ORIGINAL RESEARCH

Prehospital and Disaster Medicine Vol. 26, No. 2

Infectious Respiratory Disease Outbreaks and Pregnancy: Occupational Health and Safety Concerns of Canadian NursesKaren P. Phillips, PhD;1,2 Tracey L. O’Sullivan, PhD;1,3,4 Darcie Dow, MSc;5

Carol A. Amaratunga PhD2,5,6

1. Interdisciplinary School of Health

Sciences, Faculty of Health Sciences,

University of Ottawa, Canada

2. Institute of Population Health, University

of Ottawa, Canada

3. Élisabeth Bruyère Research Institute,

Ottawa, Canada, Canada

4. School of Nursing, Faculty of Health

Sciences, University of Ottawa, Canada

5. Justice Institute of British Columbia,

Vancouver, Canada

6. Department of Community Medicine

and Epidemiology, University of Ottawa,

Canada

Correspondence:

Karen Phillips, PhD,

43 Templeton Street, Room 215 Ottawa,

Ontario K1N 6N5

Canada

E-mail: Karen.Phillips@uottawa.ca

Keywords: infectious disease outbreaks;

inf luenza; nurses; occupational health;

pregnancy; severe acute respiratory syndrome

Abbreviations:

CDC = [US] Centers for Disease Control

and Prevention

IUGR = intrauterine growth restriction

PPE = personal protective equipment

SARS = severe acute respiratory syndrome

SIM = structure interview matrix

WHO = World Health Organization

Received: 17 December 2009

Accepted: 06 January 2010

Revised: 26 January 2010

Online publication: 5 May 2011

doi:10.1017/S1049023X11000100

AbstractIntroduction: This paper is a report of a qualitative study of emergency and critical care nurses’ perceptions of occupational response and preparedness during infectious respiratory disease outbreaks including severe acute respiratory syndrome (SARS) and influenza.Problem: Healthcare workers, predominantly female, face occupational and personal challenges in their roles as first responders/first receivers. Exposure to SARS or other respiratory pathogens during pregnancy represents additional occupational risk for health-care workers.Methods: Perceptions of occupational reproductive risk during response to infectious respiratory disease outbreaks were assessed qualitatively by five focus groups comprised of 100 Canadian nurses conducted between 2005 and 2006.Results: Occupational health and safety issues anticipated by Canadian nurses for future infectious respiratory disease outbreaks were grouped into four major themes: (1) appre-hension about occupational risks to pregnant nurses; (2) unknown pregnancy risks of anti-infective therapy/prophylaxis; (3) occupational risk communication for pregnant nurses; and (4) human resource strategies required for pregnant nurses during outbreaks. The reproductive risk perceptions voiced by Canadian nurses generally were consistent with reported case reports of pregnant women infected with SARS or emerging influenza strains. Nurses’ fears of fertility risks posed by exposure to infectious agents or anti-infec-tive therapy and prophylaxis are not well supported by the literature, with the former not biologically plausible and the latter lacking sufficient data.Conclusions: Reproductive risk assessments should be performed for each infectious respiratory disease outbreak to provide female healthcare workers and in particular pregnant women with guidelines regarding infection control and use of anti-infective therapy and prophylaxis.

Phillips KP, O’Sullivan TL, Dow D, Amaratunga CA: Infectious respiratory disease outbreaks and pregnancy: Occupational health and safety concerns of Canadian nurses. Prehosp Disaster Med 2011;26(2):114–121.

IntroductionEmergence of severe acute respiratory syndrome (SARS) (2002–2003) created the impetus for enhanced global and regional pandemic influenza planning.1 Severe acute respiratory syndrome infected more than 8,000 people in more than 29 countries, with more than 800 deaths, predominantly in China, Canada, Singapore, Hong Kong, and Taiwan.2 The SARS outbreaks were followed closely by outbreaks of an extremely viru-lent influenza virus (A/H5N1), which re-emerged in the Hong Kong population in 2003 after crossing the avian-human species barrier for the first time in 1997.3 Laboratory confirmed cases (445) of H5N1 influenza have been reported in 15 countries with 263 deaths as of 11 December 2009.4 Countries with significant numbers of cases include Indonesia, Vietnam, Egypt, and China.4 In April 2009, a new global response was initi-ated in response to numerous cases of influenza A/H1N1 emerging from Mexico,5 with an influenza pandemic declared on 11 June 2009 by the World Health Organization (WHO).6 As of 06 December 2009, the WHO Regional Offices reported approxi-mately 9,596 deaths in more than 208 countries/territories.7 Each infectious respira-tory disease outbreak has fostered increased global awareness of the need for pandemic

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April 2011 Prehospital and Disaster Medicine

as generally well suited for studies of work culture, cross-cultural populations, and both shared and common knowledge.29

ParticipantsAs part of a larger study designed to examine perceptions of emergency preparedness among Canadian nurses following the SARS outbreak, a purposeful sample of Canadian nurses was recruited to participate in focus groups to discuss their occu-pational experiences and perceptions of infectious disease out-breaks. Recruitment was facilitated by the Canadian Federation of Nurses Unions, Registered Nursing Association of Ontario, College of Registered Nurses of Nova Scotia, British Columbia Registered Nurses Association, local newspapers, and e-mail listservs using a brief summary of the project objectives and details of their participation. Respondents were reimbursed $50 for participation time in focus groups.

Data CollectionFocus groups were conducted using the SIM format28 with two rounds of research questions, beginning with one-on-one inter-views, small group synthesis discussions, and larger plenary group discussions. A pilot SIM focus group initially was held with 10 participants, at which time it became apparent that a minimum number of 16 participants optimized functional group dynamics and ease of facilitation. Five SIM focus groups, including the pilot, ultimately were conducted between November 2005 and February 2006 in major cities in eastern Ontario (n = 10, n = 25), southwestern Ontario (n = 15), British Columbia (n = 27), and Nova Scotia (n = 23) for a total of 100 participants.

A series of eight questions was posed to each focus group by a designated facilitator and included participants’ perceptions of infectious disease outbreaks with emphasis on psychologi-cal impacts, bioterrorism, recommendations for organizational supports, stigma, willingness to work, gendered work-life chal-lenges, and quarantine. Field notes were comprised of notes taken by participants (one-on-one discussions, group synthesis f lip chart) and notes taken by the research team who were stra-tegically placed within each small group (group discussion and synthesis, larger plenary group discussion). The facilitator’s role was limited to leading the discussion and did not involve field note taking.

Ethical ConsiderationsThis study was approved by a university institutional ethics review board. All participants signed informed consent forms. A description of the purpose of the study, source of funding and research team was made available to the participants at the time of recruitment, reiterated verbally at the onset of each focus group and in writing as part of the consent forms. Participants were made aware that they were free to withdraw from the study at any time without personal consequence and that their partici-pation would remain confidential.

Data AnalysisThe data (field notes) were analyzed using thematic content anal-ysis, supported by NVIVO-TM software. Field notes from each focus group were coded within the context of instrumental, infor-mational and emotional supports for nurses.27 Emergent themes were established by consensus of three associates on the research team. The data from five focus groups reached saturation, both across and within geographical regions.30–32 Dependability33

influenza preparedness planning, particularly to establish occu-pational health and safety guidelines for the response commu-nity that includes healthcare workers. In Canada, healthcare workers represented over 40% of SARS infections, including three deaths,1 thereby emphasizing the need to consider poten-tial health impacts for response groups.8 As most healthcare workers are female,9 gender-specific susceptibility to infectious agents may include negative pregnancy outcomes.10

Historically, pregnant women were among the most susceptible to virulent infectious respiratory diseases.11 During the 1918–19 Spanish influenza (H1N1) pandemic,12 and again during the 1957–58 Asian influenza A /H2N2 pandemic,13,14 maternal mor-tality rates ranged from 30–50%. Indeed, following the 1968–69 pandemic, (“Hong Kong flu” A/H3N2)15 an interdepartmental conference convened at the University of California, Los Angeles in 1970 noted that pregnant women were more likely to contract influenza, experience spontaneous abortion and stillbirth, with increased risk of death following development of pneumonia.16 A total of 1,988 Swine Influenza cases in Wisconsin produced a single fatality, notably an infected pregnant woman and also resulted in the infection of attendant healthcare workers.17

More recently, there are several published reports of pregnant women infected with SARS that describe maternal and imme-diate pregnancy outcomes (Table 1).18–24 Perinatal and maternal outcomes are more likely to include severe maternal morbidity and mortality and preterm delivery when women are infected in late pregnancy (2nd/3rd trimester). Women infected with SARS in the first trimester tended to survive, however sponta-neous abortion was common.18,19 Reports of H5N1-infection in pregnant women describe the clinical courses of laboratory con-firmed H5N1 infection during 2nd/3rd trimester for two women who ultimately died (Table 2). These case studies represent valu-able data to better understand the clinical course of these infec-tious respiratory diseases in pregnant women and strategies for case management.

It is well established that healthcare workers involved in col-lection of blood, sputum, and respiratory medical interventions are at risk from airborne transmission of infectious respiratory agents.25 Beyond the biomedical risks, infectious disease out-breaks often are accompanied by psychological stress, including fear, anxiety, and dread, particularly if the outbreak is perceived as not under personal control, or associated with adverse, irre-versible outcomes.26 Organizational social supports previously have been proposed as mechanisms to buffer the stress of emer-gency response by providing clear and consistent guidelines, training and resources that address the emotional, informa-tional, and instrumental needs of workers.8,27

In the context of Canada’s experience with SARS and the emergence of influenza A/H5N1 (“avian influenza”), the aim of this study was to describe emergency and critical care nurses’ perceptions of occupational reproductive-related risks during infectious respiratory disease outbreaks.

MethodsDesignThis qualitative study was designed to increase awareness of the occupational needs of Canadian healthcare workers in the post-SARS era of infectious disease outbreaks. Focus groups, using a structured interview matrix (SIM) format28 were conducted to allow nurses to express their needs, experiences and recommen-dations. The use of focus groups for data collection is recognized

116 Infectious Respiratory Disease Outbreaks and Pregnancy

Prehospital and Disaster Medicine Vol. 26, No. 2

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Phillips, O’Sullivan, Dow, et al 117

April 2011 Prehospital and Disaster Medicine

was ensured by the consistent use of common research questions, trained facilitators who adapted the SIM focus group design and the participation of a conserved team of researchers in both data collection and analysis. Credibility was achieved through the design of focus groups, which required participants to document peer-interviews and group synthesis discussions.30,34

ResultsParticipant CharacteristicsFive focus groups held in Canada were comprised of 100 nurses representing a range of specialties (emergency and critical care, management, infection control) and unions, work clas-sifications (full-time, part-time, and casual) and years of work experience. “Nurses” were predominantly female (94 women), with six male participants.

Perceptions of Reproductive Risks by Canadian NursesFour major reproductive themes emerged as specific and unique occupational health and safety concerns for nurses.

Theme 1: Apprehension About Occupational Risks to Pregnant NursesThe first theme relates to the nurses’ perception of the occu-pational risks faced by pregnant workers responding to infec-tious disease outbreaks. Nurses were greatly concerned about the risk posed to pregnant workers and the unborn child. This was ref lected by a nurse from Nova Scotia who related that if a nurse was “… newly pregnant, how will she feel about exposing herself and the fetus?” A British Columbia nurse simply stated that if she was pregnant “… I’m not going to put myself and my baby at risk”. These comments made by health professionals well aware of the potential for vertical transmission of viruses do illustrate an important consideration for pregnant healthcare workers and occupational responsibilities. A Nova Scotia nurse considered this a conflict between personal risk and child pro-tection. She ref lected on how she would feel if she was pregnant and her duty was to respond during an outbreak. “If I’m preg-nant do I assume the risk? Is this analogous to not going to work to protect a child?” Concerns expressed by nurses were not lim-ited to biological risks, but also included the stress and anxiety anticipated to accompany an infectious disease outbreak. As dis-cussed, Canada’s healthcare community was directly impacted by the 2003 SARS outbreaks. A British Columbia nurse noted that “women who are pregnant have more anxieties, and valid health risks to a fetus”. Anxieties also were anticipated by a nurse from the focus group in Ontario, “Pregnancy brings fear for an unborn child, and guilt of harm to a baby”. Thus, psychological stress and its impacts on pregnancy in association with SARS

Citation Region Study Design Sample Interventions Trimester Outcome

*Shu et al. N Engl J Med 2006;54(13):1421–1422. China Case-report †1 pregnant ICU 2nd maternal death

*Taylor et al. PLoS ONE 2008;3(10):e3410. Vietnam Case-report ¥1 pregnant ICU, mech vent 3nd maternal death

Phillips © 2011 Prehospital and Disaster Medicine

Table 2—Infl uenza A/H5N1-infections during pregnancy

*Polymerase chain reaction (PCR) and/or A/H5N1 antibody confirmed; ¥oseltamivir, †broad spectrum antibiotics. (ICU = intensive care unit; mech. vent = mechanical ventilation

infection or infection with other viral agent were identified as important occupational concerns by Canadian nurses. Several nurses expressed concerns that fertility would be impacted with both the acute loss of a pregnancy and unknown long-term effects, as expressed by a nurse from Ontario who noted that workers “exposure to infections while pregnant means nurses are faced with the possibility of not being able to have children”. There currently is no evidence to suggest that infection with these viruses is related to long-term fertility in men or women.

Theme 2: Unknown Pregnancy Risks of Anti-Infective Therapy and ProphylaxisThe second emergent theme identified by focus group partici-pants related to perceived reproductive risks associated with anti-infective therapy/prophylaxis. The nurses ref lected with concern on emergency planning policies, which recommended that antiviral medications would be prioritized for nurses and other front line responders, in particular were concerned about the unknown reproductive risks to men and women associated with such medications. An Ontario nurse remarked that “female workers, who are pregnant or trying to conceive a child, may not want to take the prophylactic medication. Men may become sterile as a result of this.” It is important to note that there is no evidence to support an association between male or female infer-tility, acute or long-term, following use of currently available anti-infective therapies. The concerns about fertility expressed by the nurses in this sample seem to ref lect a misconception about the risks posed by these drugs and an important subject for future risk communication/education. Women who are pregnant or breastfeeding would be at risk as “prophylaxis, meds/vaccines would have constant effect” exclaimed a British Columbia nurse, suggesting that not only in utero exposure to anti-infective ther-apies was risky, but also exposure of neonates via drug metabo-lites expressed in breast milk. Nurses’ lack of knowledge of the safety of anti-infective therapies for breastfeeding represents an important topic for future research initiatives and occupational risk education.

Theme 3: Occupational Risk Communication for Pregnant NursesThe third emergent theme pertained to the need for occupational safety information related to pregnancy. Focus group participants recognized that the field of health care has a high proportion of female employees, and therefore, the pregnancy risks must be considered. Nurses from all four cities expressed the need for more information. An Ontarian nurse identified that not only pregnant nurses, but also women who were actively trying to conceive or “potentially pregnant nurses also have concerns” that

118 Infectious Respiratory Disease Outbreaks and Pregnancy

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would benefit from opportunities to receive health risk informa-tion specific to pregnancy and occupational exposures. The need to provide health risk information to workers in healthcare set-tings was essential due to the “large numbers of females … and unknown effects on pregnancy”, as expressed by a nurse from Nova Scotia. As discussed, participants perceived that respira-tory infections and anti-infective therapies were somehow asso-ciated with male and female infertility, an association that is not supported by the literature.

Theme 4: Human Resource Strategies Required for Pregnant Nurses during OutbreaksThe final theme related to the perception by focus group partici-pants that pregnant nurses needed to redeployed during infec-tious disease outbreaks. Recognizing the occupational health risks faced by pregnant nurses, an Ontario nurse argued that “You wouldn’t assign the pregnant or potentially pregnant nurses to patients with a communicable disease”. This perception was echoed by most participants who believed that redeployment of pregnant workers during the outbreak was reasonable and should be required as a precautionary measure. Reassignment of preg-nant workers is not necessarily mandated across different juris-dictions and healthcare settings. An Ontario nurse emphasized that “staff, particularly those who are pregnant… there should be a process that they are aware of where they can be transferred or reassigned so they feel safe” This issue of reassignment is complicated, dependent on union, human resource and regula-tory agency policies and recommendations. The perception that nurses need to“feel safe” seems to ref lect the psychological stress and anxiety that is anticipated in the event of a widespread infec-tious disease outbreak. An Ontarian nurse also perceived that pregnant workers would be unduly stressed physically and emo-tionally by “long work hours, the added stress of wearing PPE (personal protective equipment) and psychosocial issues”, which of course would be faced by all health care workers. Emotional and physical stress can contribute negatively to pregnancy out-comes, and it does seem likely that workers throughout their pregnancy would require routine adjustments to PPE fit testing and refinements to occupational ergonomics.

DiscussionCanadian nurses anticipate significant reproductive risks associ-ated with occupational healthcare response to infectious disease outbreaks in this qualitative study. Although these perceptions have been informed to some extent by nurses’ training, experience and education in emergency response and infection control, there are limitations of this study that must be considered. The partici-pant sample included nurses from a range of healthcare positions, including management, union and emergency-critical care that were not disaggregated for this study. Unfortunately perceptions of reproductive risks voiced by these nurses were not related to specific occupational scope of practice or their personal and occu-pational experiences with SARS or other infectious disease out-breaks in Canada. The personal experiences of nurses also were not documented and it may be possible that family members or close friends of some of the participants were impacted by SARS or other infectious disease outbreaks. Further, the individual per-sonal reproductive histories of the participants were not obtained, which also may have influenced perceptions of risk, particularly related to fertility. The recruitment strategy employed necessar-ily targeted actively working nurses who identified themselves as

members of this profession. Thus, individuals who had changed professions, outside the healthcare field, because of SARS or other unrelated reasons are not represented in this data. Finally, focus groups inherently are limited by the tendency for group perceptions and norms to overshadow or silence individual voic-es.29 The SIM design28 used here did enable individual inter-views that may have mitigated this limitation somewhat, but this is still an important consideration.

The study is applicable to other healthcare settings outside of Canada and healthcare workers in general; however, the empha-sis and concern regarding risks to pregnancy and fetus during an infectious disease outbreak may ref lect the high participa-tion of women in this sample. Finally, in the intervening time between the SARS outbreak in Canada (2003) and the study period (November 2005 and February 2006), the issue of SARS was discussed nationally through a public inquiry,1 media cov-erage of the negative experiences faced by nurses in particular, and culminating with the creation of the Public Health Agency of Canada. Therefore, The timeframe of this study limits the participants’ risk perceptions within the context of SARS and “avian influenza” H5N1, a new virus and topical subject dur-ing the time of the interviews. Participants were well aware of the gaps in Canada’s SARS response and shared a professional outrage because of their colleagues’ susceptibility and ultimately high morbidity/mortality during Canada’s experience with SARS,1 which could have influenced the perceptions of per-sonal risk, fear, anxiety, and vulnerability.35

Understanding Reproductive Risks Posed by Infectious Respiratory DiseasesIt has been reported previously that nurses require a range of sup-ports during infectious disease outbreaks, including informational supports (accurate, appropriate and timely communication), emo-tional supports (addressing distress) and instrumental supports (such as PPE and vaccines).8,10,28,35 This analysis of nurses’ per-ceptions of reproductive risks posed by occupational exposures to infectious respiratory agents identified two important areas that could be effectively addressed by occupational supports: (1) emo-tional supports to address fears and anxieties related to pregnancy and (2) informational supports to provide specific information regarding pregnancy risks following exposure to specific infec-tious agents and exposure to anti-infective therapies.

The unknown pregnancy risks of exposure to SARS or other infectious agents were critical concerns for Canadian nurses who anticipated that significant guilt, anxiety and fear would accom-pany exposure to an infectious agent during pregnancy. This is consistent with the anticipatory concerns expressed by pregnant women during the Hong Kong SARS outbreak including risk of contracting SARS, transmission to fetus, and risk of terato-genicity with drug treatment.36 Perinatal stress and anxiety are associated with intrauterine growth restriction (IUGR), preterm labor and shorter gestation.37 The trauma induced in pregnant women who were near the World Trade Center dur-ing the terrorist attacks on 11 September 2001 was associated with decreased infant head circumference, birth weight, birth length, gestational duration and increased risk of IUGR.38,39 Healthcare organizations should provide emotional support options for pregnant healthcare workers to help buffer anticipa-tory concerns, fears, and anxiety.

Canadian nurses also perceived a significant risk for preg-nancy upon exposure to SARS or other infectious disease

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agents. These pregnancy risk perceptions are supported by the published case studies of SARS and H5N1 (Tables 1 and 2). Whereas the mother’s health is certainly at risk from these infec-tions and pregnancy viability may indeed be compromised, live-born infants may not necessarily experience infection or disease complications, demonstrated by several case reports.20,23,24,40,41 In cases of SARS infections, anti-SARS antibodies have been detected in maternal blood, umbilical blood, and amniotic f luid from a pregnant SARS patient, suggesting that the fetus may be protected by the immune response.42

Nurses also were concerned about the potential reproduc-tive risks posed by anti-infective therapies and prophylaxis dur-ing an infectious disease outbreak. Two standard protocols for patients infected with SARS emerged during the outbreak: first, with patients who were treated in Hong Kong with antibiotics, corticosteroids, and ribavirin and second, with patients treated in Toronto with broad-spectrum antibiotics and intravenous ribavirin.23,43 Ribavirin is a broad spectrum nucleoside analogue used against ribonucleic acid viruses and coronaviruses,43,44 and also is an established reproductive toxicant, demonstrated in ani-mal studies.45–47 Its use as an antiviral agent has prompted the creation of the Ribavirin Pregnancy Registry in the US, which has reported more than 70 pregnancy outcomes since January 2004.48 This cross-sectional study of 12 pregnant women reported that patients were informed of the embryocidal risks of ribavirin and speculated that treatment with ribavirin (11/12 patients) may be related to spontaneous abortions observed in their sample.19 Indeed, it is recommended for patients treated with ribavirin in early pregnancy be given the option for termination of pregnancy because of the potential for reproductive toxicity.19 Subsequent to the SARS outbreak, it has been recommended that ribavirin be introduced only after clinical efficacy has been demonstrated,

Citation Region Sample Interventions Outcome

*CDC. MMWR Dispatch 2009;28:1–3.

US 3 pregnant women‡

3rd trimester: ICU, mech. vent¥†

2nd/3rd trimester: 2 hospitalized¥, released

ARDS, maternal death, C-section, livebirth

Pregnancy ongoing

*Jamieson. Lancet 2009;374(9688):451–458.

US

34 pregnant women‡

3- 1st trimester, 28- 2nd/3rd trimester 3- unknown

17 antiviral therapy¥,11 hospitalized >24h, 3

ICU

1 spontaneous abortion (1st trimester)2 deliveries during hospitalization for

influenza, febrile intrapartum6 cases pneumonia1 preterm delivery, healthy twins

(3rd trimester)1 maternal death (3rd trimester),

Described in:*Jamieson. Lancet 2009;374(9688):451–458.

US

6 deaths reported to CDC of pregnant women April 15–June 16, 2009‡

1st trimester: mech vent¥

2nd/3rd trimester: 5 mech. vent¥

ARDS, maternal death, fetal lossARDS,5 maternal deaths, 5 livebirths,

C-section

Phillips © 2011 Prehospital and Disaster Medicine

Table 3—Infl uenza A/H1N1-infections during pregnancy

*confirmed cases: real-time reverse-transcriptase PCR/viral culture; probable case: acute febrile respiratory illness/positive for inf luenza A, but negative for H1 and H3; ‡Cases described in CDC, 2009. MMWR Dispatch 58:1–3 are included in the 34 cases described in Jamieson, 2009. Lancet 2009; 374(9688):451–458. The single mortality (CDC, 2009. MMWR Dispatch 58:1–3) is also included in the 6 deaths reported to the CDC April 15–June 16, 2009. ¥oseltamivir, †broad spectrum antibiotics. (ICU = intensive care unit; mech. vent = mechanical ventilation

particularly due to its reproductive toxicity and lack of in vitro antiviral effects on SARS-CoV.49,50 Oseltamivir is a neuramini-dase inhibitor recommended for use against H5N1,51 and more recently it has been recommended together with zanamivir for cases of H1N1 influenza.52 Although animal studies and human case reports do not suggest significant reproductive toxicity for these antivirals,51,53 the US Centers for Disease Control CDC has included a discussion of the gaps in knowledge in its interim guidelines for H1N1 treatment.52 Both oseltamivir and zana-mivir are classified by the US Food and Drug Administration (FDA) as “Pregnancy Category C” agents as there have been no clinical studies to assess safety during pregnancy.54

Canadian nurses also expressed concerns regarding the risks of both infectious disease exposure and anti-infective therapies on fertility for both men and women. No association between exposure to infectious respiratory agents (e.g. SARS, influenza) and infertility has been reported. It appears that this is a mis-perception held by nurses in this sample that could be addressed through information supports. Similarly, no evidence exists to link exposure to anti-infective therapies and prophylaxis to infertility. Indeed, the Practice Committee of the American Society for Reproductive Medicine (2008) recommends only that influenza and other vaccines be administered prior to con-ception if possible. Finally, nurses’ perceptions that breastfeed-ing may be dangerous during infection or upon exposure to anti-infective therapies are also not well supported. Only one study has assessed the safety of oseltamivir during breastfeeding and reports no clinically significant levels of drug metabolites transmitted to the nursing infant.55 Based on the Wentges-van Holthe study and pharmacokinetics data, the Canadian Medical Association Journal reported that oseltamivir and zanamivir are compatible with breastfeeding.54

120 Infectious Respiratory Disease Outbreaks and Pregnancy

Prehospital and Disaster Medicine Vol. 26, No. 2

7. World Health Organization: Pandemic H1N1 2009 Update 78. Available at http://

www.who.int/csr/don/2009_12_11a/en/index.html. Accessed 16 December 2009.

8. Amaratunga CA, O’Sullivan TL, Phillips KP, et al: Ready, aye ready? Support

mechanisms for health care workers in emergency planning: A critical gap analysis

of three hospital emergency plans. Am J Disaster Med. 2004,2(4):195–210.

9. Shields M, Wilkins K: Findings from the 2005 National Survey of the

Work and Health of Nurses: Statistics Canada Catalogue No.83-003-XPE.

Ottawa: Minister of Industry; Canadian Institute for Health Information;

Health Canada. Available at http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_

page=AR_1588_E&cw_topic=1588. Accessed 16 December 2009.

10. Amaratunga CA, Phillips KP, O’Sullivan TL, et al: Chapter 7: The need for healthcare

worker sex and gender-sensitive supports during infectious disease outbreaks, In:

Tyshenko MG, Paterson C. (eds), SARS Unmasked: Risk Communication of Pandemics

and Influenza in Canada. Montreal, CA: McGill-Queen’s University Press, 2010.

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on Immunization Practices (ACIP). MMWR 2006;55(RR-10):1–42.

12. Harris JW: Inf luenza occurring in pregnant women. JAMA 1919;72:978–983.

Notable changes in risk communication and the identifica-tion of pregnant women as a vulnerable group are evident since the emergence of H1N1 influenza. The WHO, CDC, and the Public Health Agency of Canada (PHAC), among other organizations, recognized that pregnant women infected with H1N1 are at increased risk for complications, with detailed Web pages and directives specifically discussing the treatment, pri-ority vaccination and management of H1N1 infections during pregnancy.52,56,57 Further, the CDC recommends that mothers continue to breastfeed even if they suspect they are infected with H1N1, due to the beneficial immune protection conferred.58 However, it is unknown if this information was received by pregnant women and the extent to which the information alle-viated anxiety and stress. Case histories for 34 confirmed or probable cases of H1N1 infections in pregnant US women59–61 were published at the time of this article (Table 3), with a more comprehensive clinical portrait of H1N1 infection in pregnant women undoubtedly to emerge as more cases are published.

Human Resource Issues Related to Pregnant Healthcare WorkersThe global SARS outbreak in 2003 revealed the occupational risks posed to healthcare workers.2 Nurses in this study made strong arguments for the redeployment of pregnant workers during infectious disease outbreaks. The issue of work reas-signment for pregnant workers is a complex occupational issue with implications for unions, hospitals, and regulatory and national health agencies, and is beyond the scope of this paper. However, it is important to note nurses’ perceptions that human resource supports for pregnant healthcare workers may not be available on demand and that different policies are in place across healthcare institutions and unions. The WHO published a position paper on the ethics of pandemic inf lu-enza health care response which contains recommendations for establishing the scope of healthcare workers’ obligations and to also consider workers fragile health status, including preg-nancy, in their work assignments.62

Another important human resource issue is the tracking of occupational exposures versus community exposures. Nurses in this study focused almost exclusively on occupationally derived exposures. However it also is possible that healthcare workers may be infected through personal and community contacts. This distinction is important from an occupational perspective and sound public health contact tracing principles. During the SARS outbreak, both Canadian and US healthcare facilities put in place a series of strategies to track occupational

exposures and limit the spread of infections among staff and patients which included controlled entry and access to health-care facilities, daily contact records with patients, assignment logs and patient/healthcare worker surveillance.63 As with any occupational exposure, the responsibility is for the worker to report occupational exposures and injuries to appropriate bod-ies, including institutional occupational health departments. Occupational health and infection control should design educa-tional interventions related to pregnancy and infectious disease response for workers who have part-time or casual employment contracts and may not have routine access to occupational health services. No information is currently available on the total pro-portion of health care workers infected with H5N1 or H1N1 globally, as a result of occupational exposure however three of the 34 pregnant women infected with H1N1 reported to the CDC were health care workers.60 Health professionals were not overrepresented among H1N1-infections in the US,64 possibly due to vaccine prioritization.

ConclusionsInfectious respiratory disease during pregnancy is potentially life-threatening, representing complicated management issues for mother and fetus. Therefore, pregnant healthcare work-ers should be advised regarding the potential risks posed by infectious disease outbreak response. Occupational directives should detail reproductive consequences upon exposure to spe-cific infectious agents and anti-infective therapies along with the efficacy of anti-infective prophylaxis. Importantly, gaps in knowledge or information should also be provided to healthcare workers, such as the “Pregnancy Category C” classification of most anti-infective therapies. It is imperative that reproductive risks be assessed, documented, and communicated to healthcare workers, as lack of knowledge and misinformation may be barri-ers to effective infectious disease outbreak response.

AcknowledgementsFunding support for this project was provided by Defense Research and Development Canada, through the Canadian Chemical, Biological Radiological Nuclear and Explosive Research and Technology Initiative (CRTI; CA Amaratunga Principal Investigator). The authors acknowledge the contri-butions of the Institute of Population Health Caring About Health Care Workers project research team, particularly Louise Lemyre, Wayne Corneil, Eileen O’Connor and Daniel Krewski who are co-investigators on the project.

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