Strategies for seasonal influenza spreading prevention across the worlforce

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Strategies for seasonal influenza Spreading prevention across the workforce

Contents

1

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

© The Economist Intelligence Unit Limited 2013


Strategies for seasonal influenza Spreading prevention across the workforce

About the
report

Strategies for seasonal influenza: 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 influenza and the prevention measures companies are
putting in place.
This report draws on two main sources for its research and
findings:

• 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

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

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

 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):

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

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

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

• Frank Fox, head of occupational health, Anglo American
• Stefan Lang, chief medical officer 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 officer, Deutsche Post DHL
(Germany)
2

• Angus MacGregor, director of human resources, Eversheds
(UK)

• Philippe Aeschlimann, spokesman, Nestle SA (Switzerland)
• Gill Macleod, chief executive, RoonLane Medical (UK)
• Amy Costello, senior benefits analyst, Staples (US)
• Lisa Hamblet, vice president, Staples Facility Solutions,
Staples (US)

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

• Tim Stevenson, head of medical services, Virgin Atlantic
Airways (UK)
• Tom Sondergeld, director of team member health benefits
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

© The Economist Intelligence Unit Limited 2013

Strategies for seasonal influenza Spreading prevention across the workforce

Executive
summary

Seasonal influenza 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 flu
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.

In order to better understand the perception of
seasonal influenza 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.

Difficulties in diagnosing seasonal influenza 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 influenza or lack confidence 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 influenza
prevention initiatives. Such knowledge gaps are
compounded by a paucity of third party literature
on the economic impact of seasonal influenza.

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

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

3

© The Economist Intelligence Unit Limited 2013

The key findings of this research include the
following:

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


Strategies for seasonal influenza Spreading prevention across the workforce

influenza, but there is a split in how countries
perceive trends in influenza-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 influenza compared
with three years ago, based largely in the UK,
Germany and the US. This contributes to a higher
risk profile for influenza overall in the US, the
UK and particularly Germany than in the more
southern European countries.
Most companies conduct influenza mitigation,
although some lack a coordinated approach:

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

4

© The Economist Intelligence Unit Limited 2013

last official pandemic in 2009 are fading, focus
is tapering and the potential for complacency
is building. Experts also say that there is an
artificial distinction between pandemic and
epidemic influenza, leading to a tendency for
businesses to concentrate on the former and give
insufficient attention to the latter.
The effectiveness of current influenza
initiatives are under the microscope: Despite
increased employee awareness of influenza over
the past few years, low employee receptiveness
to seasonal influenza 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 influenza 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 influenza initiatives. Therefore, enabling
executives to judge the financial merits of

investing in influenza 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 influenza mitigation efforts.


Strategies for seasonal influenza Spreading prevention across the workforce

Introduction
Picking influenza out of
a crowd

Even for experts,
[making] the
distinction
between influenza
and respiratory
viral infections is
incredibly difficult.
Dr Jonathan Van-Tam,
Professor of Health Protection,

University of Nottingham

CDC Seasonal Influenza
Questions & Answers,
/>about/qa/disease.htm.

1

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

2

5

Few would deny that seasonal influenza has an
annual impact on the populations of the US and
Europe. In the US, between 5% and 20% of the
population gets influenza each season; there
are some 36,000 deaths, and more than 200,000
are hospitalised annually as a result of seasonal
flu-related complications, according to the
Centers for Disease Control and Prevention (CDC)
in Atlanta, Georgia.1 In Europe, the number of
annual deaths from influenza 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 influenza is
far smaller.
Yet getting an accurate picture of the prevalence
of influenza can be difficult, as the measurements
themselves are frequently the subject of
disagreement. One of the first difficulties in
assessing the impact of seasonal influenza is
defining and diagnosing it. Seasonal influenza
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, influenza experts
say it is often difficult to accurately determine
the extent of a given seasonal epidemic.

© The Economist Intelligence Unit Limited 2013

“The fundamental problem is that, even for
experts, [making] the distinction between
influenza and respiratory viral infections is
incredibly difficult,” 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 influenza.
While most people severely affected by seasonal

influenza 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 influenza 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: influenza in numbers). The figures
give a taste of the magnitude of the impact, but
assessing the business cost of seasonal influenza
is an imperfect science at best. As we will see
later on, this lack of clarity exists at company
level too, so that influenza strategies—to the


Strategies for seasonal influenza Spreading prevention across the workforce

Chart 1: January blues
US adult population reporting influenza in January from 2009 to 2013
(% of respondents reporting influenza)

2.9%

2.4%

January 2009

January 2010

4.7%

3.2%

2.6%

January 2011

January 2012

January 2013

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

January average: 4.7%

Above average

Below average

Age group
5.34%

4.91%

4.42%

4.19%

18-29

30-44

45-64

65+

Monthly income

Gender

6.51%
4.51%

4.88%

Male

Female

Smoking

3.70%

3.14%

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

Asthma

5.74%

Smoker

4.46%

5.25%

Non-smoker

Yes

4.63%

No

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

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 figures—roughly the same size as the
five western European economies covered by
this report: Germany, France, the UK, Italy and
6

© The Economist Intelligence Unit Limited 2013

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.


Strategies for seasonal influenza Spreading prevention across the workforce

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

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
3

CDC. National Early Season
Flu Vaccination Coverage,
United States, 2012-13 Flu
Season, www.cdc.gov/flu/
fluvaxview/nifs-estimatesnov2012.htm.

4

Molinari NA, OrtegaSanchez 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.

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 flu-like illness stay home until 24 hours
after their fever has disappeared. The CDC
guidelines also advise employers to review sickleave policies and try to provide flexible 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 influenza vaccinations. In February
2013 the Advisory Committee on Immunization
Practices’ (ACIP) called for influenza vaccines for
anyone six months or older (35% of the country’s
adult population had had the vaccine for the
most recent flu 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 influenza in the two regions.
The most significant differences are that in the US
employees are more aware of seasonal influenza,

the virus is more likely to have become an
increased business priority and senior managers
tend to be more involved in influenza 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.

5

6

Ibid.

7

Ibid.

8

Ibid.

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

9

7

The business cost: influenza in numbers
 According to one study, annual influenza
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 influenza epidemics
cost around US$16.3bn a year on average, or
20% of the total burden of influenza.7
 A study by a US pharmaceutical chain,
Walgreens, from September 2011, found
© The Economist Intelligence Unit Limited 2013

that influenza was responsible for 100m lost
workdays in the 2010-11 flu season.
 A September 2010 report from the US
National Business Group on Health identified
24.7m cases of seasonal influenza each year,
resulting in 3.1m hospitalised days and annual
direct medical costs of around US$10.4bn.8
 In Europe, influenza 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

Strategies for seasonal influenza Spreading prevention across the workforce

Chart 2: Atlantic chill
US, German and British adult populations reporting influenza or cold during 2012
(% of respondents reporting cold or influenza)

Influenza

US

6

Germany

UK

5

5

4

4

3

3

2

2

1

1

0

0
Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Common cold

Sep

US

Oct

Nov

Germany

Dec

UK

12

12

10

10

8

8

6

6

4

4

2

2

0

0
Jan

Feb

Mar

Apr

May

Jun

Source: Gallup-Healthways Well-Being Index.

8

6

© The Economist Intelligence Unit Limited 2013

Jul

Aug

Sep

Oct

Nov

Dec


Strategies for seasonal influenza Spreading prevention across the workforce

1
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 officer, Deutsche Post
DHL

Business perceptions of seasonal
influenza

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

Chart 3: Mild discomfort
How would you characterise the
overall risk of seasonal influenza
to your business?
(% respondents)

Non-existent
(inc don't know)

7%

54%
34%
5%

Minimal

Moderate

High

Source: Economist Intelligence Unit survey, June 2013.

This majority opinion is generally consistent
across the US and western Europe. There are,
9

© The Economist Intelligence Unit Limited 2013

nonetheless, some significant 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 influenza as a moderate or high
risk, rather than minimal or no risk. On average,
39% of respondents see seasonal influenza 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 flu in [the
UK] but it’s not a very big deal,” says Rod Ratsma,

head of UK business continuity for a consulting
firm, Marsh Risk Consulting. “But there are parts
of the world where there is less access to flu jabs
and anti-virals. A lot of first 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
officer 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.”


Strategies for seasonal influenza Spreading prevention across the workforce

Chart 4: Sick days
What is the biggest cost to your business associated with
seasonal influenza?
(% respondents)

Absenteeism (sick pay, employing
temporary workforce)
Operational costs (loss of

business, drop in productivity,
slower projects)
Health costs (treatment,
hospitalisation, insurance)
Planning & 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%

“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.”

2%

Source: Economist Intelligence Unit survey, June 2013.

Presenting at work
Absenteeism is by far the biggest cost to
businesses of seasonal influenza. 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
influenza, 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 influenza or influenza-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
figures above the average, whereas Spain, Italy
and France either post a net increase below
average or report a net decrease.
10

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 influenza, 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 influenzalike symptoms.

© The Economist Intelligence Unit Limited 2013

For others, however, the corporate position on
absenteeism is not so black and white. Narrow
benefit 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 influenza
season brought no dramatic changes from the


Strategies for seasonal influenza Spreading prevention across the workforce

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

What makes a pandemic?
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

Companies from the US are most likely to report
greater employee awareness, with nearly twothirds 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 influenza season.
Much of this raised awareness is the result of a
regular drumbeat of public health and media
warnings about new strains of the influenza virus

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

Chart 5: Going viral
How have the following changed at your organisation during the latest influenza season
compared with three years ago?
(% of respondents)

Increase

No change

28%

Decrease

Don't know/Not applicable

50% 38%

47% 22%
3%

Worker absences with influenza
or flu-like symptoms
Source: Economist Intelligence Unit survey, June 2013.

11

© The Economist Intelligence Unit Limited 2013

9%

Employee awareness about
seasonal influenza

2%


Strategies for seasonal influenza Spreading prevention across the workforce

company-wide formalisation of this approach
to five years ago, when official communications
around the pandemic threat began to pick up.
This convinced management about the benefits
of investing in influenza 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
influenza. At Eversheds, a UK-based law firm,
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 significant
change in absence due to seasonal flu 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 flu outbreak. “We
had the plan in place for three years before we
had to implement it for swine flu/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 global
Yet this heightened awareness carries its own
risks too. Each time a new strain of influenza
is identified 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 official
influenza pandemic in recent years, the H1N1
swine flu pandemic in 2009, and four pandemics
in the last 100 years (see Mass panic: Breaking
news of pandemic flu). “Avian flu has certainly
raised consciousness among organisations about
the potential impact that the seasonal flu 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 reflected
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
influenza 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 influenza 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 influenza a higher priority than before,
ten times higher than the equivalent figure 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 influenza—four outbreaks in 100 years
Pandemic
1918-19

Estimated number of deaths worldwide
Spanish influenza

H1N1

20-50m

1957 - 1958

Asian flu

H2N2

1-4m

1968 - 1969

Hong Kong flu

H3N2

1-4m

2009

Swine flu

H1N1

152,000 to 576,000

Source: European Center for Disease Prevention and Control.
12

© The Economist Intelligence Unit Limited 2013


Strategies for seasonal influenza Spreading prevention across the workforce

Mass panic: Breaking news of pandemic flu

10

Metro, 26 April 2009.

“Mass Graves could be

used in autumn bout of
swine flu,” Kiran Randhawa,
The London Evening
Standard, 19 August 2009

11

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.
US Centers for Disease
Control and Prevention fact
sheet on Avian Influenza A
Virus, />flu/avianflu/h7n9-virus.

htm, August 13 2013.

16

13

Many businesses interviewed for this report
blame the lack of a broader urgency to tackle
seasonal influenza in part on the media’s high
profile coverage of potential pandemic influenza
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 flu—the only actual influenza
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 flu “could kill
up to 120m,” quoting leading medical experts
who warned the virus looked more similar to
the lethal Spanish flu of 1918 than the H5N1
avian flu 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 flu 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 influenza variant.12
By autumn 2009, a news agency, Agence FrancePresse, appeared to be looking for a middle
ground, with a report quoting the head of the

© The Economist Intelligence Unit Limited 2013

CDC, Thomas Frieden, who confirmed a death
toll of around 10,000 during the first seven
months of the outbreak in the US; a “much
higher” fatality rate than in a usual flu 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 flu. Although the UK had recorded nearly
500 deaths in the first 12 months of the swine
flu outbreak, the initial media saturation of the
first few weeks of the outbreak had evaporated.
However, there were higher numbers in
intensive care with flu by winter 2010.14
Nonetheless, media apathy could be as

dangerous as mass pandemonium. During the
avian flu 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 flu 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 influenza: the most
recent avian flu 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


Strategies for seasonal influenza Spreading prevention across the workforce

2

Preventing seasonal influenza

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

influenza 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.

Chart 6: Corporate prescriptions
Does your company have a formal
strategy to reduce the spread of
seasonal influenza among employees?
(% respondents)

50%
Yes

50%
No or don't know

Source: Economist Intelligence Unit survey, June 2013.

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
14

© The Economist Intelligence Unit Limited 2013

year-round information campaigns in all the
global locations where the group operates and
where influenza 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;
[influenza] 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 influenza 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 influenza 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


Strategies for seasonal influenza Spreading prevention across the workforce

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

We recently did
a survey and

found that 80%
of employees are
coming into the
workplace even
when they have the
flu.

Lisa Hamblet, vice president,
Staples Facility Solutions

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 offices, 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
flu” pandemic, the company made its annual
influenza vaccination campaign the topic of its
global campaign.
Communications around seasonal influenza
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 influenza 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 specific communication lines
used by pilots and flight crews, as well as by other
departments.
Other companies in the business-to-business
(B2B) environment run parallel education
programmes about influenza prevention for both

15

© The Economist Intelligence Unit Limited 2013

employees and customers. Speaking to large
corporate customers about the importance of
cleaning is a regular part of the working day
ahead of the influenza season, says Lisa Hamblet,
vice-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 flu 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 flu season. Part of
this education programme includes counseling
businesses to encourage sick employees to work
from home. “We recently did a survey and found
that 80% of employees are coming into the
workplace even when they have the flu,” 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 influenza 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 specific
influenza 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,


Strategies for seasonal influenza Spreading prevention across the workforce

Chart 7: Spreading the word

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

43%

Signs & posters around the workplace

34%

Company-wide emails/newsletters
Face-to-face training about prevention
(hand washing etc)

25%

E-learning/webinars about prevention

25%

Messages from senior management promoting
influenza reduction as a business priority

23%

Surveying employees to understand workplace
perceptions of influenza

16%

Monitoring guidance from WHO, CDC,
Google flu tracker etc

16%
15%

Bringing in external health experts to give talks
Appoint employees as volunteer "flu champions"

10%

We do not communicate with employees on
seasonal influenza

25%

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

Provide on-site seasonal influenza vaccinations
for employees
Increase focus on workplace hygiene during influenza
season (make hand gels/masks available, increase
frequency of disinfecting common areas)

39%
38%
34%

Send home employees with influenza-like symptoms
Reimburse employees for seasonal influenza
vaccinations obtained privately

32%

Encourage working from home/telecommuting
during influenza season

22%

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

17%

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

17%
16%

Make vaccinations available to employees' families
Offer vouchers, gifts or other incentives to encourage
employee participation in company's prevention efforts
We do not conduct activities focused on
seasonal influenza
Source: Economist Intelligence Unit survey, June 2013.

16

© The Economist Intelligence Unit Limited 2013

8%
16%


Strategies for seasonal influenza Spreading prevention across the workforce

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
influenza 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 arm

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

The vast majority of companies (84%) conduct
some form of prevention activity each influenza
season. This is significantly higher than the
even one-half of companies that have a formal
influenza policy, suggesting that for a sizeable
minority of respondents (34%) corporate efforts
to mitigate influenza 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
influenza activities to regional or local levels.
In the absence of an overall strategy for dealing
with seasonal influenza, companies risk a
patchwork approach that could undermine the
objective of making employees receptive to
corporate influenza 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 influenza among their
employees, closely followed by increased focus
on workplace hygiene, sending employees home
with influenza-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%)

17

© The Economist Intelligence Unit Limited 2013

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

Strategies for seasonal influenza Spreading prevention across the workforce

least likely to offer vaccinations to employees in
the first place. Walgreens offers free vaccinations
for all employees, regardless of health plan or
work status. As Tom Sondergeld, director of team
member health benefits and wellbeing, explains,
“Family members of those within the health
plan are also able to receive free flu 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 influenza, particularly on increased
CDC, National Early Season
Flu Vaccination Coverage,
United States, 2012-13 flu
season, www.cdc.gov/flu/
fluvaxview/nifs-estimatesnov2012.htm.

17

CDC, Health Care
Personnel Flu Vaccination,
Internet Panel Survey,
United States, November

2012, Recommendations,
www.cdc.gov/flu/
fluvaxview/hcp-ipsnov2012.htm.

18

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

19

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

20

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

21

18

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
influenza vaccinations during the 2011-12
flu 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 flu shot three years ago and didn’t have any
side effects,’” he adds.

Doctor’s note: saying one thing, doing another
When it comes to being vaccinated against
seasonal influenza, healthcare workers are not
always first 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 influenza 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

flu 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 findings 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 influenza vaccines for healthcare
workers.19
In both regions, very few hospitals have been
willing to make vaccines mandatory, given the
inherent difficulties 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
© The Economist Intelligence Unit Limited 2013

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


Strategies for seasonal influenza Spreading prevention across the workforce

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 significantly higher uptake of
50-70% taking it in Asia, compared with around
25% in Europe.
At Anglo American, influenza vaccines are
offered free on-site in all locations. The average

19

© The Economist Intelligence Unit Limited 2013

uptake in its offices 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 benefit is no longer visible.


Strategies for seasonal influenza Spreading prevention across the workforce

3

Fighting mistrust, misunderstanding

and misinformation

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

Chart 8: Knowing what is good for you
Top three factors most likely to raise the status of influenza
prevention as a business priority
(Top responses)

1 Updates to official recommendations
2 Perceived threat of pandemic influenza outbreak
3 Ability to measure business cost
Top three factors most likely to restrict the success of

corporate initiatives around seasonal influenza prevention
(Top responses)

1 Low employee receptiveness to influenza messaging
2 High cost of prevention measures
3 Lack of data on the business impact of influenza
Source: Economist Intelligence Unit survey, June 2013.

20

© The Economist Intelligence Unit Limited 2013

effects—to explain the relatively low take-up of
influenza 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 flu shots,” says Dr
Tautz of Deutsche Post DHL. “Everyone knows
about the effort but some people distrust the flu
campaign because of negative side-effects.”
There is, moreover, a perception that seasonal
influenza 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 influenza as
a uniformly minor ailment, they are less likely to
take precautionary measures seriously. Experts
also point to an artificial distinction between
pandemic and epidemic influenza, which has led

to a tendency of businesses to put more emphasis
on the former and give insufficient attention to
the latter. Thus employees are often less aware of
the potential for serious illness or death resulting
from the seasonal influenza variety.
Dr Quarry and Dr Van-Tam note that yearly
epidemic versions of the flu 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 flu viruses] don’t disappear
from human circulation after they have produced
a pandemic. They re-circulate as seasonal flu, 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


Strategies for seasonal influenza Spreading prevention across the workforce

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

Audience engagement

There is no real
difference in the

way seasonal flu
spreads to the
way pandemic
flu spreads; the
difference will be
the scale.

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

There is agreement among companies that more
and better quality scientific evidence is needed
to change minds. Part of the reluctance of many
employees to engage in company influenza
measures stems from confusion of the quality of
medical evidence over how influenza spreads and
presents itself. Moreover, the provision of better
information to help shape employee behavior
goes beyond vaccinations. Amy Costello, a senior
benefits analyst at Staples, an office 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 influenza. Passive forms of
messaging continue to be the most popular

form of communication, typified 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 influenza,
surveying employees to understand points of
view or appointing employee “flu champions”
to spread the message. Even fewer still offer
incentives for employees to take part in influenza
initiatives. “Employee engagement is crucial to
[the success of] flu clinics, and if employees don’t
feel getting a flu shot is beneficial 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

21

© The Economist Intelligence Unit Limited 2013

efforts via corporate intranets or host webinars
on the importance of proper hygiene and
maintaining personal space during flu 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 costeffectiveness
Across the US and western Europe there is
some variation in the perceived obstacles to
effective influenza prevention. Low employee
receptiveness to influenza 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 influenza prevention
initiatives).
In the case of the US and Germany, it is difficult
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 financial 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
influenza vaccines that are the most significant
cost. Several US companies also admit to relying
on large US pharmacy chains, such as Walgreens
and Rite-Aid, which offer flu 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
difficulties as their counterparts in the US.2
Interestingly, Germany reported higher incidence
of influenza than either the US or the UK for eight
months during 2012 (see Chart 2).


Strategies for seasonal influenza Spreading prevention across the workforce

Nonetheless, the high cost of prevention
measures is generally seen as the second-biggest
obstacle to mitigating the impact of influenza
prevention initiatives across the sample. At a time
of tight financial budgets, with many companies
reviewing the benefits that they are offering
employees, seasonal influenza investments
are likely to come under tighter scrutiny. There
are, moreover, a rising number of illnesses and
afflictions 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 influenza
(outside a pandemic threat).
Some companies, such as United Technologies,
have been adapting their influenza 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 threat

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

22

United Technologies has kept up its commitment
to influenza 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 reflects
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 influenza initiatives than those that say they
© The Economist Intelligence Unit Limited 2013

do (28%). “When many companies are looking to
stretch their dollars, it can be difficult to justify
on-site flu shots, considering it can be difficult 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 influenza is
patchy. Only 7% of companies are effective at
gathering and analyzing data to inform future
seasonal influenza initiatives. Nearly one-half
of companies (46%) believe that they gather
sufficient data about the impact of seasonal
influenza 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 five (22%)
companies admit to not gathering any data on
seasonal influenza at all. Even companies with
comprehensive influenza prevention programmes
and strategies in place, such as United
Technologies, do not collect data on seasonal
influenza. Having 200,000 employees makes this
a significant 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
definition and diagnosis of seasonal influenza,
together with the fact that most cases of
suspected influenza are not officially diagnosed.


Strategies for seasonal influenza Spreading prevention across the workforce

Chart 9: Return on influenza

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

Agree or disagree: My company does
not have the metrics to measure the
effectiveness of any particular
influenza initiative

(% respondents)

(% respondents)

Don't know

Don't know

1%

46%
Poor, very poor or

non-existent

1%

28%

53%

Disagree

Well or very well

47%
Agree

24%
Neutral

Source: Economist Intelligence Unit survey, June 2013.

As a result, many managers find it difficult to
assess the prevalence of flu 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 flu 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 influenza have not historically been significant
cost drivers for employers compared with other
conditions, such as diabetes and hypertension.

23

© The Economist Intelligence Unit Limited 2013

Whatever the reason for this deficit of data,
the overall group of respondents to our survey
deem it to be the third most significant barrier
hampering the success of their influenza
initiatives—and the highest for respondents in
the UK. The difficulty for companies to accurately
judge the full impact of seasonal flu 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 influenza would be a major way of
raising influenza as a business priority (just
behind official 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 influenza prevention measures.


Strategies for seasonal influenza Spreading prevention across the workforce

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

24

© The Economist Intelligence Unit Limited 2013

policy for dealing with influenza. The status
of influenza 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 significant
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 influenza as a business
priority, and increased involvement of
senior management in influenza 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.