warnings have made companies better prepared, but have increased the risk of complacency: Official recommendations from public health bodies and perceived risks of pandemic influenza are the top two factors likely to raise the status of influenza as a business priority. Therefore, regular warnings about potential pandemic influenza outbreaks have unsurprisingly raised the status of general influenza prevention as a business priority. Many companies now feel better prepared to deal with influenza in general. Still, as the memories of the 4 © The Economist Intelligence Unit Limited 2013 last official pandemic in 2009 are fading, focus is tapering and the potential for complacency is building. Experts also say that there is an artificial distinction between pandemic and epidemic influenza, leading to a tendency for businesses to concentrate on the former and give insufficient attention to the latter. The effectiveness of current influenza initiatives are under the microscope: Despite increased employee awareness of influenza over the past few years, low employee receptiveness to seasonal influenza prevention initiatives is the most commonly mentioned factor restricting the success of those initiatives. Health experts and occupation health executives report a persistent level of employee misunderstanding about seasonal influenza and mistrust of prevention methods. This suggests that companies need to become more informative, more creative and more involved in engaging employees, rather than simply relying on signs and posters to get the message across; particularly when there are no elevated concerns about a potential pandemic. Justifying the cost of prevention is not an exact science: High costs of prevention measures are believed to restrict the success of influenza initiatives. Therefore, enabling executives to judge the financial merits of investing in influenza prevention is important at a time when budgets remain under strain and ageing employers are bringing other illnesses and ailments into the workplace. Yet far more companies (47%) do not have metrics to measure the effectiveness of prevention initiatives than those that say they do (28%): measuring the level of employee uptake of vaccination initiatives is the one metric that most companies use, if anything. Being able to collect accurate data about the business impact of the virus is a preliminary step to measuring the return on investment (ROI) of influenza mitigation efforts.
  6. 6. Strategies for seasonal influenza Spreading prevention across the workforce Introduction Picking influenza out of a crowd Even for experts, [making] the distinction between influenza and respiratory viral infections is incredibly difficult. Dr Jonathan Van-Tam, Professor of Health Protection, University of Nottingham CDC Seasonal Influenza Questions & Answers, http://www.cdc.gov/flu/ about/qa/disease.htm. 1 Commission of the European Communities, Council Recommendation on seasonal influenza vaccine, July 13 2009, Brussels, Belgium. 2 5 Few would deny that seasonal influenza has an annual impact on the populations of the US and Europe. In the US, between 5% and 20% of the population gets influenza each season; there are some 36,000 deaths, and more than 200,000 are hospitalised annually as a result of seasonal flu-related complications, according to the Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia.1 In Europe, the number of annual deaths from influenza are estimated to be around 40,000 in a moderate year and 220,000 in a particularly severe epidemic, based on the EU population of around 500m in 2008, although the number of recorded deaths from influenza is far smaller. Yet getting an accurate picture of the prevalence of influenza can be difficult, as the measurements themselves are frequently the subject of disagreement. One of the first difficulties in assessing the impact of seasonal influenza is defining and diagnosing it. Seasonal influenza is a respiratory illness with symptoms that often include a high fever, headache, fatigue, coughs, sore throat, nasal congestion, muscle aches or upset stomach. Since many of these symptoms are also associated with the common cold and other respiratory infections, influenza experts say it is often difficult to accurately determine the extent of a given seasonal epidemic. © The Economist Intelligence Unit Limited 2013 “The fundamental problem is that, even for experts, [making] the distinction between influenza and respiratory viral infections is incredibly difficult,” says Dr Jonathan Van-Tam, professor of health protection at the University of Nottingham’s School of Community Health Sciences, and consultant to the World Health Organization (WHO) on pandemic influenza. While most people severely affected by seasonal influenza are the elderly, the young, and those with pre-existing health conditions, it also has an annual impact on the working-age population in these regions, most noticeably in terms of employee absenteeism. But getting an accurate impact of seasonal influenza on the US and European economies can be even harder to pin down. There is substantially more information available for the US than for Europe; yet even here, much of the data cited by agencies—ranging from the US Department of Health and Human Services to the CDC—comes from the same source (see The business cost: influenza in numbers). The figures give a taste of the magnitude of the impact, but assessing the business cost of seasonal influenza is an imperfect science at best. As we will see later on, this lack of clarity exists at company level too, so that influenza strategies—to the
  7. 7. Strategies for seasonal influenza Spreading prevention across the workforce Chart 1: January blues US adult population reporting influenza in January from 2009 to 2013 (% of respondents reporting influenza) 2.9% January 2011 January 2010 2.6% January 2012 2.4% January 2009 4.7% 3.2% January 2013 US adult population reporting influenza during January 2013 by select groups (% of respondents reporting influenza in each group) January average: 4.7% Above average Below average Age group 5.34% 4.91% 4.42% 4.19% 18-29 30-44 45-64 65+ Monthly income Gender 6.51% 4.51% 4.88% Male Female Smoking 3.70% 3.14% <$3,000 $3,000 to $7,499 $7,500+ Asthma 5.74% Smoker 4.46% 5.25% Non-smoker Yes 4.63% No Source: Gallup-Healthways Well-Being Index (calculated by asking 1000 Americans each day whether they had a cold or influenza the previous day) extent that they exist—are largely based on perceptions rather than hard data. Different prescriptions in the US and Europe The population of the US is 314m, according to our 2012 figures—roughly the same size as the five western European economies covered by this report: Germany, France, the UK, Italy and 6 © The Economist Intelligence Unit Limited 2013 Spain. The standout difference between these two geographical regions, separated by the Atlantic Ocean, is who pays for healthcare. The US healthcare system is largely privatised and based on health insurance linked with employment for all but the most indigent populations and those over 65. By contrast, national governments are more actively involved in the provision of both healthcare and health insurance in many European countries.
  8. 8. Strategies for seasonal influenza Spreading prevention across the workforce Within this context it is important to understand the varying approaches in the US and western Europe, in terms of how prescriptive they are with regard to the annual threat from seasonal influenza. This is because respondents to our survey cited recommendations from public health authorities and updates to official advice as the factors most likely to raise the status of seasonal influenza as a business priority. Preparing for the Flu (Including 2009 H1N1 Flu); A communication toolkit for Businesses and employers; US Department of Health and Human Services, Centers for Disease Control and US Department of Homeland Security 3 CDC. National Early Season Flu Vaccination Coverage, United States, 2012-13 Flu Season, www.cdc.gov/flu/ fluvaxview/nifs-estimatesnov2012.htm. 4 Molinari NA, OrtegaSanchez IR, Messonnier ML, et al. The annual impact of seasonal influenza in the US: Measuring disease burden and costs. Vaccine. 2007;25 (27): 5085-5096. The US provides more centralised guidance to businesses and employers via a set of CDC guidelines that cover both pandemic and epidemic threats. They also include a number of recommendations, among them: that employees with flu-like illness stay home until 24 hours after their fever has disappeared. The CDC guidelines also advise employers to review sickleave policies and try to provide flexible leave policies for employees who are sick or caring for sick household members.3 The European Centre for Disease Prevention and Control (ECDC), by contrast, offers more general guidelines regarding hygiene, with no tailored guides for businesses, although individual countries, such as the UK, often provide their own advice through national health bodies. The US is the only country to recommend universal influenza vaccinations. In February 2013 the Advisory Committee on Immunization Practices’ (ACIP) called for influenza vaccines for anyone six months or older (35% of the country’s adult population had had the vaccine for the most recent flu season by November 20124). Meanwhile, individual European countries vary in the extent to which they advocate or provide vaccinations to those outside the at-risk groups, with none going nearly as far as the US. All of the distinctions above do not, however, generally result in two distinctive approaches to mitigating seasonal influenza in the two regions. The most significant differences are that in the US employees are more aware of seasonal influenza, the virus is more likely to have become an increased business priority and senior managers tend to be more involved in influenza initiatives than their European peers. If anything, there is more of a divide between the US, the UK and Germany on the one hand and Italy, Spain and France on the other hand. 5 6 Ibid. 7 Ibid. 8 Ibid. OECD (2011), “Influenza vaccination for older people”, Health at a Glance 2011: OECD Indicators, OECD Publishing. 9 7 The business cost: influenza in numbers  According to one study, annual influenza epidemics impose a burden of US$87.1bn on the US economy5, amounting to between 0.24% and 0.79% of US GDP.6 Nearly one-third (31%) of this burden is borne by the working age population (18-64), equating to US$27bn.  The same study found that lost earnings from illness and death related to influenza epidemics cost around US$16.3bn a year on average, or 20% of the total burden of influenza.7  A study by a US pharmaceutical chain, Walgreens, from September 2011, found © The Economist Intelligence Unit Limited 2013 that influenza was responsible for 100m lost workdays in the 2010-11 flu season.  A September 2010 report from the US National Business Group on Health identified 24.7m cases of seasonal influenza each year, resulting in 3.1m hospitalised days and annual direct medical costs of around US$10.4bn.8  In Europe, influenza accounts for around 10% of sickness absence from work, with the cost of lost productivity in France and Germany estimated at around US$9.3bn and US$14.1bn annually.9
  9. 9. Strategies for seasonal influenza Spreading prevention across the workforce Chart 2: Atlantic chill US, German and British adult populations reporting influenza or cold during 2012 (% of respondents reporting cold or influenza) Influenza US 6 Germany UK 6 5 5 4 4 3 3 2 2 1 1 0 0 Jan Feb Mar Apr May Jun Jul Aug Common cold Sep US Oct Nov Germany Dec UK 12 12 10 10 8 8 6 6 4 4 2 2 0 0 Jan Feb Mar Apr May Jun Source: Gallup-Healthways Well-Being Index. 8 © The Economist Intelligence Unit Limited 2013 Jul Aug Sep Oct Nov Dec
  10. 10. Strategies for seasonal influenza Spreading prevention across the workforce 1 The challenge is to maintain our supply chain, so it’s important to protect all of our employees, but the main focus is on people working in the operational business. Dr. Andreas Tautz, chief medical officer, Deutsche Post DHL Business perceptions of seasonal influenza Seasonal influenza is not viewed as a significant business risk by the majority of European and US companies. While few (7%) see it as a nonexistent risk, the majority (54%) characterise the risk as minimal. “I don’t see [seasonal influenza] as a significant threat, but one of the reasons is because we have such awareness of what flu or flu-like sickness can do, so it’s not as big a concern as it was in the past few years,” says Al Smith, director for safety at a US bus operator, Greyhound. Chart 3: Mild discomfort How would you characterise the overall risk of seasonal influenza to your business? (% respondents) Non-existent (inc don't know) 7% 54% 34% 5% Minimal Moderate High Source: Economist Intelligence Unit survey, June 2013. This majority opinion is generally consistent across the US and western Europe. There are, 9 © The Economist Intelligence Unit Limited 2013 nonetheless, some significant variations by country: in Spain, more than eight in ten (83%) respondents report minimal or no risk from the virus; whereas Germany is the only country in the sample where a majority of respondents (52%) view seasonal influenza as a moderate or high risk, rather than minimal or no risk. On average, 39% of respondents see seasonal influenza as moderate or high risk. The UK and the US join Germany above this average, while France and Italy join Spain below this average. The perception of business risk tends to be higher among larger companies, particularly those that operate internationally, or have employees who travel frequently or work in remote locations. “It’s sensible to think about seasonal flu in [the UK] but it’s not a very big deal,” says Rod Ratsma, head of UK business continuity for a consulting firm, Marsh Risk Consulting. “But there are parts of the world where there is less access to flu jabs and anti-virals. A lot of first world companies rely on the Indian sub-continent for support work. The world is a small place when you talk about supply chain.” Typical examples of these kinds of “at risk” companies can be found in industries such as travel & leisure, natural resources, and logistics. “Our business is dependent on our people, who are on the road for our customers practically every day,” says Dr Andreas Tautz, chief medical officer for Deutsche Post DHL in Bonn, Germany. “The challenge is to maintain our supply chain, so it’s important to protect all of our employees, but the main focus is on people working in the operational business.”
  11. 11. Strategies for seasonal influenza Spreading prevention across the workforce Chart 4: Sick days What is the biggest cost to your business associated with seasonal influenza? (% respondents) Absenteeism (sick pay, employing temporary workforce) Operational costs (loss of business, drop in productivity, slower projects) Health costs (treatment, hospitalisation, insurance) Planning & prevention (vaccinations, messaging, time allocated) Intangible costs (morale, reputation) There are no or minimal costs to the business from seasonal influenza Don’t know 43% 18% 16% 11% 4% 5% “If people are under the weather, we encourage them to stay home and not come into work when they aren’t feeling well,” says Mr Smith of Greyhound. “We don’t want to put them or our customers at risk due to their not feeling well.” 2% Source: Economist Intelligence Unit survey, June 2013. Presenting at work Absenteeism is by far the biggest cost to businesses of seasonal influenza. The costs of sick pay, employing temporary staff and other expenditure related to absenteeism is ranked by respondents to our survey above other costs to businesses to do with seasonal influenza, such as health insurance premiums or prevention measures such as vaccinations, attracting roughly twice the number of votes from respondents, or in some cases even more so. This is true for US and western European companies of all sizes. Compared with three years ago, there has only been a marginal net increase of 6% in the number of companies reporting an increase in employee absenteeism with influenza or influenza-like symptoms (the overall business impact of the virus during that time has grown similarly incrementally). That being the case overall, the UK, the US and Germany report double-digit figures above the average, whereas Spain, Italy and France either post a net increase below average or report a net decrease. 10 Notwithstanding these trends, it is important to keep in mind the extent to which employees are under pressure to come to work at a time when concerns about job security are on the minds of many workers in both Europe and the US. When asked about the factors that have restricted or are most likely to restrict company initiatives around seasonal influenza, a company culture of “presenteeism” is among the top half of this list of factors. Individual companies, however, adamantly deny that such pressures exist in their own workplaces. One of the most popular prevention steps undertaken by companies is to send home any employee displaying influenzalike symptoms. © The Economist Intelligence Unit Limited 2013 For others, however, the corporate position on absenteeism is not so black and white. Narrow benefit policies that limit sick days can dissuade employees from staying at home. For Dr Van-Tam, direct pressure from employers is more common than it might appear—and far more critical to business than is currently perceived. “The biggest issue for employers is not their infection control procedures and not their vaccination policies, although clearly these matter, but the extent to which they tolerate workplace absence or understand what ‘presenteeism’ might actually mean,” says Dr Van-Tam. “The underlying sentiment, ‘oh, it’s only a cold, why aren’t you in work?’ doesn’t hold true if you think about viral load. I might well get a couple more days productivity [out of someone working for me] if they come in with a cold, but they might destroy my productivity for longer by passing the virus to me and other colleagues.” Change in the air? For the majority of companies the last influenza season brought no dramatic changes from the
  12. 12. Strategies for seasonal influenza Spreading prevention across the workforce season three years before. The most notable trend during this time—by a considerable amount—is a boost in employee awareness about seasonal influenza. Exactly one-half of respondents (50%) say that awareness has increased and 38% say it has remained the same (the percentages are even greater in larger companies than in smaller ones). What makes a pandemic? Repeated education really helps because people are starting to really catch on and learn some of the lessons without having to be told all the time. Judy Harvey, corporate industrial hygiene and workplace safety manager, United Technologies. ‘An epidemic occurring worldwide, or over a very wide area, crossing international boundaries and usually affecting a large number of people.’ Dictionary of Epidemiology Companies from the US are most likely to report greater employee awareness, with nearly twothirds of US companies (65%) citing increased awareness, followed by the UK (56%), France (48%) and Germany (42%). By contrast, just 26% of Italian companies and 34% of Spanish companies report increased employee awareness during the most recent influenza season. Much of this raised awareness is the result of a regular drumbeat of public health and media warnings about new strains of the influenza virus becoming a pandemic. “If newspapers are full of stories, people come and want the vaccination. If newspapers don’t write anything about influenza then people forget about it. That’s quite normal,” says Stefan Lang, chief medical officer at BASF, a German chemical company. “We do advertising every year, but when swine flu was going on the number [of employees getting vaccinated] was the highest we ever had.” With each new pandemic strain, government agencies on both sides of the Atlantic have issued reminders and advice to employers with the aim of discussing the differences between pandemic influenza and the seasonal variety, as well as suggesting the continuum between them. This combination has a clear impact on business perception of influenza in general, since the two factors most likely to raise the status of seasonal influenza prevention as a business priority are updates to official advice from public health bodies and the perceived threat of a pandemic influenza outbreak. United Technologies, a US multinational conglomerate, conducts a variety of activities around seasonal influenza, from posters, emails and educational campaigns, to sanitiser stations and on-site vaccination clinics. Judy Harvey, a manager in the corporate industrial hygiene and workplace safety department, pinpoints the Chart 5: Going viral How have the following changed at your organisation during the latest influenza season compared with three years ago? (% of respondents) Increase No change 28% Decrease Don't know/Not applicable 50% 38% 47% 22% 3% Worker absences with influenza or flu-like symptoms Source: Economist Intelligence Unit survey, June 2013. 11 © The Economist Intelligence Unit Limited 2013 9% Employee awareness about seasonal influenza 2%
  13. 13. Strategies for seasonal influenza Spreading prevention across the workforce company-wide formalisation of this approach to five years ago, when official communications around the pandemic threat began to pick up. This convinced management about the benefits of investing in influenza prevention on an annual basis. “Repeated education really helps, because people are starting to really catch on and learn some of the lessons without having to be told all the time,” says Ms Harvey. Since then a general level of preparedness has been evident on both sides of the Atlantic, which could partly explain why companies are not generally concerned about the risk of seasonal influenza. At Eversheds, a UK-based law firm, employees remain well informed, with higher activity prompted by reports of pandemic threats, according to the human resources director, Angus MacGregor. “There has been no significant change in absence due to seasonal flu and the awareness level is generally good,” he says. Dr William Fried is senior medical director for a US insurer, Aetna, and clinical lead for the company’s pandemic core team, which was set up in the wake of the 2006 avian flu outbreak. “We had the plan in place for three years before we had to implement it for swine flu/H1N1. We pull it off the shelf and update it on an annual basis, as advice from the CDC and WHO changes,” says Mr Fried. Going global Yet this heightened awareness carries its own risks too. Each time a new strain of influenza is identified as a potential pandemic but subsequently remains localised, the level of complacency among employers and employees continues to grow. Contrary to what the public perception may be, there has been one official influenza pandemic in recent years, the H1N1 swine flu pandemic in 2009, and four pandemics in the last 100 years (see Mass panic: Breaking news of pandemic flu). “Avian flu has certainly raised consciousness among organisations about the potential impact that the seasonal flu can have,” says Jenny Hawker, a health management consultant for a consulting group, Mercer. “But because that potential pandemic didn’t come to fruition, some of that concern has eased again.” To some extent, this low level concern is reflected in the survey. A slight majority of respondents (52%) across the sample say that there has been no change in the business priority of seasonal influenza today compared with three years ago. Meanwhile, just over one-third of those surveyed (37%) say that their businesses are now putting greater priority on seasonal influenza compared with the one in ten (10%) that are paying less attention to it, representing a net increase of just over one in four (27%). By country, the US reports the biggest net increase (41%) in respondents now making seasonal influenza a higher priority than before, ten times higher than the equivalent figure for France (4%). Similar double-digit increases are reported in the UK (34%) and Germany (28%), compared with single digit increases in Italy (8%) and Spain (9%). A century of pandemic influenza—four outbreaks in 100 years Pandemic 1918-19 Estimated number of deaths worldwide Spanish influenza H1N1 20-50m 1957 - 1958 Asian flu H2N2 1-4m 1968 - 1969 Hong Kong flu H3N2 1-4m 2009 Swine flu H1N1 152,000 to 576,000 Source: European Center for Disease Prevention and Control. 12 © The Economist Intelligence Unit Limited 2013
  14. 14. Strategies for seasonal influenza Spreading prevention across the workforce Mass panic: Breaking news of pandemic flu 10 Metro, 26 April 2009. “Mass Graves could be used in autumn bout of swine flu,” Kiran Randhawa, The London Evening Standard, 19 August 2009 11 12 “Scientists see this flu strain as relatively mild,” Karen Kaplan and Alan Zarembo, latimes.com, 30 April 2009. 13 “10,000 swine flu deaths in US: estimates”, Agence France-Presse, 20 December 2009. 14 “Fergus’s Medical Files: Keeping a sense of proportion about swine flu,” www.bbc.co.uk, 31 December 2010. 15 “The False Bird Flu Scare,” Dr Marc Siegel, The Nation, 18 May 2006. US Centers for Disease Control and Prevention fact sheet on Avian Influenza A Virus, http://www.cdc.gov/ flu/avianflu/h7n9-virus. htm, August 13 2013. 16 13 Many businesses interviewed for this report blame the lack of a broader urgency to tackle seasonal influenza in part on the media’s high profile coverage of potential pandemic influenza strains, which subsequently remain localised. An idea of the intensity of this media coverage can be seen from a brief review of the 2009-10 outbreak of the H1N1 virus, more commonly known as swine flu—the only actual influenza pandemic since 1970 (for now). The sudden emergence of the virus in Mexico in spring 2009 and initial reports of its high mortality rate prompted headlines in a UK free tabloid circular, Metro, that swine flu “could kill up to 120m,” quoting leading medical experts who warned the virus looked more similar to the lethal Spanish flu of 1918 than the H5N1 avian flu that had preceded it three years earlier.10 As panic mounted over the summer, a UK newspaper, The London Evening Standard, reported that the UK government was preparing to create mass graves to cope with a surge of swine flu victims in the autumn.11 To be sure, not all news outlets shared this view; at the same time as the UK tabloids were raising the temperature, a US newspaper, Los Angeles Times, was reporting that scientists studying the virus closely appeared to agree that the hybrid strain of H1N1 originating in Mexico did not look likely to be as lethal as previous pandemics, or even have the morbidity levels of the average seasonal influenza variant.12 By autumn 2009, a news agency, Agence FrancePresse, appeared to be looking for a middle ground, with a report quoting the head of the © The Economist Intelligence Unit Limited 2013 CDC, Thomas Frieden, who confirmed a death toll of around 10,000 during the first seven months of the outbreak in the US; a “much higher” fatality rate than in a usual flu season, although the number of hospitalisations was the same.13 A little more than a year later, a medical correspondent for the BBC, Fergus Walsh, pointed out the tendency of overwrought headlines to obscure the actual threat posed by swine flu. Although the UK had recorded nearly 500 deaths in the first 12 months of the swine flu outbreak, the initial media saturation of the first few weeks of the outbreak had evaporated. However, there were higher numbers in intensive care with flu by winter 2010.14 Nonetheless, media apathy could be as dangerous as mass pandemonium. During the avian flu outbreak in China and East Asia in 2006, an article in a US magazine, The Nation, decried a recently-aired US TV movie, Fatal Contact: Bird Flu in America, for the way it “capitalizes on fear by depicting a crippling loss of basic services and mass graves.” Up to that point, avian flu had resulted in 114 deaths in nine years. What is more, the H5N1 strain in its current form “cannot routinely affect humans in its current form.”15 Seven years on, there is some evidence that the media is losing interest in influenza: the most recent avian flu outbreak in China earlier this year, this time of the H7N9 variety, has met more muted press coverage, despite the deaths of nearly one-third of those with reported cases of the disease.16
  15. 15. Strategies for seasonal influenza Spreading prevention across the workforce 2 Preventing seasonal influenza Exactly one-half of all respondents to our survey say that they have a formal policy for dealing with seasonal influenza. The likelihood of a company having an umbrella approach to dealing with influenza increases with the size of a company: over one-half (55%) of those with revenue over US$500m and a similar percentage (56%) of those with 500 or more employees report having a formal strategy in place. Typically these companies tend to be multinationals with greater geographical exposure to the virus. Chart 6: Corporate prescriptions Does your company have a formal strategy to reduce the spread of seasonal influenza among employees? (% respondents) 50% Yes 50% No or don't know Source: Economist Intelligence Unit survey, June 2013. A UK airline, Virgin Atlantic, has a series of protocols in place, which includes regular monitoring of disease activity in the parts of the world in which it operates. DHL has set up a group-wide “master plan” that involves 14 © The Economist Intelligence Unit Limited 2013 year-round information campaigns in all the global locations where the group operates and where influenza is present. Anglo American, a British mining company, has a similarly active surveillance programme. The company belongs to a number of travel medicine societies that pick up and disseminate information from the WHO and the CDC. “We are a company that has international operations and lots of travel; [influenza] is a risk to us and it is part of our overall approach to risk management,” says Frank Fox, head of occupational health at Anglo American. A number of company executives interviewed said that they have a formal plan to combat potential pandemics, elements of which can be applied to seasonal influenza planning as well. “I think there is more of a balance emerging because organisations have reacted very strongly to recent pandemic threats and that has triggered some very structured planning, a lot of episodes of alert, and there is now a sense that there is a better level of preparedness,” says Gill Macleod, chief executive of RoodLane Medical, a London-based primary care and occupational health company. Some large multinational companies, meanwhile, effectively delegate influenza policy to regional or individual company units. A Swiss food conglomerate, Nestle Group, has no global corporate policy but makes a prevention and treatment brochure available internally. According to a company spokesman, Philippe Aeschlimann, the group “encourages its markets to provide voluntary vaccinations against the
  16. 16. Strategies for seasonal influenza Spreading prevention across the workforce seasonal flu and encourages its employees to take up this offer.” Generally, companies in France (62%) and Italy (56%) are more likely to have a formal policy in place than those in the UK (38%) or even the US (50%). Getting the message across Around three-quarters (74%) of companies communicate with employees about seasonal influenza in some respect, using various methods of raising awareness and imparting education during the influenza season. Large companies are more likely to use influenza awareness communications than smaller ones, although the intensity of focus on these campaigns tends to ebb and flow in between alerts and coverage of the next possible pandemic influenza outbreak. We recently did a survey and found that 80% of employees are coming into the workplace even when they have the flu. Lisa Hamblet, vice president, Staples Facility Solutions At Anglo American, for instance, the company conducted a large information campaign on hygiene around the H1N1 outbreak, says Dr Fox. Although these messages have been less intense in recent years, hand sanitizer dispensers remain in all offices, around lifts and toilets. BASF undertakes a global health promotion campaign each year on a topical subject such as smoking cessation or obesity. During the “swine flu” pandemic, the company made its annual influenza vaccination campaign the topic of its global campaign. Communications around seasonal influenza are often linked in with other viruses and illnesses related to general hygiene. At Virgin Atlantic, the company posts regular reminders about hygiene and hand washing to mitigate the spread of influenza and to help to ward off gastrointestinal and upper respiratory infections. As Tim Stevenson, head of medical services at Virgin, explains, the company is also able to target messages at specific communication lines used by pilots and flight crews, as well as by other departments. Other companies in the business-to-business (B2B) environment run parallel education programmes about influenza prevention for both 15 © The Economist Intelligence Unit Limited 2013 employees and customers. Speaking to large corporate customers about the importance of cleaning is a regular part of the working day ahead of the influenza season, says Lisa Hamblet, vice-president of Staples Facility Solutions, a unit of the company’s B2B arm, Staples Advantage. “We really encourage them to increase the cleaning of areas that are commonly used during flu season—doorknobs, etc—and really encourage employees to clean their own workspaces,” she says, noting that the company sees a spike in sales of tissues, hand sanitisers, gloves and masks during the flu season. Part of this education programme includes counseling businesses to encourage sick employees to work from home. “We recently did a survey and found that 80% of employees are coming into the workplace even when they have the flu,” says Ms Hamblet. The most popular method of communication is putting up signs and posters around the workplace, followed by company-wide newsletters or emails. From a geographical perspective, 66% of French companies said that they used signs and posters, compared with 34% of companies in the UK and just 32% in Spain. French companies were also much more likely to employ messages from senior management in their influenza campaigns, with 46% saying they use such messages, double the overall average. US companies are close to the overall average. A pharmacy chain, Walgreens, uses manager communications and messages on time clocks and e-mail to drive home the hygiene message, while Greyhound conducts annual employee hygiene training programmes. Aetna operates a corporate intranet site with links to specific influenza prevention programmes and has a “very robust work at home and telework plan”, says Dr Fried. Meanwhile, UK companies are more likely to use e-learning or webinars to communicate with employees, with 40% saying they use them,
  17. 17. Strategies for seasonal influenza Spreading prevention across the workforce Chart 7: Spreading the word What communication does your organisation undertake around seasonal influenza? (Select all that apply) (% respondents) 43% Signs & posters around the workplace 34% Company-wide emails/newsletters Face-to-face training about prevention (hand washing etc) 25% E-learning/webinars about prevention 25% Messages from senior management promoting influenza reduction as a business priority 23% Surveying employees to understand workplace perceptions of influenza 16% Monitoring guidance from WHO, CDC, Google flu tracker etc 16% 15% Bringing in external health experts to give talks Appoint employees as volunteer "flu champions" 10% We do not communicate with employees on seasonal influenza 25% What conduct does your organisation undertake around seasonal influenza? (Select all that apply) (% respondents) Provide on-site seasonal influenza vaccinations for employees Increase focus on workplace hygiene during influenza season (make hand gels/masks available, increase frequency of disinfecting common areas) 39% 38% 34% Send home employees with influenza-like symptoms Reimburse employees for seasonal influenza vaccinations obtained privately 32% Encourage working from home/telecommuting during influenza season 22% Focus seasonal influenza initiatives on higher risk employees (such as asthmatics or frequent travellers) 17% Reduce business travel during influenza season, or to infected areas/offices 17% 16% Make vaccinations available to employees' families Offer vouchers, gifts or other incentives to encourage employee participation in company's prevention efforts We do not conduct activities focused on seasonal influenza Source: Economist Intelligence Unit survey, June 2013. 16 © The Economist Intelligence Unit Limited 2013 8% 16%
  18. 18. Strategies for seasonal influenza Spreading prevention across the workforce compared with 25% for the general company sample. Yet UK companies are also the most likely of any of the six countries surveyed to say that they do not communicate with employees about influenza at all. Over one-third say that they do not do so, compared with just 18% in each of France and Germany. Giving prevention a shot in the arm What happens if people show up for work sick? Are you going to ask those with a temperature to take off a week? Mishandling these issues is something that really affects a company’s reputation afterwards. Rod Ratsma, head of UK business continuity management, Marsh Risk Consulting The vast majority of companies (84%) conduct some form of prevention activity each influenza season. This is significantly higher than the even one-half of companies that have a formal influenza policy, suggesting that for a sizeable minority of respondents (34%) corporate efforts to mitigate influenza do not form part of a structured prevention strategy led from the top. Often multinational companies with multiple sites in various countries tend to devolve influenza activities to regional or local levels. In the absence of an overall strategy for dealing with seasonal influenza, companies risk a patchwork approach that could undermine the objective of making employees receptive to corporate influenza policies. “What happens if people show up for work sick? Are you going to supply antivirals? Are you going to ask those with a temperature to take off a week? Mishandling these issues is something that really affects a company’s reputation afterwards,” says Mr Ratsma of Marsh Risk Consulting. Providing on-site vaccinations is the most popular measure companies are taking to prevent seasonal influenza among their employees, closely followed by increased focus on workplace hygiene, sending employees home with influenza-like symptoms and reimbursing employees for private vaccinations. Larger companies are more likely to conduct these activities than smaller companies; all except for sending employees home, which is the most popular measure for small companies to put in place. French companies are the most likely to provide vaccinations on-site (60%), with the US (32%) 17 © The Economist Intelligence Unit Limited 2013 the least likely to do so—despite being the only country in this study with a nationwide recommendation for universal vaccination against influenza. This could be related to the fact that the cost of vaccinations is less likely to be subsidised in the US. It is also partly a matter of greater choice and flexibility: US companies are more likely to reimburse employees for the cost of private vaccinations than the overall survey average. UK companies are similarly above average in this regard. Ms Hawker of Mercer UK notes that on-site vaccinations are increasingly becoming a part of the broader health and wellness programmes that many European companies are beginning to offer. Even so, not all companies are willing to undertake comprehensive onsite vaccination campaigns in the absence of convincing evidence of their cost-effectiveness. Dr Stevenson of Virgin Atlantic says that his company does not have a regular influenza vaccination programme in place, as it assumes that high-risk employees are getting the vaccine at their GP’s office. With thousands of employees, Virgin has to think carefully before taking on the cost of such an option, says Dr Stevenson, although he does undertake a regular risk assessment around seasonal influenza. “We offered it a few years ago and were left with hundreds of doses that weren’t used,” he adds. Extending vaccinations to family members of employees is less common. Only 16% of companies across the sample offer this as part of their influenza prevention initiatives, despite there being more of an understanding nowadays that influenza is very much bound up in children, circulating in the young before spreading to the rest of the family. There is some regional divergence, nonetheless. Companies in the US are twice as likely as western European companies (22% and 11%, respectively) to extend vaccinations to family members, even though US companies are the
  19. 19. Strategies for seasonal influenza Spreading prevention across the workforce least likely to offer vaccinations to employees in the first place. Walgreens offers free vaccinations for all employees, regardless of health plan or work status. As Tom Sondergeld, director of team member health benefits and wellbeing, explains, “Family members of those within the health plan are also able to receive free flu shots at our stores.” Is there anyone at home? When it comes to employee engagement with prevention activities, companies in the US and Europe once again report the impact of pandemic influenza, particularly on increased CDC, National Early Season Flu Vaccination Coverage, United States, 2012-13 flu season, www.cdc.gov/flu/ fluvaxview/nifs-estimatesnov2012.htm. 17 CDC, Health Care Personnel Flu Vaccination, Internet Panel Survey, United States, November 2012, Recommendations, www.cdc.gov/flu/ fluvaxview/hcp-ipsnov2012.htm. 18 “Seasonal influenza vaccination in EU/EEA, influenza season 2011-12, VENICE II Consortium, September 2012-February 2013, page 6. 19 “Mandatory flu shots opposed by some health care workers,” USA Today, January 16 2013. 20 Report from the First European Influenza Summit, European Scientists Fighting Influenza (ESWI), Brussels, Belgium, May 26 2011, page 9. 21 18 vaccine uptake. Bupa Health Clinics, a UK private healthcare provider, has a workforce of 33,000. It began to offer all of its own employees free influenza vaccinations during the 2011-12 flu season, and has seen a 12% increase in uptake in vaccines for patient-facing staff, says Graham Johnson, clinical lead for nursing at the company. “Increased publicity, and particularly the pandemics, focused people’s attention and although there hasn’t been one recently and there are none on the horizon, people think, ‘I had a flu shot three years ago and didn’t have any side effects,’” he adds. Doctor’s note: saying one thing, doing another When it comes to being vaccinated against seasonal influenza, healthcare workers are not always first in line. Take-up rates vary widely within the US and Europe, with an ongoing medical debate about the extent to which vaccinations protect doctors and nurses from catching influenza from their patients, or from spreading the illness to the most vulnerable patient populations—as well as the population at large. In the US, nearly two-thirds (63%) of all health workers had been vaccinated for the latest flu season as of November 2012, compared with just over one-third (35%) of the general American adult population.17 The Centers for Disease Control and Prevention (CDC) is aiming for 90% compliance among health care workers by 2020, citing recent findings that vaccination among these workers can help to reduce patient fatalities.18 In Europe, 27 of 28 European countries surveyed by Vaccine European New Integrated Collaboration Effort (VENICE) recommend influenza vaccines for healthcare workers.19 In both regions, very few hospitals have been willing to make vaccines mandatory, given the inherent difficulties of imposing such a policy. Some individual hospitals in the US that have tried doing so have faced a series of lawsuits by nurses and other employees who were dismissed © The Economist Intelligence Unit Limited 2013 over their unwillingness to be vaccinated or wear masks when treating patients.20 Other hospitals in Europe have achieved some success with this approach, albeit short lived. At the University Hospital Hamburg-Eppendorf in northern Germany—one of Europe’s largest hospitals with 4,500 healthcare workers on its payroll—the vaccination rate prior to the 2009 pandemic scare was similar to the 15-20% rate prevailing among healthcare workers across Germany. The hospital created an in-house task force to coordinate a pro-vaccination campaign, including communication to employees via newsletters and posters, as well as the creation of an in-house hotline for questions from staff members and local vaccination points across the hospital. Crucially, the hospital also required those choosing not to get a flu shot to wear a face mask to protect themselves and patients. Dr Gabriele Anderson, the hospital’s chief occupational health doctor, cited this obligation, and the associated discomfort, as the key factor prompting a change of mind among many of the hospital’s health workers, with the result that the vaccination rate leapt to 74% during the 2009/10 flu season. Yet in this case, the “pandemic effect” on vaccination rates could also clearly be seen; by the 2010/11 flu season, vaccination rates had fallen to 27%.21
  20. 20. Strategies for seasonal influenza Spreading prevention across the workforce In different regions of the world cultural differences can affect the number of employees willing to engage with preventative efforts. Doug Quarry, a medical director at International SOS, a medical assistance company, works with clients in a number of different jurisdictions, ranging from Scotland to China and Mongolia. He notes that when offering vaccine campaigns on clients’ behalf, there is a significantly higher uptake of 50-70% taking it in Asia, compared with around 25% in Europe. At Anglo American, influenza vaccines are offered free on-site in all locations. The average 19 © The Economist Intelligence Unit Limited 2013 uptake in its offices around the globe is around 50% to 60% of the workforce, although uptake in more remote sites can vary, says Dr Fox. “Some operations are particularly good,” he says. “In Brazil, the niobium and nickel operations have a 100% uptake. It’s a cultural thing. Brazilians listen to their healthcare advice a little better than the rest of us.” He adds that the initial result was a large drop in absenteeism, although the programme has now been running for a number of years, so the benefit is no longer visible.
  21. 21. Strategies for seasonal influenza Spreading prevention across the workforce 3 Fighting mistrust, misunderstanding and misinformation Given the raised awareness among employees, it is notable that respondents list a lack of employee receptiveness to seasonal influenza messaging as the top factor limiting the success of company initiatives to mitigate the virus. The existence of this disconnect demonstrates the challenge that companies continue to face in changing perceptions of seasonal influenza and bridging the gap between awareness and understanding. The knowledge gaps are immediately evident in the uptake of vaccinations. According to healthcare professionals and some HR experts, there is lingering skepticism over how well vaccinations protect the general public. Many refer to the standard myths associated with influenza vaccines—that they are ineffective, cause flu symptoms or have other nasty side- Chart 8: Knowing what is good for you Top three factors most likely to raise the status of influenza prevention as a business priority (Top responses) 1 Updates to official recommendations 2 Perceived threat of pandemic influenza outbreak 3 Ability to measure business cost Top three factors most likely to restrict the success of corporate initiatives around seasonal influenza prevention (Top responses) 1 Low employee receptiveness to influenza messaging 2 High cost of prevention measures 3 Lack of data on the business impact of influenza Source: Economist Intelligence Unit survey, June 2013. 20 © The Economist Intelligence Unit Limited 2013 effects—to explain the relatively low take-up of influenza vaccines by both the general public and in many workplaces, even those that offer vaccinations for free. “We need a clear business case for the positive effect of flu shots,” says Dr Tautz of Deutsche Post DHL. “Everyone knows about the effort but some people distrust the flu campaign because of negative side-effects.” There is, moreover, a perception that seasonal influenza is only a concern for those most at risk from the virus, such as the old, very young and those with existing ailments. Dr Quarry of International SOS and others suggest that as long as the general public views seasonal influenza as a uniformly minor ailment, they are less likely to take precautionary measures seriously. Experts also point to an artificial distinction between pandemic and epidemic influenza, which has led to a tendency of businesses to put more emphasis on the former and give insufficient attention to the latter. Thus employees are often less aware of the potential for serious illness or death resulting from the seasonal influenza variety. Dr Quarry and Dr Van-Tam note that yearly epidemic versions of the flu virus have evolved, in many cases, from former pandemic strains such as H1N1. “There is an absolute connection between the two and people don’t get it,” says Dr Van-Tam. “[Pandemic flu viruses] don’t disappear from human circulation after they have produced a pandemic. They re-circulate as seasonal flu, as H1N1 is doing at present. The intervals between totally new pandemic viruses can be very short or very long. Suddenly, you get to the point where one virus peters out, and is replaced by a new
  22. 22. Strategies for seasonal influenza Spreading prevention across the workforce type and the cycle begins anew. There is no real difference in the way seasonal flu spreads to the way pandemic flu spreads; the difference will be the scale.” Audience engagement There is no real difference in the way seasonal flu spreads to the way pandemic flu spreads; the difference will be the scale. Dr Jonathan Van-Tam, Professor of Health Protection, University of Nottingham There is agreement among companies that more and better quality scientific evidence is needed to change minds. Part of the reluctance of many employees to engage in company influenza measures stems from confusion of the quality of medical evidence over how influenza spreads and presents itself. Moreover, the provision of better information to help shape employee behavior goes beyond vaccinations. Amy Costello, a senior benefits analyst at Staples, an office supply chain company, notes that educating employees, including reminding them how personal habits can make a difference in avoiding illness, helps workers to make more informed decisions about how to protect themselves. All of these gaps and misunderstandings point to a lack of effective employee engagement around seasonal influenza. Passive forms of messaging continue to be the most popular form of communication, typified by posters and signs around the workplace, followed by e-mails and newsletters. Fewer companies employ more active measures, such as bringing in external experts to educate employees about influenza, surveying employees to understand points of view or appointing employee “flu champions” to spread the message. Even fewer still offer incentives for employees to take part in influenza initiatives. “Employee engagement is crucial to [the success of] flu clinics, and if employees don’t feel getting a flu shot is beneficial to them, that’s always a barrier to the success of the clinic,” says Janice Hartgens, global occupational health manager for UPS, a global package delivery company. Messaging from senior management is growing in popularity, but for now it is still less common among companies than not communicating at all. While several of the larger companies interviewed for this report conduct regular educational 21 © The Economist Intelligence Unit Limited 2013 efforts via corporate intranets or host webinars on the importance of proper hygiene and maintaining personal space during flu season, there appears to be little follow-up analysis about the numbers of employees taking part and the impact of such measures. Establishing a model for costeffectiveness Across the US and western Europe there is some variation in the perceived obstacles to effective influenza prevention. Low employee receptiveness to influenza messaging is more of an issue in western Europe than the US; France and Italy account for a large part of this divergence. Meanwhile, the high cost of prevention measures tops the list in the US and Germany (poor data is the chief concern for UK companies, which is explored further below, whereas Spanish companies are most likely to say there are no barriers to influenza prevention initiatives). In the case of the US and Germany, it is difficult to make generalisations about two countries that are geographically and culturally so different. Still, in each case some explanations suggest themselves. In the US, companies bear more of the financial burden of employee healthcare than their European peers. Given that the CDC and medical vendors tend to supply educational materials for free, it is the provision of on-site influenza vaccines that are the most significant cost. Several US companies also admit to relying on large US pharmacy chains, such as Walgreens and Rite-Aid, which offer flu vaccines in multiple locations around the country. As for Germany, works councils mean employees have strong bargaining power and representation at management level. It is one of the few EU countries where pharmaceutical companies are largely able to set their own prices for drugs, so employers could face some of the same difficulties as their counterparts in the US.2 Interestingly, Germany reported higher incidence of influenza than either the US or the UK for eight months during 2012 (see Chart 2).
  23. 23. Strategies for seasonal influenza Spreading prevention across the workforce Nonetheless, the high cost of prevention measures is generally seen as the second-biggest obstacle to mitigating the impact of influenza prevention initiatives across the sample. At a time of tight financial budgets, with many companies reviewing the benefits that they are offering employees, seasonal influenza investments are likely to come under tighter scrutiny. There are, moreover, a rising number of illnesses and afflictions competing for these resources. Problems associated with an ageing workforce top the list of concerns in large US and European multinationals such as BASF and United Technologies, alongside “lifestyle” conditions such as hypertension and stress. On a day-to-day basis these conditions are routinely considered more important health priorities for occupational health departments than seasonal influenza (outside a pandemic threat). Some companies, such as United Technologies, have been adapting their influenza prevention measures to changing circumstances. Vaccinations are budgeted for when United Technologies sets its overall budgeting plans for the year. Most sites offer free vaccinations, but where budgets are currently tight some have started charging a nominal amount of around US$5-10 for vaccinations to recuperate some of the costs. Determining the level of the threat Benefit assessment and pricing of pharmaceuticals, HealthPolicyMonitor, The Bertelsmann Stiftung Foundation (finish citation), 2010. 22 22 United Technologies has kept up its commitment to influenza prevention, despite being unable to measure the return on investment on this revenue—outside of tracking the uptake of vaccinations (which is on the rise). But for many other companies, concern about costs reflects a broader uncertainty about the return they are likely to achieve (or can demonstrate) on investments they have made regarding the health and welfare of employees. Considerably more companies (47%) do not have any metrics to measure the effectiveness of influenza initiatives than those that say they © The Economist Intelligence Unit Limited 2013 do (28%). “When many companies are looking to stretch their dollars, it can be difficult to justify on-site flu shots, considering it can be difficult to prove a return on investment,” says Ms Costello of Staples. “We know it’s the right thing to do by keeping associates healthy at work, but you need to tie that to the cost of absenteeism and presenteeism and healthcare costs.” Data is an important prerequisite for companies to begin to measure the success or failure of prevention measures, but the amount of information collected on seasonal influenza is patchy. Only 7% of companies are effective at gathering and analyzing data to inform future seasonal influenza initiatives. Nearly one-half of companies (46%) believe that they gather sufficient data about the impact of seasonal influenza on their businesses, but lose some the value of that data in the application. That leaves a similarly sizeable group (46%) who rate their data collection efforts as either poor or lower. Within that number, over one in five (22%) companies admit to not gathering any data on seasonal influenza at all. Even companies with comprehensive influenza prevention programmes and strategies in place, such as United Technologies, do not collect data on seasonal influenza. Having 200,000 employees makes this a significant undertaking, says Ms Harvey, which management has yet to ask for. Other companies do not see the merit of collecting such data on a regular basis. “We tracked employee absenteeism during the H1N1 pandemic, but didn’t notice any impact in the functioning of the business,” says Dr Fried of Aetna. “We maintain the ability to do it [collect data on absences, etc., but haven’t felt the need [to do so] since then.” The task of collecting data is complicated by the confusion alluded to above, over the medical definition and diagnosis of seasonal influenza, together with the fact that most cases of suspected influenza are not officially diagnosed.
  24. 24. Strategies for seasonal influenza Spreading prevention across the workforce Chart 9: Return on influenza How well is your organisation collecting and using data about the impact of seasonal influenza on your business? Agree or disagree: My company does not have the metrics to measure the effectiveness of any particular influenza initiative (% respondents) (% respondents) Don't know Don't know 1% 46% or Poor, very poor non-existent 1% 28% 53% Disagree Well or very well 47% Agree 24% Neutral Source: Economist Intelligence Unit survey, June 2013. As a result, many managers find it difficult to assess the prevalence of flu in their organisations in years not dominated by a major epidemic. “From a statistical point of view, it’s hard enough to get managers to put accurate diagnoses down, and they aren’t doctors,” says Dr Stevenson of Virgin Atlantic. “When you see a sickness record and someone says they have had flu three times in a year, they probably mean a simple upper respiratory tract infection.” Regional differences are especially notable here: 27% of US companies say they don’t collect data—the highest in the sample (compared with only 6% in France). This could result from the fact that the CDC undertakes regular data collection and surveillance in the US, which it actively communicates with employers, although there is little anecdotal support for this theory among companies. Aetna’s Dr Fried suggests that another explanation could be that claims related to influenza have not historically been significant cost drivers for employers compared with other conditions, such as diabetes and hypertension. 23 © The Economist Intelligence Unit Limited 2013 Whatever the reason for this deficit of data, the overall group of respondents to our survey deem it to be the third most significant barrier hampering the success of their influenza initiatives—and the highest for respondents in the UK. The difficulty for companies to accurately judge the full impact of seasonal flu in their workplace is compounded by a lack of third party literature on the topic. In an era when companies are collecting more and more data on every aspect of their business, it seems anachronistic to have such a void, so it is hardly surprising that business leaders would like to see this change. According to respondents, gaining the ability to measure or quantify the business impact of seasonal influenza would be a major way of raising influenza as a business priority (just behind official advice and a perceived threat of a pandemic outbreak). In turn, this information could be passed on to employees, so that they can understand the “business case” for engaging with influenza prevention measures.
  25. 25. Strategies for seasonal influenza Spreading prevention across the workforce Influenza by industry Companies in the healthcare sector (including pharmaceuticals & biotech) are generally at the forefront when it comes to the prioritisation of seasonal influenza and its prevention. Nearly two in three (64%) have a formal influenza policy and over one-half (57%) perceive the virus as a moderate or high risk. This compares with an overall average of 50% and 39%, respectively. Only one in ten healthcare companies does not communicate with employees about the virus, and even fewer (one in twenty) conduct no activities around seasonal influenza whatsoever. Subsequently, healthcare companies are more likely to report raised employee awareness than the other industries analysed in particular detail in this study: consumer goods, financial services, manufacturing, and professional services. It is also the only industry of these five to report a net decrease in absenteeism. At the other end of the scale, companies in the professional services industry are generally below average. Just over one in five (22%) professional services companies has a formal 24 © The Economist Intelligence Unit Limited 2013 policy for dealing with influenza. The status of influenza as a business priority and senior management involvement in policy is least likely to have changed in this industry, where over one-half of companies (56%) do not communicate with employees and a significant minority (44%) do not conduct any prevention activities. In spite of all this, respondents in professional services report no net increase in employee absenteeism. Manufacturing companies generally sit in the middle of these two extremes, with a few notable exceptions. The perception of risk is lowest (33%) in manufacturing. Even so, manufacturing companies are most likely to report an elevation of influenza as a business priority, and increased involvement of senior management in influenza messaging. Manufacturing companies are most likely to provide on-site vaccinations (52%). This is higher than both the average (40%), as well as the healthcare sector response (43%), although the numbers even out when taking account of the percentage of companies that reimburse employees for obtaining private vaccinations.
  26. 26. Strategies for seasonal influenza Spreading prevention across the workforce Conclusion Corporate preparation for the potential impact of seasonal influenza may have increased in recent years, alongside employee awareness, but this is largely owing to regular warnings about potential pandemic outbreaks. Employers may feel ready for the threat of influenza in general, having a strategy to pull down off the shelf, but they should be aware of the complacency this breeds. Employees, for instance, may only heed messaging and take-up prevention measures when an imminent threat of an outbreak is in the news. At the same time, this raised awareness brings with it an opportunity to educate an audience with heightened interest. Only this will not last forever. Five years on, the high alert about a pandemic influenza threat is beginning to wear off. The central topics of occupational health campaigns have moved on. Hand gels may be left over, but so is misunderstanding of influenza and mistrust of prevention methods. Companies should consider what information they provide to their workforce. Raising awareness is one thing; spreading understanding is quite another. A better understanding of the science of influenza, including the connection between the pandemic and seasonal varieties and the ways in which influenza is 25 spread, may make employees more receptive to company messages. The ways that companies communicate these messages should also be looked at afresh: putting up posters every season may maintain awareness, but will achieve little without engagement. Before this can happen, managers must be able to understand the business impact of seasonal influenza. Few companies appear to see seasonal influenza as a central health priority. This may be entirely correct when absenteeism from influenza lasts a few days, compared with longer-term illnesses, such as diabetes and heart disease. Yet many companies also admit that they do not collect adequate information about the impact of seasonal influenza to be able to make an objective assessment. Filling in these knowledge gaps should enable managers to formulate more confident and more targeted strategies for dealing with the virus; build a business case for prevention initiatives outside of pandemic outbreaks, and allocate resources to where they deliver the most effective returns. After all, seasonal influenza is not going away. As globalisation continues to bring companies and countries closer together, exposure to the virus in all its forms is only going to increase. © The Economist Intelligence Unit Limited 2013
  27. 27. Strategies for seasonal influenza Spreading prevention across the workforce Appendix 1 Survey results In June 2013 The Economist Intelligence Unit conducted a global survey of 418 executives. Our sincere thanks go to all those who took part in the survey. Please note that not all answers add up to 100%, either because of rounding or because respondents were able to provide multiple answers to some questions. Does your company have a formal strategy or policy in place to reduce the spread of seasonal influenza among employees? (% respondents) Yes 50 No 48 Don't know 2 How would you characterise the overall risk of seasonal influenza to your business? (% respondents) Non-existent 7 Minimal 54 Moderate 34 High 5 26 © The Economist Intelligence Unit Limited 2013
  28. 28. Strategies for seasonal influenza Spreading prevention across the workforce What, if any, is the biggest cost to your business associated with seasonal influenza? (% respondents) Absenteeism (sick pay, employing temporary workforce) 43 Operational costs (loss of business, drop in productivity, slower projects) 18 Health costs (treatment, hospitalisation, insurance) 16 Planning and prevention (vaccinations, messaging, time allocated) 11 Intangible costs (morale, reputation) 4 There are no or minimal costs to the business from seasonal influenza 5 Don’t know 2 In your view, how have the following changed at your organisation during the latest influenza season compared to three years ago? Select one column for each row (% respondents) Substantial increase Moderate increase No change Moderate decrease Substantial decrease Don't know/ Not applicable Worker absences with influenza or flu-like symptoms 5 23 47 17 5 3 Employee awareness about seasonal influenza 11 39 38 7 2 2 52 7 Priority to business of seasonal influenza prevention and awareness 6 30 31 Senior executive/management involvement in seasonal influenza strategy 8 31 47 8 4 3 13 4 3 8 2 3 7 2 3 Business impact of last seasonal influenza season 3 18 58 Company-wide preparations and/or resources allocated to the upcoming influenza season 3 23 60 Focus on seasonal influenza compared to other employee health priorities 3 23 62 How well is your organisation collecting and using data about the impact of seasonal influenza on your business? (% respondents) Very well—we effectively gather and analyse almost all the relevant data and use it to predict and shape our approach to future outbreaks 7 Well—we gather and analyse most of the relevant data we need but some value is lost through lack of thoroughness or application 46 Poorly—we gather some data effectively but it is mainly used for record keeping rather than analysis or application 19 Very poorly—we gather patchy data, preventing us from doing anything meaningful with it 5 Non-existent—we do not collect any data on seasonal influenza at the moment 22 Don’t know 1 27 © The Economist Intelligence Unit Limited 2013
  29. 29. Strategies for seasonal influenza Spreading prevention across the workforce What, if any, communication does your organisation undertake around seasonal influenza? Select all that apply (% respondents) Signs & posters around the workplace 43 Company-wide emails/newsletters 34 Face-to-face training about prevention (hand washing, etc) 25 E-learning/webinars about prevention 25 Messages from senior management promoting influenza reduction as a business priority 23 Surveying employees to understand workplace perceptions of influenza 16 Monitoring guidance from WHO, CDC, Google flu tracker, etc 16 Bringing in external health experts to give talks 15 Appoint employees as volunteer "flu champions" 10 Other (please specify) 1 We do not communicate with employees on seasonal influenza 25 Don't know 1 What, if any, conduct does your organisation undertake around seasonal influenza? Select all that apply (% respondents) Provide on-site seasonal influenza vaccinations for employees 39 Increase focus on workplace hygiene during influenza season (make available hand gels/masks, increase frequency of disinfecting common areas) 38 Send home employees with influenza-like symptoms 34 Reimburse employees for seasonal influenza vaccinations obtained privately 32 Encourage working from home/telecommuting during influenza season 22 Focus seasonal influenza initiatives on higher risk employees (such as asthmatics or frequent travellers) 17 Reduce business travel during influenza season, or to infected areas/offices 17 Make vaccinations available to employees' families 16 Offer vouchers, gifts or other incentives to encourage employee participation in company's prevention efforts 8 Other (please specify) 1 We do not conduct activities focused on seasonal influenza 16 Don't know 1 28 © The Economist Intelligence Unit Limited 2013
  30. 30. Strategies for seasonal influenza Spreading prevention across the workforce Which of the following factors have raised or would most likely raise the status of influenza prevention as a business priority at your company? Select up to two (% respondents) Updates to official advice/recommendations from public health bodies/authorities 34 Perceived threat of pandemic influenza outbreak (eg, avian influenza) 31 Ability to measure and/or quantify the business cost of seasonal influenza 25 Experiencing a severe outbreak of seasonal influenza 20 Noticeable changes overtime to environmental climate 13 Changes in industry or regional best practice 12 Increased attention from media and/or general public 10 Expansion of company (eg, entering new markets, increasing employee headcount) 9 Pressure from stakeholders (eg, trade unions/employee representatives) 6 Nothing 9 Don't know 2 Which of the following factors have restricted or are most likely to restrict the success of your company's initiatives around seasonal influenza prevention? Select up to two (% respondents) Low employee receptiveness to influenza messaging 25 High cost of prevention measures 19 Lack of data on the business impact of influenza 18 Company culture of "presenteeism" (ie, sick employees turning up for work) 17 Lack of company resources (eg, money, time) 16 Difficulty in coordinating the process 13 Regulatory restrictions/rules 13 Lack of leadership from senior management 12 Lack of expertise/know-how/technology inside of company 6 Other (Please specify) 1 There are no barriers at my company 16 Don't know 3 29 © The Economist Intelligence Unit Limited 2013
  31. 31. Strategies for seasonal influenza Spreading prevention across the workforce To what extent do you agree with the following statements about your company? Select one column in each row (% respondents) Strongly agree Somewhat agree Neutral Somewhat disagree Strongly disagree Don't know My company sets specific goals for its long term seasonal influenza programme 13 27 29 9 20 2 My company does more to tackle seasonal influenza than our competitors 7 21 38 14 13 7 My company does not have metrics to measure the effectiveness of any particular influenza initiative 18 29 24 16 12 1 My company has seen a drop in employee absenteeism due to heightened concerns about job security 7 28 37 10 12 5 My company is undergoing a change in work practices or processes (eg, rise in remote working, increased automation), leading to less person-to-person contact 5 20 40 16 18 2 My company is generally spending more money on the health and wellbeing of our employees 12 28 37 13 8 2 Which of the following best describes your title? (% respondents) Board member 3 CEO/President/Managing director 15 CFO/Treasurer/Comptroller 8 CHRO/Head of HR 6 CIO/Technology director 4 Other C-level executive 15 SVP/VP/Director 50 Where are you personally located? (% respondents) United States of America 39 Spain 13 France 12 Germany 12 Italy 12 United Kingdom 12 30 © The Economist Intelligence Unit Limited 2013
  32. 32. Strategies for seasonal influenza Spreading prevention across the workforce In which region are you personally located? (% respondents) Western Europe 61 North America 39 What are your main functional roles? Select all that apply (% respondents) General management 23 Finance 20 Human resources 17 Operations and production 14 IT 12 Strategy and business development 12 Marketing and sales 11 Occupational health 10 Risk 6 R&D 6 Customer service 4 Information and research 4 Legal 3 Procurement 2 Supply-chain management 1 31 © The Economist Intelligence Unit Limited 2013
  33. 33. Strategies for seasonal influenza Spreading prevention across the workforce What is the primary industry your organisation is in? (% respondents) Financial services 14 Manufacturing 14 Consumer goods 11 Healthcare, pharmaceuticals and biotechnology 10 Professional services 8 Energy and natural resources 6 Construction and real estate 5 IT and technology 5 Entertainment, media and publishing 4 Transportation, travel and tourism 4 Retailing 4 Utilities 3 Automotive 3 Chemicals 3 Telecommunications 2 Education 1 Logistics and distribution 1 Government/Public sector 1 Agriculture and agribusiness 1 What is your organisation’s annual global revenue in US dollars? Please select the most appropriate option if your company does not report revenue in US dollars (% respondents) Less than $100m 19 $100m to $500m 29 $500m to $1bn 28 $1bn to $5bn 13 $5bn to $10bn 4 $10bn or more 6 32 © The Economist Intelligence Unit Limited 2013
  34. 34. Strategies for seasonal influenza Spreading prevention across the workforce How many full-time employees does your company have in total? (% respondents) 1 to 9 9 10 to 49 8 50 to 99 6 100 to 249 13 250 to 499 15 500 to 999 13 1000 to 9999 28 10,000 to19,999 3 20,000 + 6 33 © The Economist Intelligence Unit Limited 2013
  35. 35. While every effort has been taken to verify the accuracy of this information, The Economist Intelligence Unit Ltd. cannot accept any responsibility or liability for reliance by any person on this report or any of the information, opinions or conclusions set out in this report.
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