Influenza and Audiologists: Ethics and Economics Finally Agree on Something

Anyone who picked up a newspaper or turned on the news on January 10th knows that the Centers for Disease Control and Prevention (CDC) is tracking an “overwhelming” influenza outbreak across the US that is thought to grow more vicious before it abates.{{1}}[[1]]At the same time, the CDC has reported the largest outbreak of pertussis in the US in 60 years (42,000 cases) while Canadians and Brittons have been battling norovirus flu epidemics so highly infectious that whole hospital wards are/were shut down and disinfected.[[1]] The current virus type is H3N2, not seen in the US in a big way since 2007/08.  When H3N2 knocks, death rates more than double compared to seasons in which H1N1 predominates.{{2}}[[2]]MMWR study. Estimates of Deaths Associated with Seasonal Influenza — United States, 1976–2007. CDC Morbidity and Mortality Weekly Report.  August 27, 2010 / 59(33);1057-1062.[[2]]

Nobody but journalists wants to cause a panic by calling it a pandemic, but history may feel more comfortable using that word. The death percentage in CDC “benchmark cities” reached 7.3% last week, crossing the agency’s defined epidemic threshold.   Public health officials, if not the media, are far more concerned with containing the spread of infection than by using words that frighten people into flocking to already overwhelmed hospitals and clinics, bringing a bunch of infected people in contact with those not yet infected.  Nevertheless the Governor of New York declared a state health emergency for flu on January 13th and who knows where this will have gone by the time this post is published.

Terrible But What’s Flu Got to Do with Economics?

 

The flu is expensive, even in a “good” year, a year when the flu is mild and the economy is strong.  This is not one of those years. The economic burden to society is likely to be especially high this season, based on several metrics.

Overall Costs:  Estimates of seasonal influenza short-term costs and long-term burden run in the $26.8~ $87.1 Bil range, depending on the year (c.f., Table 1, right).  Costs vary by year and locale (see county map below), due to factors including population age and concentration.   If that’s not enough to get your attention, consider cost estimates of a flu pandemic, where the annual economic burden jumps up to $71.3 to 166.5 Bil.{{3}}[[3]]Meltzer MI, Cox NJ, Fukuda K: The economic impact of pandemic influenza in the United States: priorities for intervention. Emerg Infect Dis 1999, 5(5):659–671.[[3]] For those of us who like to throw numbers around in a careless fashion, that’s roughly  1/10th of the US Federal deficits of recent years.

Medical Costs:  Over 30 years ago, annual medical cost estimates of influenza were $1 to 3 Bil, according to the Office of Technology Assessment. {{4}}[[4]]US Congress: Office of Technology Assessment: Cost-effectivness of Influenza Vaccination. Washington, DC: GPO; 1981.

[[4]]. Medical costs continue to rise as a percentage of GDP.  You can imagine what current medical costs for a flu outbreak might be.

Loss of Worker Productivity.  Flu hits businesses hard, whether employees work or not.  There are several measures of productivity loss from influenza.

• Absenteeism: Average number of work days lost to flu ranges from 1.5 to 4.9 days per illness, but that’s just for lab-confirmed flu diagnosis.  Statistics jump to 3.7-5.9 days/illness if the flu diagnosis is reported by a physician (but not lab confirmed).  Self-reports range from less than a day up to 4.3 days/illness.  Any way you slice it, the flu results in lost working days.
• Reduced staff performance: Even after workers return to the job, they’re almost certainly functioning at reduced capacity until they regain full strength. Those who’ve had H3N2 flu in past outbreaks know from experience that full recovery takes awhile.
• Presenteeism:  Some of the stricken ill come to work for a variety of reasons familiar to most of us. Some show up out of a misguided sense of responsibility; others work in an office culture that frowns on those who can’t man up and show up; others don’t get paid unless they show up; still others fear for their job security in a weak economy.  Whatever the reason, the result is an economic cost due to the working sick:
  

  “…spread[ing] illness to more workers and further damag[ing] the employers’ ability to meet demand.”

   

 Definitely Terrible, But What’s the Ethical Connection and What’s Any of this Got to Do with Audiologists?

 

In a nutshell, it’s whether vaccination should be a requirement for those who work in hearing healthcare, or whether individual hearing healthcare workers have the right to forego vaccination.  Besides the obvious (see above) deleterious effects to the business, there are serious considerations about the effect of illness exposure to fellow workers and the public served.

It may come as a surprise to readers, as it surprised me, to learn that there is a large body of philosophical discussion and legal opinion on the specific question of flu vaccine and public policy toward healthcare workers.  It is far too large — and too important — to summarize here.   But here’s the gist of the argument applied to the current flu season:

• Physicians are compelled to “do no harm.”  Hopefully, Audiologists and their co-workers are held to that same directive.{{5}}[[5]]American Academy of Audiology’s Code of Ethics (Part 1, Principle 2, Rule 2B) requires its members to deliver services to patients using “all reasonable precautions to avoid injury.“[[5]]
• The “harm principle” developed by philosopher and economist  John Stuart Mill {{6}}[[6]]Mill, JS. “On Liberty,”1869.[[6]]says that an individual’s rights can only be over-ruled to prevent harm to others.
• Harm includes financial as well as physical, which is how this discussion ends up in an Economics post.
•  H3N2 is the predominant flu strain this year. It kills more than twice as many people as the more-typical H1N1 flu.
• The current flu vaccination is considered 62% effective and wards against H1N1, H3N2, and type B viruses.
• Regardless of strain, 90% of flu deaths are in the 65 and over age group.
• Audiologists and other hearing healthcare workers work primarily with older adults — those most prone to lethal effects of influenza.
• Failure to take all reasonable measure to ward off flu among hearing healthcare workers places their patients at unnecessary risk for harm, even death.
• Hearing healthcare workers who exercise their individual right to forego vaccination are violating the harm principal and are behaving unethically.

l’ll explore those points in some detail next time, even though this week’s headlines are beginning to revise the estimates of just how bad (financially and physically) this season’s flu is going to be.  Bad flu or not, the topic highlights Audiologists’ new-found role on the world stage and the accompanying responsibilities that accrue.

Next post will try to do justice to the topic and contain this writer’s moral outrage at providers and professional organizations who advocate selling our services and products but turn a blind or unconscious eye toward social responsibility for those we serve.