The first confirmed case of human avian influenza A(H7N9) in Hong Kong and the suspension of volunteer services: impact on palliative care.

To the Editor:

Hospice is intended to provide palliative care for patients with a terminal diagnosis and offer psychosocial support to them and their families. Volunteers are integral to the history of hospice and continue to play a vital role. However, economic, policy, and demographic challenges in the 21st century raise questions about how best to manage this essential resource, as we are facing twin pressures of increased demand and declining volunteer applicants for palliative care involvement. Hong Kong, a special administrative region in China with 6.7 million people of which 13% are age 65 and older, has the longest life expectancy in the world second to Japan; therefore, we are facing a continuous demand in geriatrics and palliative care services. We recently had our first confirmed human case of avian influenza A(H7N9). This poses an additional challenge in palliative care as infection control measures had suspended volunteer services in all public hospitals, including palliative care units and hospices.

Demand for end-of-life (EOL) care is growing at the same time as reductions in resources are taking place. With the global economic downturn, people are working longer because of economic pressures, reduced pensions, and later retirement age, which may limit the number of volunteers participating in palliative care. EOL care volunteer roles vary considerably by organization and country as well as over time. It is delivered throughout the world in a wide range of settings, such as purpose-built hospices, day care units, and nursing homes. Historically, there have been restrictions on what hospice volunteers can do in direct patient care, which is related to not only risk management issues but also traditional practices. In Hong Kong, volunteers are recruited from universities, charitable organizations, and various religious bodies. They assist in psychosocial care, bereavement care, organization of day center activities, hair cutting, musical performance, and engagement in patients' life review. The roles of volunteers are thought to be complementary to those of professional staff. The literature has reported that family caregivers appreciate the emotional support, availability, sustained relationships, and respite that volunteers can provide.

Human infections with avian influenza A(H7N9) were first identified in China in March 2013. Most laboratory-confirmed cases occurred in urban areas in people who reported exposure to live poultry in the seven days before illness onset. Intensive follow-up of more than 2500 close contacts of laboratory-confirmed cases identified just five potential secondary H7N9 virus infections, which is consistent with low person-to-person transmissibility. However, it was estimated that the fatality risk for all ages was up to 36% on admission to hospital. Risk of mechanical ventilation or fatality could be up to 69%, and of admission to an intensive care unit, requirement for mechanical ventilation, or fatality could approach 83%.

The first confirmed human avian influenza A(H7N9) in Hong Kong was reported on December 2, 2013, a 36-year-old Indonesian domestic helper with recent travel to Shenzhen in mainland China. She was in critical condition and required intensive care unit admission with extracorporeal membrane oxygenation support. Since the outbreak of severe acute respiratory syndrome caused by a novel coronavirus in late 2002 in Hong Kong, the hospital infection control team had adopted a proactive approach in infection control measures. A response plan for avian influenza was launched in Hong Kong, with the level elevated to serious response level (S2) since the first confirmed human case of H7N9 in our locality. Visiting hours for palliative units have been limited to less than four hours per day, with not more than two visitors per visit. Visitors to public hospitals are required to put on surgical masks and perform hand hygiene before and after visiting patient areas. Furthermore, volunteer services and clinical attachment in public hospitals have been suspended. Details of infection control measures with regard to palliative care settings are listed in Table 1 .

Table 1

Infection Control Measures During Serious Response Level (S2) in Hong Kong (Palliative Care Setting)

Areas	Infection Control Measures
Staff	1. Surgical masks are required in all patient areas
	2. Continue complying with standard, droplet, and contact precautions
	3. Be vigilant in practicing hand hygiene
	4. Gloves should not be worn routinely, and they do not replace hand hygiene
	5. Continue reporting to the infection control team (ICT) regarding staff sickness and suspected clustering of flu outbreak
Patient	1. Remain vigilant for patients with respiratory symptoms
	2. Advise and provide masks to patients with respiratory symptoms
	3. Be aware of any clustering of fever or respiratory infections in patients and inform ICT of clustering
Visitor	1. Visiting hours: palliative care wards—4 hours per day; two persons at a time; unless on compassionate grounds
	2. Visitors should wear surgical mask in clinical areas
	3. Reinforce hand hygiene
	4. Advise not to pay hospital visit if visitor has fever or respiratory symptoms
Volunteer	1. Suspension of volunteer services

In Hong Kong, all volunteers are required to attend infection control workshops before their hospital attachment. Research into the effects of increasing regulations on the volunteer workforce would be valuable in assisting managers to negotiate the changing arena of volunteerism. As well, studies concerning infection control measures' effect on the quality of life of affected patients and their relatives also are warranted in future palliative care research. The tensions involved in negotiating the boundary areas that volunteers inhabit, that is, between informality and regulations, might influence their experiences and satisfaction. Currently, our palliative care unit is following the aforementioned guideline but would handle the restriction on family visits on compassionate grounds, taking into account that most of our patients are in critically ill condition. We advise our staff, patients, and visitors to wash their hands frequently with soap, especially before touching the mouth, nose, or eyes, and while handling food or eating. As well, frequent cleaning and disinfection of hospital public areas and wards by using appropriate disinfectants are in practice, aiming to keep the risk of an H7N9 outbreak to a minimum. We are keeping a close watch on the evolution of H7N9 human cases in Hong Kong and neighboring cities in China and will resume normal volunteer services and visiting policies once the condition has been deemed under control.

In conclusion, palliative care and hospices are part of larger health care systems, and we clearly have a responsibility to our patients and the wider community regarding infection control. Although ethical dilemmas may arise between the concomitant needs for both comprehensive psychosocial care and infection outbreak control, we must appreciate volunteers as integral to the interdisciplinary model in palliative care. Those who support and manage volunteers need to handle these issues sensitively to make the most of this important resource.