Strategies for seasonal influenza: spreading prevention across the worlforce

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1 © The Economist Intelligence Unit Limited 2013

Strategies for seasonal infl uenza 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 14

Chapter 3: Fighting mistrust, misunderstanding and misinformation 20

Conclusion 25

Appendix: Survey results 26



About the report

Strategies for seasonal infl uenza: 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 infl uenza and the prevention measures companies are putting in place.

This report draws on two main sources for its research and fi ndings:

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 fi nancial services or manufacturing. Around one-half of these companies have more than 500 employees or more than US$500m in annual revenue.

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):

• William Fried, senior medical director, Aetna (US)

• Frank Fox, head of occupational health, Anglo American

• Stefan Lang, chief medical offi cer 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 offi cer, Deutsche Post DHL (Germany)

• 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

• Helen Darling, president and chief executive, National Business Group on Health (US)

• Philippe Aeschlimann, spokesman, Nestle SA (Switzerland)

• Gill Macleod, chief executive, RoonLane Medical (UK)

• Amy Costello, senior benefi ts analyst, Staples (US)

• Lisa Hamblet, vice president, Staples Facility Solutions, Staples (US)

• Judy Harvey, manager, corporate industrial hygiene and workplace safety program, United Technologies (US)

• Jonathan Van-Tam, School of Community Health Sciences, University of Nottingham (UK); consultant on pandemic infl uenza to the World Health Organization

• Janice Hartgens, global occupational health manager, UPS (US)

• Tim Stevenson, head of medical services, Virgin Atlantic Airways (UK)

• Tom Sondergeld, director of team member health benefi ts 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



Executive summary

Seasonal infl uenza 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 fl u 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.

Diffi culties in diagnosing seasonal infl uenza 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 infl uenza or lack confi dence 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 infl uenza prevention initiatives. Such knowledge gaps are compounded by a paucity of third party literature on the economic impact of seasonal infl uenza.

While employers and employees tend to be more aware than they were several years ago about the threat posed by seasonal infl uenza, this has more to do with the “pandemic effect” created by regular warnings about potential global outbreaks, rather than any change in strategy.

In order to better understand the perception of seasonal infl uenza 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.

The key fi ndings of this research include the following:

Few companies know the business impact of seasonal infl uenza: As most cases of suspected infl uenza are not offi cially diagnosed, many managers fi nd it diffi cult to assess its frequency in their organisations. A sizeable minority of companies (47%) rate their data collection efforts “poor” or lower—with one in fi ve (22%) collecting no data at all. There is also a distinct lack of third party information available on the business impact of seasonal infl uenza. 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 infl uenza would raise prevention as a business priority.

Southern European businesses are feeling fewer “symptoms” of the virus: Absenteeism is by far the biggest business cost associated with



infl uenza, but there is a split in how countries perceive trends in infl uenza-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 infl uenza compared with three years ago, based largely in the UK, Germany and the US. This contributes to a higher risk profi le for infl uenza overall in the US, the UK and particularly Germany than in the more southern European countries.

Most companies conduct infl uenza mitigation, although some lack a coordinated approach: Three-quarters of companies communicate with employees about infl uenza, with poster campaigns and email newsletters being the favoured method. Fully 84% of companies conduct some form of seasonal infl uenza prevention activity, such as on-site vaccinations and an elevated focus on workplace hygiene during the infl uenza season. Yet only one-half (50%) of companies have a formal strategy in place to mitigate the virus. The gap between these fi gures suggests that a signifi cant minority of infl uenza 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: Offi cial recommendations from public health bodies and perceived risks of pandemic infl uenza are the top two factors likely to raise the status of infl uenza as a business priority. Therefore, regular warnings about potential pandemic infl uenza outbreaks have unsurprisingly raised the status of general infl uenza prevention as a business priority. Many companies now feel better prepared to deal with infl uenza in general. Still, as the memories of the

last offi cial pandemic in 2009 are fading, focus is tapering and the potential for complacency is building. Experts also say that there is an artifi cial distinction between pandemic and epidemic infl uenza, leading to a tendency for businesses to concentrate on the former and give insuffi cient attention to the latter.

The effectiveness of current infl uenza initiatives are under the microscope: Despite increased employee awareness of infl uenza over the past few years, low employee receptiveness to seasonal infl uenza 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 infl uenza 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 infl uenza initiatives. Therefore, enabling executives to judge the fi nancial merits of investing in infl uenza 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 infl uenza mitigation efforts.



Few would deny that seasonal infl uenza has an annual impact on the populations of the US and Europe. In the US, between 5% and 20% of the population gets infl uenza each season; there are some 36,000 deaths, and more than 200,000 are hospitalised annually as a result of seasonal fl u-related complications, according to the Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia.1 In Europe, the number of annual deaths from infl uenza 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 infl uenza is far smaller.

Yet getting an accurate picture of the prevalence of infl uenza can be diffi cult, as the measurements themselves are frequently the subject of disagreement. One of the fi rst diffi culties in assessing the impact of seasonal infl uenza is defi ning and diagnosing it. Seasonal infl uenza 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, infl uenza experts say it is often diffi cult to accurately determine the extent of a given seasonal epidemic.

IntroductionPicking infl uenza out of a crowd

1 CDC Seasonal Influenza Questions & Answers, http://www.cdc.gov/flu/about/qa/disease.htm.

2 Commission of the European Communities, Council Recommendation on seasonal influenza vaccine, July 13 2009, Brussels, Belgium.

“The fundamental problem is that, even for experts, [making] the distinction between infl uenza and respiratory viral infections is incredibly diffi cult,” 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 infl uenza.

While most people severely affected by seasonal infl uenza 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 infl uenza 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: infl uenza in numbers). The fi gures give a taste of the magnitude of the impact, but assessing the business cost of seasonal infl uenza is an imperfect science at best. As we will see later on, this lack of clarity exists at company level too, so that infl uenza strategies—to the

Even for experts, [making] the distinction between infl uenza and respiratory viral infections is incredibly diffi cult.

Dr Jonathan Van-Tam, Professor of Health Protection, University of Nottingham



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 fi gures—roughly the same size as the fi ve western European economies covered by this report: Germany, France, the UK, Italy and

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.

US adult population reporting influenza in January from 2009 to 2013(% of respondents reporting influenza)

Age group

Gender Monthly income

Smoking Asthma

US adult population reporting influenza during January 2013 by select groups(% of respondents reporting influenza in each group)

Chart 1: January blues

January 2009 January 2013January 2012January 2011January 2010

Smoker Non-smoker Yes No

<$3,000 $7,500+$3,000 to $7,499Male Female

18-29 65+45-6430-44

2.9%4.7%

2.6%3.2%2.4%

5.34%4.19%4.42%4.91%

6.51%

3.14%3.70%

5.74%4.46% 5.25% 4.63%

4.51% 4.88%

Above averageJanuary average: 4.7% Below average

Source: Gallup-Healthways Well-Being Index (calculated by asking 1000 Americans each day whether they had a cold or influenza the previous day)



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 infl uenza. This is because respondents to our survey cited recommendations from public health authorities and updates to offi cial advice as the factors most likely to raise the status of seasonal infl uenza as a business priority.

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 fl u-like illness stay home until 24 hours after their fever has disappeared. The CDC guidelines also advise employers to review sick-leave policies and try to provide fl exible 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 infl uenza vaccinations. In February 2013 the Advisory Committee on Immunization Practices’ (ACIP) called for infl uenza vaccines for anyone six months or older (35% of the country’s adult population had had the vaccine for the most recent fl u 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 infl uenza in the two regions. The most signifi cant differences are that in the US employees are more aware of seasonal infl uenza, the virus is more likely to have become an increased business priority and senior managers tend to be more involved in infl uenza 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.

3 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

4 CDC. National Early Season Flu Vaccination Coverage, United States, 2012-13 Flu Season, www.cdc.gov/flu/fluvaxview/nifs-estimates-nov2012.htm.

According to one study, annual infl uenza 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 infl uenza epidemics cost around US$16.3bn a year on average, or 20% of the total burden of infl uenza.7

A study by a US pharmaceutical chain, Walgreens, from September 2011, found

that infl uenza was responsible for 100m lost workdays in the 2010-11 fl u season.

A September 2010 report from the US National Business Group on Health identifi ed 24.7m cases of seasonal infl uenza each year, resulting in 3.1m hospitalised days and annual direct medical costs of around US$10.4bn.8

In Europe, infl uenza 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

The business cost: infl uenza in numbers

6 Ibid.

7 Ibid.

8 Ibid.

9 OECD (2011), “Influenza vaccination for older people”, Health at a Glance 2011: OECD Indicators, OECD Publishing.

5 Molinari NA, Ortega-Sanchez 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.



US, German and British adult populations reporting influenza or cold during 2012(% of respondents reporting cold or influenza)

Influenza

Common cold

Chart 2: Atlantic chill

0

1

2

3

4

5

6

0

1

2

3

4

5

6UKGermany US

UKGermany US

DecNovOctSepAugJulJunMayAprMarFebJan

0

2

4

6

8

10

12

0

2

4

6

8

10

12

DecNovOctSepAugJulJunMayAprMarFebJan

Source: Gallup-Healthways Well-Being Index.



Seasonal infl uenza is not viewed as a signifi cant business risk by the majority of European and US companies. While few (7%) see it as a non-existent risk, the majority (54%) characterise the risk as minimal. “I don’t see [seasonal infl uenza] as a signifi cant threat, but one of the reasons is because we have such awareness of what fl u or fl u-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.

This majority opinion is generally consistent across the US and western Europe. There are,

nonetheless, some signifi cant 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 infl uenza as a moderate or high risk, rather than minimal or no risk. On average, 39% of respondents see seasonal infl uenza 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 fl u in [the UK] but it’s not a very big deal,” says Rod Ratsma, head of UK business continuity for a consulting fi rm, Marsh Risk Consulting. “But there are parts of the world where there is less access to fl u jabs and anti-virals. A lot of fi rst 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 offi cer 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.”

Business perceptions of seasonal infl uenza1

How would you characterise theoverall risk of seasonal influenzato your business?(% respondents)

5%

54%

34%

Source: Economist Intelligence Unit survey, June 2013.

7% Non-existent(inc don't know)

Minimal

Moderate

High

Chart 3: Mild discomfort

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 offi cer, Deutsche Post DHL



Presenting at workAbsenteeism is by far the biggest cost to businesses of seasonal infl uenza. 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 infl uenza, 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 infl uenza or infl uenza-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 fi gures above the average, whereas Spain, Italy and France either post a net increase below average or report a net decrease.

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 infl uenza, 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 infl uenza-like symptoms.

“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.”

For others, however, the corporate position on absenteeism is not so black and white. Narrow benefi t 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 infl uenza season brought no dramatic changes from the

Chart 4: Sick days

What is the biggest cost to your business associated withseasonal influenza?(% respondents)


Operational costs (loss ofbusiness, drop in productivity,

slower projects)

Absenteeism (sick pay, employingtemporary workforce)

Health costs (treatment,hospitalisation, insurance)

Planning & prevention(vaccinations, messaging,

time allocated)

Intangible costs(morale, reputation)

There are no or minimalcosts to the business from

seasonal influenza

Don’t know 2%

5%

4%

11%

16%

43%

18%



becoming a pandemic. “If newspapers are full of stories, people come and want the vaccination. If newspapers don’t write anything about infl uenza then people forget about it. That’s quite normal,” says Stefan Lang, chief medical offi cer at BASF, a German chemical company. “We do advertising every year, but when swine fl u 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 infl uenza and the seasonal variety, as well as suggesting the continuum between them. This combination has a clear impact on business perception of infl uenza in general, since the two factors most likely to raise the status of seasonal infl uenza prevention as a business priority are updates to offi cial advice from public health bodies and the perceived threat of a pandemic infl uenza outbreak.

United Technologies, a US multinational conglomerate, conducts a variety of activities around seasonal infl uenza, 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

season three years before. The most notable trend during this time—by a considerable amount—is a boost in employee awareness about seasonal infl uenza. 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).

Companies from the US are most likely to report greater employee awareness, with nearly two-thirds 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 infl uenza season.

Much of this raised awareness is the result of a regular drumbeat of public health and media warnings about new strains of the infl uenza virus

How have the following changed at your organisation during the latest influenza seasoncompared with three years ago?(% of respondents)

Chart 5: Going viral


Worker absences with influenzaor flu-like symptoms

Employee awareness aboutseasonal influenza

Increase No change Decrease Don't know/Not applicable

50%28% 47% 22%3%

38%9%

2%

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

What makes a pandemic?



company-wide formalisation of this approach to fi ve years ago, when offi cial communications around the pandemic threat began to pick up. This convinced management about the benefi ts of investing in infl uenza 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 infl uenza. At Eversheds, a UK-based law fi rm, 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 signifi cant change in absence due to seasonal fl u 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 fl u outbreak. “We had the plan in place for three years before we had to implement it for swine fl u/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 globalYet this heightened awareness carries its own risks too. Each time a new strain of infl uenza is identifi ed 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 offi cial infl uenza pandemic in recent years, the H1N1 swine fl u pandemic in 2009, and four pandemics in the last 100 years (see Mass panic: Breaking news of pandemic fl u). “Avian fl u has certainly raised consciousness among organisations about the potential impact that the seasonal fl u 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 refl ected 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 infl uenza 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 infl uenza 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 infl uenza a higher priority than before, ten times higher than the equivalent fi gure 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 infl uenza—four outbreaks in 100 yearsPandemic Estimated number of deaths worldwide

1918-19 Spanish infl uenza H1N1 20-50m

1957 - 1958 Asian fl u H2N2 1-4m

1968 - 1969 Hong Kong fl u H3N2 1-4m

2009 Swine fl u H1N1 152,000 to 576,000

Source: European Center for Disease Prevention and Control.



Many businesses interviewed for this report blame the lack of a broader urgency to tackle seasonal infl uenza in part on the media’s high profi le coverage of potential pandemic infl uenza 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 fl u—the only actual infl uenza 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 fl u “could kill up to 120m,” quoting leading medical experts who warned the virus looked more similar to the lethal Spanish fl u of 1918 than the H5N1 avian fl u 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 fl u 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 infl uenza variant.12

By autumn 2009, a news agency, Agence France-Presse, appeared to be looking for a middle ground, with a report quoting the head of the

CDC, Thomas Frieden, who confi rmed a death toll of around 10,000 during the fi rst seven months of the outbreak in the US; a “much higher” fatality rate than in a usual fl u 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 fl u. Although the UK had recorded nearly 500 deaths in the fi rst 12 months of the swine fl u outbreak, the initial media saturation of the fi rst few weeks of the outbreak had evaporated. However, there were higher numbers in intensive care with fl u by winter 2010.14

Nonetheless, media apathy could be as dangerous as mass pandemonium. During the avian fl u 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 fl u 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 infl uenza: the most recent avian fl u 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

Mass panic: Breaking news of pandemic fl u

10 Metro, 26 April 2009.

11 “Mass Graves could be used in autumn bout of swine flu,” Kiran Randhawa, The London Evening Standard, 19 August 2009

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.

16 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.



Exactly one-half of all respondents to our survey say that they have a formal policy for dealing with seasonal infl uenza. The likelihood of a company having an umbrella approach to dealing with infl uenza 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.

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

Preventing seasonal infl uenza2year-round information campaigns in all the global locations where the group operates and where infl uenza 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; [infl uenza] 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 infl uenza 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 infl uenza 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

Does your company have a formalstrategy to reduce the spread ofseasonal influenza among employees? (% respondents)

Chart 6: Corporate prescriptions


Yes50%No or don't know

50%



seasonal fl u 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 acrossAround three-quarters (74%) of companies communicate with employees about seasonal infl uenza in some respect, using various methods of raising awareness and imparting education during the infl uenza season. Large companies are more likely to use infl uenza awareness communications than smaller ones, although the intensity of focus on these campaigns tends to ebb and fl ow in between alerts and coverage of the next possible pandemic infl uenza outbreak.

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 offi ces, 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 fl u” pandemic, the company made its annual infl uenza vaccination campaign the topic of its global campaign.

Communications around seasonal infl uenza 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 infl uenza 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 specifi c communication lines used by pilots and fl ight crews, as well as by other departments.

Other companies in the business-to-business (B2B) environment run parallel education programmes about infl uenza prevention for both

employees and customers. Speaking to large corporate customers about the importance of cleaning is a regular part of the working day ahead of the infl uenza season, says Lisa Hamblet, vi ce-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 fl u 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 fl u season. Part of this education programme includes counseling businesses to encourage sick employees to work from home. “We recently did a survey and f ound that 80% of employees are coming into the workplace even when they have the fl u,” 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 infl uenza 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 specifi c infl uenza 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,

We recently did a survey and found that 80% of employees are coming into the workplace even when they have the fl u.

Lisa Hamblet, vice president, Staples Facility Solutions



What communication does your organisation undertake aroundseasonal influenza? (Select all that apply)(% respondents)


Increase focus on workplace hygiene during influenzaseason (make hand gels/masks available, increase

frequency of disinfecting common areas)

Signs & posters around the workplace

Company-wide emails/newsletters

Face-to-face training about prevention(hand washing etc)

E-learning/webinars about prevention

Messages from senior management promotinginfluenza reduction as a business priority

Surveying employees to understand workplaceperceptions of influenza

Monitoring guidance from WHO, CDC,Google flu tracker etc

Bringing in external health experts to give talks

Appoint employees as volunteer "flu champions"

We do not communicate with employees onseasonal influenza

What conduct does your organisation undertake around seasonal influenza?(Select all that apply)(% respondents)

Provide on-site seasonal influenza vaccinationsfor employees

Send home employees with influenza-like symptoms

Reimburse employees for seasonal influenzavaccinations obtained privately

Encourage working from home/telecommutingduring influenza season

Focus seasonal influenza initiatives on higher riskemployees (such as asthmatics or frequent travellers)

Reduce business travel during influenza season,or to infected areas/offices

Make vaccinations available to employees' families

Offer vouchers, gifts or other incentives to encourageemployee participation in company's prevention efforts

We do not conduct activities focused onseasonal influenza

Chart 7: Spreading the word

43%

34%

25%

25%

23%

16%

16%

15%

10%

25%

39%

38%

34%

32%

22%

17%

17%

16%

8%

16%



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 infl uenza 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 armThe vast majority of companies (84%) conduct some form of prevention activity each infl uenza season. This is signifi cantly higher than the even one-half of companies that have a formal infl uenza policy, suggesting that for a sizeable minority of respondents (34%) corporate efforts to mitigate infl uenza 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 infl uenza activities to regional or local levels.

In the absence of an overall strategy for dealing with seasonal infl uenza, companies risk a patchwork approach that could undermine the objective of making employees receptive to corporate infl uenza 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 infl uenza among their employees, closely followed by increased focus on workplace hygiene, sending employees home with infl uenza-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%)

the least likely to do so—despite being the only country in this study with a nationwide recommendation for universal vaccination against infl uenza. 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 fl exibility: 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 on-site 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 infl uenza vaccination programme in place, as it assumes that high-risk employees are getting the vaccine at their GP’s offi ce. 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 infl uenza. “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 infl uenza prevention initiatives, despite there being more of an understanding nowadays that infl uenza 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

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



When it comes to being vaccinated against seasonal infl uenza, healthcare workers are not always fi rst 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 infl uenza 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 fl u 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 fi ndings 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 infl uenza vaccines for healthcare workers.19

In both regions, very few hospitals have been willing to make vaccines mandatory, given the inherent diffi culties 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

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 fl u 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 fl u season. Yet in this case, the “pandemic effect” on vaccination rates could also clearly be seen; by the 2010/11 fl u season, vaccination rates had fallen to 27%.21

Doctor’s note: saying one thing, doing another17 CDC, National Early Season Flu Vaccination Coverage, United States, 2012-13 flu season, www.cdc.gov/flu/fluvaxview/nifs-estimates-nov2012.htm.

18 CDC, Health Care Personnel Flu Vaccination, Internet Panel Survey, United States, November 2012, Recommendations, www.cdc.gov/flu/fluvaxview/hcp-ips-nov2012.htm.

19 “Seasonal influenza vaccination in EU/EEA, influenza season 2011-12, VENICE II Consortium, September 2012-February 2013, page 6.

20 “Mandatory flu shots opposed by some health care workers,” USA Today, January 16 2013.

21 Report from the First European Influenza Summit, European Scientists Fighting Influenza (ESWI), Brussels, Belgium, May 26 2011, page 9.

least likely to offer vaccinations to employees in the fi rst place. Walgreens offers free vaccinations for all employees, regardless of health plan or work status. As Tom Sondergeld, director of team member health benefi ts and wellbeing, explains, “Family members of those within the health plan are also able to receive free fl u 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 infl uenza, particularly on increased

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 infl uenza vaccinations during the 2011-12 fl u 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 fl u shot three years ago and didn’t have any side effects,’” he adds.



uptake in its offi ces 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 benefi t is no longer visible.

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 signifi cantly higher uptake of 50-70% taking it in Asia, compared with around 25% in Europe.

At Anglo American, infl uenza vaccines are offered free on-site in all locations. The average



Given the raised awareness among employees, it is notable that respondents list a lack of employee receptiveness to seasonal infl uenza 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 infl uenza 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 infl uenza vaccines—that they are ineffective, cause fl u symptoms or have other nasty side-

Fighting mistrust, misunderstanding and misinformation3

Chart 8: Knowing what is good for you

Top three factors most likely to raise the status of influenzaprevention as a business priority

Top three factors most likely to restrict the success of corporate initiatives around seasonal influenza prevention

(Top responses)

(Top responses)

Updates to official recommendations

Low employee receptiveness to influenza messaging

Perceived threat of pandemic influenza outbreak

High cost of prevention measures

Ability to measure business cost

Lack of data on the business impact of influenza

123

123


effects—to explain the relatively low take-up of infl uenza 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 fl u shots,” says Dr Tautz of Deutsche Post DHL. “Everyone knows about the effort but some people distrust the fl u campaign because of negative side-effects.”

There is, moreover, a perception that seasonal infl uenza 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 infl uenza as a uniformly minor ailment, they are less likely to take precautionary measures seriously. Experts also point to an artifi cial distinction between pandemic and epidemic infl uenza, which has led to a tendency of businesses to put more emphasis on the former and give insuffi cient attention to the latter. Thus employees are often less aware of the potential for serious illness or death resulting from the seasonal infl uenza variety.

Dr Quarry and Dr Van-Tam note that yearly epidemic versions of the fl u 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 fl u viruses] don’t disappear from human circulation after they have produced a pandemic. They re-circulate as seasonal fl u, 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



type and the cycle begins anew. There is no real difference in the way seasonal fl u spreads to the way pandemic fl u spreads; the difference will be the scale.”

Audience engagementThere is agreement among companies that more and better quality scientifi c evidence is needed to change minds. Part of the reluctance of many employees to engage in company infl uenza measures stems f rom confusion of the quality of medical evidence over how infl uenza spreads and presents itself. Moreover, the provision of better information to help shape employee behavior goes beyond vaccinations. Amy Costello, a senior benefi ts analyst at Staples, an offi ce 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 infl uenza. Passive forms of messaging continue to be the most popular form of communication, typifi ed 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 infl uenza, surveying employees to understand points of view or appointing employee “fl u champions” to spread the message. Even fewer still offer incentives for employees to take part in infl uenza initiatives. “Employee engagement is crucial to [the success of] fl u clinics, and if employees don’t feel getting a fl u shot is benefi cial 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

efforts via corporate intranets or host webinars on the importance of proper hygiene and maintaining personal space during fl u 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 cost-effectivenessAcross the US and western Europe there is some variation in the perceived obstacles to effective infl uenza prevention. Low employee receptiveness to infl uenza 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 infl uenza prevention initiatives).

In the case of the US and Germany, it is diffi cult 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 fi nancial 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 infl uenza vaccines that are the most signifi cant cost. Several US companies also admit to relying on large US pharmacy chains, such as Walgreens and Rite-Aid, which offer fl u 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 diffi culties as their counterparts in the US.2 Interestingly, Germany reported higher incidence of infl uenza than either the US or the UK for eight months during 2012 (see Chart 2).

There is no real difference in the way seasonal fl u spreads to the way pandemic fl u spreads; the difference will be the scale.

Dr Jonathan Van-Tam, Professor of Health Protection, University of Nottingham



Nonetheless, the high cost of prevention measures is generally seen as the second-biggest obstacle to mitigating the impact of infl uenza prevention initiatives across the sample. At a time of tight fi nancial budgets, with many companies reviewing the benefi ts that they are offering employees, seasonal infl uenza investments are likely to come under tighter scrutiny. There are, moreover, a rising number of illnesses and affl ictions 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 infl uenza (outside a pandemic threat).

Some companies, such as United Technologies, have been adapting their infl uenza 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 threatUnited Technologies has kept up its commitment to infl uenza 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 refl ects 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 infl uenza initiatives than those that say they

do (28%). “When many companies are looking to stretch their dollars, it can be diffi cult to justify on-site fl u shots, considering it can be diffi cult 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 infl uenza is patchy. Only 7% of companies are effective at gathering and analyzing data to inform future seasonal infl uenza initiatives. Nearly one-half of companies (46%) believe that they gather suffi cient data about the impact of seasonal infl uenza 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 fi ve (22%) companies admit to not gathering any data on seasonal infl uenza at all. Even companies with comprehensive infl uenza prevention programmes and strategies in place, such as United Technologies, do not collect data on seasonal infl uenza. Having 200,000 employees makes this a signifi cant 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 defi nition and diagnosis of seasonal infl uenza, together with the fact that most cases of suspected infl uenza are not offi cially diagnosed.

22 Benefit assessment and pricing of pharmaceuticals, HealthPolicyMonitor, The Bertelsmann Stiftung Foundation (finish citation), 2010.



How well is your organisationcollecting and using data about theimpact of seasonal influenza on yourbusiness? (% respondents)

Chart 9: Return on influenza


Well or very wellPoor, very poor ornon-existent

Don't know1%

53%46%

Agree or disagree: My company doesnot have the metrics to measure theeffectiveness of any particularinfluenza initiative (% respondents)

Agree

Disagree

Don't know1%

Neutral

47%28%

24%

As a result, many managers fi nd it diffi cult to assess the prevalence of fl u 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 fl u 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 infl uenza have not historically been signifi cant cost drivers for employers compared with other conditions, such as diabetes and hypertension.

Whatever the reason for this defi cit of data, the overall group of respondents to our survey deem it to be the third most signifi cant barrier hampering the success of their infl uenza initiatives—and the highest for respondents in the UK. The diffi culty for companies to accurately judge the full impact of seasonal fl u 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 infl uenza would be a major way of raising infl uenza as a business priority (just behind offi cial 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 infl uenza prevention measures.



Companies in the healthcare sector (including pharmaceuticals & biotech) are generally at the forefront when it comes to the prioritisation of seasonal infl uenza and its prevention. Nearly two in three (64%) have a formal infl uenza 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 infl uenza 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, fi nancial services, manufacturing, and professional services. It is also the only industry of these fi ve 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 fi ve (22%) professional services companies has a formal

policy for dealing with infl uenza. The status of infl uenza 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 signifi cant 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 infl uenza as a business priority, and increased involvement of senior management in infl uenza 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.

Infl uenza by industry



Conclusion

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 infl uenza. Few companies appear to see seasonal infl uenza as a central health priority. This may be entirely correct when absenteeism from infl uenza 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 infl uenza to be able to make an objective assessment.

Filling in these knowledge gaps should enable managers to formulate more confi dent 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 infl uenza 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.

Corporate preparation for the potential impact of seasonal infl uenza 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 infl uenza 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 infl uenza 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 infl uenza 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 infl uenza, including the connection between the pandemic and seasonal varieties and the ways in which infl uenza is



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.

Appendix 1

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.

Yes

No

Don't know

50

48

2

(% respondents)Does your company have a formal strategy or policy in place to reduce the spread of seasonal influenza among employees?

Non-existent

Minimal

Moderate

High

7

54

34

5

(% respondents)How would you characterise the overall risk of seasonal influenza to your business?



Absenteeism (sick pay, employing temporary workforce)

Operational costs (loss of business, drop in productivity, slower projects)

Health costs (treatment, hospitalisation, insurance)

Planning and 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

2

(% respondents)What, if any, is the biggest cost to your business associated with seasonal influenza?

Substantial increase Moderate increase No change Moderate decrease Substantial decrease Don't know/ Not applicable

Worker absences with influenza or flu-like symptoms

Employee awareness about seasonal influenza

Priority to business of seasonal influenza prevention and awareness

Senior executive/management involvement in seasonal influenza strategy

Business impact of last seasonal influenza season

Company-wide preparations and/or resources allocated to the upcoming influenza season

Focus on seasonal influenza compared to other employee health priorities

351747235

227383911

13752306

34847318

341358

32860

32762

183

233

233

(% respondents)

In your view, how have the following changed at your organisation during the latest influenza season compared to threeyears ago? Select one column for each row

Very well—we effectively gather and analyse almost all the relevant data and use it to predict and shape our approach to future outbreaks

Well—we gather and analyse most of the relevant data we need but some value is lost through lack of thoroughness or application

Poorly—we gather some data effectively but it is mainly used for record keeping rather than analysis or application

Very poorly—we gather patchy data, preventing us from doing anything meaningful with it

Non-existent—we do not collect any data on seasonal influenza at the moment

Don’t know

7

46

19

5

22

1

(% respondents)How well is your organisation collecting and using data about the impact of seasonal influenza on your business?



Signs & posters around the workplace

Company-wide emails/newsletters

Face-to-face training about prevention (hand washing, etc)

E-learning/webinars about prevention

Messages from senior management promoting influenza reduction as a business priority

Surveying employees to understand workplace perceptions of influenza

Monitoring guidance from WHO, CDC, Google flu tracker, etc

Bringing in external health experts to give talks

Appoint employees as volunteer "flu champions"

Other (please specify)

We do not communicate with employees on seasonal influenza

Don't know

43

34

25

25

23

16

16

15

10

1

25

1

(% respondents)What, if any, communication does your organisation undertake around seasonal influenza? Select all that apply

Provide on-site seasonal influenza vaccinations for employees

Increase focus on workplace hygiene during influenza season (make available hand gels/masks, increase frequency of disinfecting common areas)

Send home employees with influenza-like symptoms

Reimburse employees for seasonal influenza vaccinations obtained privately

Encourage working from home/telecommuting during influenza season

Focus seasonal influenza initiatives on higher risk employees (such as asthmatics or frequent travellers)

Reduce business travel during influenza season, or to infected areas/offices

Make vaccinations available to employees' families

Offer vouchers, gifts or other incentives to encourage employee participation in company's prevention efforts

Other (please specify)

We do not conduct activities focused on seasonal influenza

Don't know

39

38

34

32

22

17

17

16

8

1

16

1

(% respondents)What, if any, conduct does your organisation undertake around seasonal influenza? Select all that apply



Updates to official advice/recommendations from public health bodies/authorities

Perceived threat of pandemic influenza outbreak (eg, avian influenza)

Ability to measure and/or quantify the business cost of seasonal influenza

Experiencing a severe outbreak of seasonal influenza

Noticeable changes overtime to environmental climate

Changes in industry or regional best practice

Increased attention from media and/or general public

Expansion of company (eg, entering new markets, increasing employee headcount)

Pressure from stakeholders (eg, trade unions/employee representatives)

Nothing

Don't know

34

31

25

20

13

12

10

9

6

9

2

(% respondents)

Which of the following factors have raised or would most likely raise the status of influenza prevention as a business priorityat your company? Select up to two

Low employee receptiveness to influenza messaging

High cost of prevention measures

Lack of data on the business impact of influenza

Company culture of "presenteeism" (ie, sick employees turning up for work)

Lack of company resources (eg, money, time)

Difficulty in coordinating the process

Regulatory restrictions/rules

Lack of leadership from senior management

Lack of expertise/know-how/technology inside of company

Other (Please specify)

There are no barriers at my company

Don't know

25

19

18

17

16

13

13

12

6

1

16

3

(% respondents)

Which of the following factors have restricted or are most likely to restrict the success of your company's initiatives aroundseasonal influenza prevention? Select up to two



Strongly agree Somewhat agree Neutral Somewhat disagree Strongly disagree Don't know

My company sets specific goals for its long term seasonal influenza programme

My company is generally spending more money on the health and wellbeing of our employees

My company has seen a drop in employee absenteeism due to heightened concerns about job security

My company does not have metrics to measure the effectiveness of any particular influenza initiative

My company does more to tackle seasonal influenza than our competitors

2209292713

7131438217

11216242918

5121037287

2

2

181640205

8133712

(% respondents)To what extent do you agree with the following statements about your company? Select one column in each row

28

My company is undergoing a change in work practices or processes (eg, rise in remote working, increased automation), leading to lessperson-to-person contact

Board member

CEO/President/Managing director

CFO/Treasurer/Comptroller

CHRO/Head of HR

CIO/Technology director

Other C-level executive

SVP/VP/Director

3

15

8

6

4

15

50

(% respondents)Which of the following best describes your title?

United States of America

Spain

France

Germany

Italy

United Kingdom

39

13

12

12

12

12

(% respondents)Where are you personally located?



Western Europe

North America

61

39

(% respondents)In which region are you personally located?

General management

Finance

Human resources

Operations and production

IT

Strategy and business development

Marketing and sales

Occupational health

Risk

R&D

Customer service

Information and research

Legal

Procurement

Supply-chain management

23

20

17

14

12

12

11

10

6

6

4

4

3

2

1

(% respondents)What are your main functional roles? Select all that apply



Financial services

Manufacturing

Consumer goods

Healthcare, pharmaceuticals and biotechnology

Professional services

Energy and natural resources

Construction and real estate

IT and technology

Entertainment, media and publishing

Transportation, travel and tourism

Retailing

Utilities

Automotive

Chemicals

Telecommunications

Education

Logistics and distribution

Government/Public sector

Agriculture and agribusiness

14

14

11

10

8

1

1

1

1

6

5

5

4

4

4

3

3

3

2

(% respondents)What is the primary industry your organisation is in?

Less than $100m

$100m to $500m

$500m to $1bn

$1bn to $5bn

$5bn to $10bn

$10bn or more

19

29

28

13

4

6

(% respondents)

What is your organisation’s annual global revenue in US dollars? Please select the most appropriate option if your companydoes not report revenue in US dollars



1 to 9

10 to 49

50 to 99

100 to 249

250 to 499

500 to 999

1000 to 9999

10,000 to19,999

20,000 +

9

8

6

13

15

13

28

3

6

(% respondents)How many full-time employees does your company have in total?

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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Health & Medicine

Strategies for seasonal influenza: spreading prevention across the worlforce