As respiratory viral infections peak in the United States, hospital emergency departments are overwhelmed, and inpatient censuses around the country reach or exceed capacity. To reduce the transmission of these viruses in the hospital setting, at some institutions, patients are placed in contact and/or droplet precautions. Patients may be cohorted together based on symptomatology or identified virus; visitors may be screened for signs and symptoms suggestive of a respiratory viral infection; and staff may be reminded to adhere to hand hygiene policies. However, many healthcare workers (HCWs) continue to work while ill,Reference Chiu, Black and Yue ¹ and the seemingly selfless acts of working with “just a cold” puts patients at risk. A culture change is needed to protect patients from ourselves as HCWs.

While strategies aimed at preventing hospital-acquired bacterial infections such as Clostridium difficile or methicillin-resistant Staphylococcus aureus have been the focus of major national infection prevention efforts, hospital-acquired respiratory viral infections (HARVIs) continue to be an underappreciated cause of morbidity and mortality. There may be >15,000 adult and 3,000 pediatric HARVI cases yearly in the United States.Reference Chow and Mermel ² Between 2015-2016, we found that 5 of 40 patients in our tertiary care hospital with HARVI required transfer to an intensive care unit; 2 of 40 patients died during hospitalization related to complications of HARVI. Most HARVI cases were due to viruses other than influenza. In some cases, HARVI occurred when patients were in a single-occupancy room and without visitors, suggesting possible transmission from infected staff caring for those patients or transmission from other patients due to breaches in staff hand hygiene or suboptimal cleaning of contaminated environmental surfaces.

Presenteeism is particularly challenging when hospitals are at capacity. Healthcare workers feel compelled to work while ill and are unsure of what constitutes being “too sick to work.” This phenomenon is driven by numerous factors reflecting system-level factors (eg, lack of redundancy or surge capacity for cross-coverage) and sociocultural factors (eg, not wanting to let down patients or colleagues).Reference Szymczak, Smathers, Hoegg, Klieger, Coffin and Sammons ^{3 –} Reference Mossad, Deshpande, Schramm, Liu and Rothberg ⁵ The Centers for Disease Control and Prevention (CDC) recommends that HCWs with fever and respiratory symptoms not report to work or stop patient care activities. ⁶ However, relying on fever in determining sick leave is problematic because half of HCWs do not have fever at the onset of influenza when the viral load in respiratory secretions are peaking and transmission risk is high.Reference Mermel ⁷ Additionally, a study of respiratory infections due to various viruses found that only 1 in 3 infected adults have a fever.Reference Chughtai, Wang, Dung and Macintyre ⁸ Lastly, presenteeism, even among a small number of peripatetic HCWs, can result in significant risk to patients.Reference Temime, Opatowski, Pannet, Brun-Buisson, Boëlle and Guillemot ⁹

Reducing HARVI transmission from symptomatic HCWs will require a change in attitudes, practices, and culture regarding sick-leave policies, as well as education of HCWs regarding the risk they pose to their patients when they come to work sick. We recommend the following measures to address this problem: (1) Hospital physician and nursing leadership must devise a sick leave policy that is nonpunitive, with redundancy and resilience, striving for a ‘jeopardy’ on-call system so that all licensed independent practitioners, house officers, and nursing staff who are ill can be temporarily replaced. (2) Because HCWs with symptoms suggestive of a respiratory viral infection are a risk to their patients even in the absence of fever, the CDC should revisit policies to broaden the scope of “too sick to work” in an effort to reduce risk to patients, particularly hospitalized patients with comorbidities that can lead to worse outcomes due to infectious and noninfectious complications.Reference Blackburn, Zhao, Pebody, Hayward and Warren-Gash ^{10 ,} Reference Kwong, Schwartz and Campitelli ¹¹ (3) Increased awareness regarding the risk and outcomes of respiratory viral infections in acutely ill hospitalized patients should start at the student-trainee level, and HCWs should be encouraged to be seen by an occupational health representative when they are unclear about whether they are too sick to work.

A collective shift in mindset will be crucial to reducing the risk we HCWs pose to our patients when working while ill with a transmissible infection. Ideally, the cultural norm will shift from a blasé faire attitude of seeing colleagues on hospital care units during the winter coughing, sneezing, with runny nose, and complaining of a sore throat to one in which the standard of care requires that such individuals not report to work.