Health-care workers in influenza pandemics.

With the possible threat of an avian influenza pandemic, the readiness of health services across the world is under the spotlight. Few doubt the critical need for preplanning, and thus agencies across the world are preparing frameworks for response. Drugs have been stockpiled, protocols prepared, and transport limitations outlined. All these plans, however, are contingent on staff.

In a recent survey in Detroit by Charlene Irvin and colleagues, only 50% of health-care workers replied “yes” when asked if they would report to work during an H5N1 avian influenza pandemic in human beings. This proportion is similar to those in a previous influenza survey in Germany and a study on attendance during a hypothetical outbreak of severe acute respiratory syndrome (SARS) in New York City. Plans often account for workers' absence, be it due to illness, attending to relatives, or transport difficulties. However, such a high proportion of doubt in such a critical group seems worrying.

The lead researcher Charlene Irvin speculates that lack of communication is the cause, with open dialogue and an appreciation of risks and protective measures being central to improving attendance. She told The Lancet: “This survey suggests that the US Government and the medical community may not be doing a very good job at educating our health-care workers about what measures would be in place to keep them safe.” She also pointed out that “83% of the ‘maybe’ respondents noted that their decision would depend on ‘How confident I am that the hospital can protect me’.”

But is education necessarily a solution? There is no doubt that doctors and nurses face real risks during infectious epidemics. Examples range from the 1918 influenza pandemic to SARS. Some measures, such as hand-washing, barriers, and protective clothing, can reduce nosocomial infections in pandemic situations. However, the effectiveness of other protective measures has not been validated. Whether oseltamivir, the preferred antiviral, reliably inhibits H5N1 infection is not known, and if it does, resistant strains will surely emerge. Vaccines, meanwhile, are still being developed.

Perhaps the issue is not education, but rather the balance of the inescapable human desire for the preservation of self and family, and an indefinable feeling of duty, altruism, and heroism. We lack coherent ethical guidelines on behaviour in such situations. Human nature is unpredictable, especially under intense pressure. But one thing is certain: if a pandemic occurs, some staff will not attend. We need to educate our workforce, estimate the proportion that will attend, and make plans that use the available staff efficiently and effectively.