Posted: September 9, 2009
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Article SummaryI wrote this short column in early June 2009 for The Synergist, a magazine for industrial hygienists, on some ways of communicating about flu – seasonal and pandemic – in the workplace. When I wrote it, most people had “recovered” from what they considered the spring “swine flu scare,” and they were in no mood to listen to any more influenza warnings. By the time the column was published in September 2009, some of the complacency had waned, and people were actually girding up (a bit) for another wave of mild-but-pervasive pandemic illness. So the column’s claim that flu preparedness is a tough sell needs to be modified somewhat. But its actual recommendations still stand.

Flu Preparedness:
An Even Tougher Sell than Usual

by Peter M. Sandman

This is the nineteenth in a series of risk communication columns I have been asked to write for The Synergist, the journal of the American Industrial Hygiene Association. The columns appear both in the journal and on this website. This one can be found (more or less identical except for copyediting details) in the September 2009 issue of The Synergist, pp. 24–27.

As I write this column in early June 2009, the new swine flu H1N1 remains mild – though even a mild flu can feel like getting hit by a truck. It’s still spreading in some parts of the United States, but seems to be receding (at least for now) in most. It has already receded in the U.S. media, and in the consciousness of the U.S. public. Swine flu is spoken of today, if at all, as that scare we went through in late April and early May.

Assuming H1N1 keeps receding and doesn’t make an early comeback, when you read this in September influenza will probably be pretty low on your priority list … and lower still on the priority lists of your workforce and your management.

That may be a huge mistake. Though H1N1 could fizzle and simply disappear, most experts are betting it will be back in the fall. Maybe it will still be mild. Maybe it will mutate into a much more virulent strain, the way the different H1N1 virus that caused the infamous 1918 pandemic did. Maybe it will mix-and-match RNA with the bird flu H5N1 virus that’s still out there (in birds, mostly), producing every virologist’s nightmare scenario: a pandemic with the easy transmissibility of H1N1 and the incredible virulence of H5N1.

Even if swine flu stays mild, we’re looking at an unusually complicated flu season. And flu-related absenteeism is a significant workplace health issue even in a good year. So here’s a rundown on influenza risk communication.

Complacency, Not Panic

The last few years have seen at least three periods of intense media focus on influenza: the vaccine shortfall of 2004–2005, the 2005 arrival of bird flu H5N1 in Europe, and the early days of the swine flu H1N1 pandemic of 2009. All three were teachable moments, chances to teach the American public that the seasonal flu is a much bigger deal than most people imagine, and that the prospect of a potentially severe pandemic is a much bigger deal than the seasonal flu.

All three teachable moments were mostly missed. Some people got the message – the pandemic preparedness community is a lot bigger than it was five years ago. But what many more “learned” (mis-learned) from these three experiences is that flu crises usually turn out to be false alarms and that officials and/or the media are fear-mongers whose warnings aren’t necessarily to be trusted.

I would wager that public concern about flu is at a low ebb – both the chronic risk of flu in general and the catastrophic risk of a severe flu pandemic. Your risk communication problem going into the 2009–2010 flu season is probably complacency, not excessive fear, and certainly not panic.

Many officials today are extremely reluctant to sound the alarm about influenza risks, for three reasons:

  • They are afraid of panicking the public – an absurd fear considering the rarity of true panic, and poll data showing extremely low levels of concern.
  • They are afraid of being accused of panicking the public – a reasonable fear, since they’re already accused of precisely that even though they have bent over backwards to avoid saying anything inflammatory.
  • And they’re afraid of being dismissed as irrelevant alarmists – the most reasonable fear of all, since so many people have already decided that flu and flu pandemics aren’t worth worrying about.

Some industrial hygienists may have the same reluctance to sound the alarm, for the same reasons. But you’re used to battling complacency and being considered unduly alarmist. Now is the time to add flu warnings to your to-do list.

Overcoming Pandemic Complacency

There are lots of risk communication strategies for overcoming complacency. You’re already familiar with many of them. (Just think about what it takes to make a safety meeting work.) But here are a few you may not know that are especially relevant to flu.

First, acknowledge the skepticism. You may want to do this directly: “A lot of you are probably pretty unconcerned about flu, and pretty skeptical about all those swine flu pandemic warnings we heard last spring.” Or take it on yourself: “I can’t believe I’m here today to sound the alarm about something as familiar and routine as flu!” There’s a risk communication seesaw link is to a PDF file at work here. Skeptics are less skeptical when the speaker acknowledges their skepticism.

Second, dramatize the magnitude of the risk rather than overstating its probability. Flu pandemics happen only about three times per century, and severe ones are less frequent still. And most people most years don’t get the flu at all. The case for precautions can’t be grounded in the implication that we’re almost sure to have a severe pandemic or that your listeners are almost sure to get the flu. Sell flu preparedness the way insurance companies sell fire and disability insurance: It could happen, it would be horrible if it did, and here’s a smart investment to reduce your risk.

Third, offer people things to do. This is a twofer. When people are fearful (which they’re not, as of June 2009), giving them things to do increases efficacy and control, which helps them bear their fear without escalating into panic or – the bigger problem – sliding into denial. And when people are complacent (which they are, as of June 2009), giving them things to do is a way to encourage increased concern. We learn from our behavior. If you can persuade employees (or management) to take precautions against the flu, maybe just because you keep harping on it, the very act of taking precautions will launch a process of reevaluation, spurred by cognitive dissonance: “Why am I doing this? It must be because I take flu seriously.”

Action Steps

So which precautions should you recommend? Here are the big three – and some also-rans:

Staying home.

The biggest workplace flu problem is “presenteeism”: people who come to work sick with the flu and infect their coworkers. Urging employees (including management employees) to stay home if they’re sick is crucial. So is sending them home if they’re sick.

But the real solution to presenteeism lies in rethinking the incentive system. This is partly about sick pay policies, partly about corporate climate. If yours is the kind of company where staying home sick is widely viewed as lazy and disloyal, you’re likely to have a lot of flu this winter.

Flu shots.

This year’s seasonal flu vaccine won’t protect against pandemic flu. The U.S. has ordered more than $200 million worth of a targeted pandemic flu vaccine, but when I was writing this, the experts hadn’t decided yet which risk groups they would advise to use it. Flu experts think it might take two shots rather than one to do the job. So there will be between one and three flu shots to urge your people to get.

Flu vaccination is especially important for people with asthma, HIV, or other underlying health conditions, who (together with the elderly) are likeliest to die from flu complications. But people who recover easily from the flu are still sick as a dog for a week – an outcome both they and your company have a stake in preventing.

The single best predictor of whether employees get flu shots is whether the company brings the shot right to them. It’s not just that a mobile vaccination clinic makes it convenient to say yes; it also makes it slightly embarrassing to say no. And it signals the company’s commitment to the program.


Nobody knows exactly how effective washing your hands and covering your cough are against the flu. But they probably help a bit, and they have no downside. So by all means take a shot at persuading people to practice good hygiene.

Bear in mind, however, that hygiene advice tends to feel infantilizing. And depending on workplace conditions, it may feel futile as well – for example, if employees’ hands are busy, if restroom visits are limited, and if there’s no way to turn off the restroom faucet and open the door without recontaminating your hands.


Surgical masks cover your cough more effectively than a sleeve or a tissue. They may also partially protect you from other people’s cough and sneeze droplets. But they’re uncomfortable, they’re not free, and they may be in short supply. U.S. officials have so far discouraged mask-wearing except in healthcare settings, and many U.S. workplaces have actually forbidden employees to wear masks. The big disadvantage of masks in most authorities’ minds is that they can arouse some fear in others. If you agree with me that complacency is the problem, not excessive fear, then that disadvantage is actually an advantage. Give some thought to saying a kind word about masks. Consider making them available with other PPE. At least make sure they’re permitted where you work. And teach those who choose to use them how to wear the masks properly.

If started soon after the onset of symptoms, antiviral drugs like Tamiflu can reduce the length and severity of people’s flu cases. These drugs didn’t get much use in the U.S. until the arrival of H5N1 and then swine H1N1. But pandemic concerns built the market for antivirals, and prescribing norms are now in flux – especially with regard to swine flu. Some companies have stockpiled antiviral drugs against the possibility of a severe pandemic.

“Social distancing” is any effort to keep people far enough apart to reduce the likelihood of flu viruses passing from one to another. Six feet appears to be the recommended distance, though more is better still and less isn’t useless. Some companies have developed elaborate social distancing strategies to enable people to work under pandemic conditions without infecting each other.

Pandemic Preparedness

All the action items listed above will help in any flu outbreak. They make sense for the seasonal flu, and they make sense for the mild H1N1 pandemic we’re currently experiencing.

If and when a severe pandemic arrives – whether it’s H1N1-turned-virulent, or H5N1, or a combination of the two, or some new flu virus altogether – companies will wish they had prepared more, and will wish their employees had prepared more too. But of course preparedness is expensive, and severe pandemics have been infrequent. Whether and how much to prepare for one is a judgment call.

When H5N1 was big news, lots of companies and more than a few individuals decided preparedness made sense. Since an H5N1 pandemic hasn’t happened yet, preparedness fizzled … even though H5N1 is still out there and still threatening. Then H1N1 arose and spread to pandemic proportions. But it was so mild the World Health Organization hesitated even to call it a pandemic. And many companies and individuals learned the mistaken lesson that even a pandemic is no biggie. With H5N1 and H1N1 both in circulation, the case for preparedness is stronger than ever. But the mood is solidly in the other direction, especially given the state of the economy.

Here are some key pandemic preparedness (severe pandemic preparedness) messages:

  • A severe pandemic is still a possibility worth preparing for – even though people are in no mood to hear it.
  • A key element in preparedness is stockpiling essentials in case supply chains are disrupted. For individuals, that means food, water, medications, and the like. For companies, it means supplies you can’t function without. Companies in a severe pandemic won’t be able to do everything they normally do. Business continuity must give way to business discontinuity: planning which activities you will jettison to make it more feasible to keep the others going despite absenteeism, supply failures, and other disruptions.
  • Employees should be cross-trained now for their “emergency duty stations” – the job they’ll be asked to do in a severe pandemic. Among other benefits, they’re likelier to come to work if it’s for a special pandemic job than if it’s for their routine job.
  • Preparedness for a severe pandemic isn’t just logistical. It’s also cognitive and emotional. If you haven’t thought through how you’ll cope if a family member is home with the flu and the hospitals are overcrowded past capacity, you haven’t started preparing yet. If you haven’t imagined what life might be like if the power company runs out of fuel, the water treatment plant runs out of chlorine, and the pharmacy runs out of cancer meds, you haven’t started preparing yet.

It may be more than you can manage right now to persuade anyone – management or workforce – to start preparing for a severe pandemic. Okay. Focus on what’s pretty close to guaranteed: a flu pandemic that will be pervasive even if it stays mild, either replacing the normal flu season or accompanying it. Start getting people ready for that.

Copyright © 2009 by Peter M. Sandman

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