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The Public Health Impacts of AB 2716


  • Introduction

    Periodic illness is an ordinary occurrence that affects all workers and families. Casual contact with colleagues, family members, classmates and strangers leads to the spread of infections such as seasonal influenza, the common cold and gastroenteritis. In fact, healthy adults average about two to four colds a year, while children experience six to ten per year.[1]

    When illness strikes, most salaried, professional workers enjoy paid sick leave and the peace of mind that it affords; they are able to stay home to rest and recuperate or take care of an ill family member without fear of losing their jobs or foregoing needed wages. However, a significant number of California workers don’t enjoy this benefit. Forty percent of all workers and 76% of low-wage workers have jobs that don’t provide any paid sick days.[3]

    In February, Assemblywoman Fiona Ma (D-San Francisco) introduced AB 2716, a bill that would address this gap by extending paid sick leave to all workers. The legislation would allow employees to accumulate one hour of paid sick leave for every 30 hours worked, up to a maximum of nine days per year.

    AB 2716 would have clear benefits for individual workers but, importantly, it would also have public health benefits that extend beyond the household and workplace. Specifically, such a policy could reduce the transmission of food borne illness, decrease disease outbreaks in nursing homes, reduce the spread of infections in childcare settings and mitigate the transmission of seasonal influenza. There is also some evidence that paid sick leave influences workers’ decisions to see a doctor, parents’ decisions to stay home and care for a sick child and patients’ decisions about treatment choices. Finally, AB 2716 has the potential to improve patient compliance with preventive health-care guidelines and chronic care management, and thus to reduce health-care spending over the long term.

    Below is a review of the literature on the public health impacts of paid sick leave. To date, research in this area has been somewhat limited. Generally speaking, the literature focuses on a few key industries and illnesses. These include the commercial food, health-services and child-care industries, and common illnesses such as gastrointestinal and respiratory infections.

    Norovirus Outbreaks On The Rise

    Between 2005 and 2006, California experienced a 445% increase in norovirus outbreaks.[2] Many of the 256 outbreaks that occurred during this period were associated with food service establishments and long-term care facilities. In such settings, one sick worker can potentially infect hundreds of customers or clients. In 2005, a Blimpie sandwich shop worker with norovirus illness sickened over 100 customers who consumed contaminated sub-marine sandwiches.[4] Similarly, in 2006, several Carrabba’s restaurant workers came to work with norovirus illness and infected over 500 customers in Lansing, Michigan. Neither establishment provided paid sick leave benefits to employees.[5, 6]

    Food borne illness outbreaks linked to ill food workers result in substantial financial losses to firms, their customers and the public. The Blimpie outbreak led to the partial closure of one client’s business, employee absences, additional pay for substitute workers, and loss of wages and revenue to the restaurant during a week-long closure.[4]

    Foodborne Illness

    More than half of all U.S. foodborne disease outbreaks reported to the Centers for Disease Control and Prevention (CDC) occur in restaurant settings.[7] Restaurant food is often handled by multiple persons, contains ingredients that come from various sources and is prepared with varying degrees of adherence to recommended guidelines. These factors contribute to the elevated risk of illness associated with eating in commercial establishments.

    One pathogen has emerged as a common culprit in restaurant-based illness outbreaks: norovirus. This agent, which causes vomiting and diarrhea, is responsible for 50% of all foodborne illnesses in the United States.[8] While 48% to 93% of all foodborne norovirus outbreaks may be linked to ill food-service workers [8, 9], only 15% of workers in restaurants and food-processing plants have paid sick days.[3]

    A key strategy in preventing norovirus outbreaks in food service establishments is encouraging sick employees to stay home from work. According to the CDC, “relatively simple measures, such as correct handling of cold foods, strict hand washing after using the bathroom and before handling food items and paid sick leave, may substantially reduce foodborne transmission of noroviruses.”[10]

    Many health departments now require food workers with certain illnesses–including gastroenteritis–to stay home.[11] The FDA made a similar recommendation in its 2005 Food Code which advises food workers with symptoms of illness to exclude themselves from work, whereas the California Retail Food Code (July 2007) puts the onus on the local health officer to exclude a symptomatic and infectious food employee from working. However, because lower-wage employees are less likely to have paid sick leave than other workers, complying with such recommendations may require significant financial sacrifice on the part of food service workers.[7, 12-14]

    Child Care

    Child day-care centers, like schools, are hotspots for the spread of infection, primarily because young children when grouped together tend to have many social contacts and an increased exposure to infectious agents. Indeed, class size is a key risk factor for infections among day-care attendees.[15]

    Sick leave may play a role in preventing child-care center illness outbreaks. In a randomized control trial, child day-care centers that undertook an infection prevention program, which included encouraging sick staff to stay home, experienced fewer illnesses than day-care centers that did not participate in the program.[16]

    When young children get sick, parents often make the choice to stay home from work to care for their children even when it requires financial sacrifice. Forty percent of parental absenteeism from work is taken to care for an ill child.[15] However, parents are much more likely to make this choice if they have paid sick day benefits– those with paid sick days are 5.2 times more likely to care for their sick children than those without the benefit.[12]

    Extending paid sick leave to all workers would allow all parents to tend to their children without losing wages. Some evidence suggests that this is a wise investment. One study found that sick children recuperate faster when cared for by their parents, [17] thus accelerating children’s and parents’ return to school and work. Moreover, when sick children are able to stay home from school or daycare they are less likely to expose their classmates to their illness and therefore prevent other children and families from falling ill.

    Caregiving

    Women provide over 72% of all informal caregiving for aging parents and other relatives.[18] Studies have consistently shown that as the level of caregiving burden increases, women’s health deteriorates.[19] For working women, the demands of work, family life and caregiving may be especially overwhelming.

    The more time a woman spends caring for others, the less likely she is to engage in prevention behaviors that would protect her own health such as exercising, getting appropriate rest and taking prescribed medications.[20] More than half (54%) of women caregivers have one or more chronic health conditions, compared with two-fifths (41%) of other women.[21] Moreover, half of all caregivers exhibit high depressive symptoms, while 38 percent of other women do so.[21]

    Under AB 2716, workers may use accrued sick time to care for a spouse, child, family member or other designated person. As such, it may help alleviate the periodic time and financial burden currently borne by caregivers when a loved one requires increased assistance. Ultimately, the respite that paid sick leave provides may lead to improved caregiver health and wellbeing.

    Nursing Homes

    Patients in nursing home settings tend to be frail and in poor health–in fact, one third of residents die within one year of admission.[22]

    Transmissible illnesses are of particular concern in such settings because chronically ill patients have difficulty fending off infections, even common ones such as influenza. Recently, sporadic norovirus illness has become a problem for long-term care facilities–according to the CDC, 23% of all norovirus outbreaks occur in nursing homes.[10]

    In California, at least 100 norovirus outbreaks occur in nursing homes each year.[23] The vast majority of patients with norovirus infections will recover within a few days, but an estimated 10% will experience more serious symptoms and eventually require hospitalization.[24] In addition, approximately 2% of those afflicted will die.[24]

    In spite of the high incidence of norovirus infection among nursing home residents, a significant proportion (27%) of nursing home workers do not have paid sick leave benefits.[25] As a result, workers may come to work ill, thus putting patients and coworkers at risk of contracting an illness.

    Research has shown that the risk of gastrointestinal and respiratory outbreaks in nursing home settings can be mitigated if employees have access to paid sick leave. Specifically, one study found that nursing homes with paid employee sick-leave policies had a significantly lower risk of experiencing a gastrointestinal or respiratory disease outbreak as those that did not.[13] Such research suggests that workers with sick leave are more likely to stay home when ill, thus preventing the spread of illness to patients.

    Access To Needed Or Wanted Health Care

    Research has shown that taking time off to rest and recuperate can speed recovery from illness.[26] However, the decision to stay home is often complicated by economic imperatives. Health coverage being equal, ill workers without paid sick days pay more for a doctor’s visit than those with paid sick leave. Workers without access to the benefit must take into account the price of lost wages in their decision to seek medical care. Consequently, the high price of seeing a doctor may serve as an obstacle to seeking needed and wanted health-care services.

    However, a 2002 study of Medical Expenditure Panel Survey data cast doubt on this hypothesis. It found that the availability of paid sick time had no effect on single mothers’ self-reported access to health-care services.[27] The study did not distinguish between acute care and chronic or preventive care, however, and utilization of recommended preventive care may be particularly sensitive to financial barriers. Compared with more immediate needs, preventive care may seem non-essential and unworthy of a sacrifice in earnings. Employers may also see a disincentive to provide paid time off for such visits–the firm is unlikely to accrue the long-term cost savings associated with promoting preventive care because workers change jobs frequently.

    However, from a public health perspective, promoting preventive and chronic care has the potential to avert serious illness, save costs over the long term and protect the community at large from certain infections (in the case of routine immunizations).[28, 29]

    In the case of dental care, preventive visits may have a more immediate pay off for employers. One study found that workers who utilize preventive dental care (i.e., regular cleaning) are less likely to experience work loss and take less time off work overall than workers who visit the dentist only for curative treatments.[30] This suggests that, because paid sick leave removes a barrier to regular dental check-ups, it may decrease work absences and their associated costs in the long run.

    Paid sick leave may also afford workers the option of pursuing preferred but more time-consuming treatments. For example, depressed patients with paid sick leave are 59 percent more likely to prefer counseling over medication.[31]

    Influenza Control

    Every year, 5 to 20% of the U.S. population acquires the flu, 200,000 people are hospitalized from influenza complications and about 36,000 people die from the illness.[32] A recent study estimated direct medical costs associated with influenza at $10.4 billion annually, and the price of lost earnings and loss of life at $16.3 billion annually.[33] Pandemic influenza outbreaks are more severe, resulting in greater morbidity, mortality and cost.

    A person with influenza will typically infect 1.8 other people.[34] As noted, some workers may have a greater impact on the localized spread of the flu because they have a high level of contact with the public or work with populations who are susceptible to infection such as patients, the elderly or children. Depending upon a number of factors, including the infectivity of the illness, immunity in the population and how many social contacts the infected individual is likely to have over the course of the day, the act of coming to work or school can potentially have a ripple effect in terms of disease transmission. For these reasons, the CDC recommends that sick workers and school-age children stay home when they have the flu to prevent others from getting sick.[35]

    Evidence from historical pandemic influenza outbreaks suggests that “social distancing,” or minimizing social contacts between people, can be an effective strategy for controlling the spread of disease. The Department of Health and Human Services recommends “liberal leave” policies and other workplace social distancing measures in its planning guidelines for pandemic flu mitigation.[36]

    Researchers at Sandia National Laboratories have shown that policies that encourage adults and children to stay at home can be effective in decreasing pandemic influenza transmission in a computer simulation of a typical community. School closures and social distancing of children is a very effective intervention because, as noted, children are key drivers of influenza transmission.[37,38] A simulation of the Asian flu outbreak of 1957–58 found that closing schools and keeping children and teenagers at home for a prolonged period of time would reduce the number of people who fall ill by 90%.[37] Paid sick leave would enable parents to care for their children during at least part of school closure or other social distancing measures recommended during pandemic influenza.

    Conclusion

    Evidence from the research literature suggests that the proposed paid sick days legislation, AB 2716, will likely have a positive impact on public health.

    Public health regulations typically seek to address issues that cannot be resolved individually, through market solutions or through private efforts alone. In the context of paid sick leave, low-wage workers–the group most likely to currently lack paid sick days–have an economic disincentive to stay home from work when ill. Moreover, in the short term, employers may see no immediate benefit from offering paid sick leave to workers; preventing the spread of illness beyond the workplace or encouraging workers to take time off for preventive or chronic disease care visits may not deliver any immediate savings. Therefore, guaranteeing paid sick leave to all workers is one way to encourage behaviors that promote public health across families, firms and communities.

    Endnotes

    1. National Institute of Allergy and Infectious Diseases. The Common Cold. [cited 2008 March 17]; Available from: http://www3.niaid.nih.gov/healthscience/healthtopics/colds/overview.htm.
    2. “Norovirus activity–United States, 2006-2007.” MMWR Morb Mortal Wkly Rep, 2007. 56(33): p. 842-6.
    3. International Women’s Policy Research Analysis of National Health Interview Survey data, 2006.
    4. “Multisite outbreak of norovirus associated with a franchise restaurant–Kent County, Michigan, May 2005.” MMWR Morb Mortal Wkly Rep, 2006. 55(14): p. 395-7.
    5. “Norovirus outbreak associated with ill food-service workers–Michigan, January–February 2006.” MMWR Morb Mortal Wkly Rep, 2007. 56(46): p. 1212-6.
    6. “Norovirus threat spurs focus on sanitation, sick leave policies.” Nation’s Restaurant News. 2006. p. 1-3.
    7. Jones, T.F. and F.J. Angulo, “Eating in restaurants: a risk factor for foodborne disease?” Clin Infect Dis, 2006. 43(10): p. 1324-8.
    8. Widdowson, M.A., et al., “Norovirus and foodborne disease, United States, 1991-2000.” Emerg Infect Dis, 2005. 11(1): p. 95-102.
    9. Guzewich, J. and M. Ross. “Evaluation of risks related to microbiological contamination of ready-to-eat food by food preparation workers and the effectiveness of interventions to minimize those risks.” 1999 [cited March 4, 2008]; Available from: http://www.cfsan.fda.gov/~ear/rterisk.html.
    10. Centers for Disease Control and Prevention, U.S. Norovirus Technical Fact Sheet. 2006 [cited March 6, 2008]; Available from: http://www.cdc.gov/ncidod/dvrd/revb/gastro/norovirus-factsheet.htm.
    11. Centers for Disease Control and Prevention, U.S. Norovirus: Food Handlers Factsheet. [cited February 28, 2008]; Available from: http://cdc.gov/ncidod/dvrd/revb/gastro/noro-foodhandlers.pdf.
    12. Heymann, S.J., S. Toomey and F. Furstenberg, “Working parents: what factors are involved in their ability to take time off from work when their children are sick?” Arch Pediatr Adolesc Med, 1999. 153(8): p. 870-4.
    13. Li, J., et al., “Impact of institution size, staffing patterns, and infection control practices on communicable disease outbreaks in New York State nursing homes.” Am J Epidemiol, 1996. 143(10): p. 1042-9.
    14. Lovell, V., No Time to Be Sick: Why Everyone Suffers When Workers Don’t Have Paid Sick Leave. 2004, Institute for Women’s Policy Research: Washington, D.C.
    15. Bell, D.M., et al., “Illness associated with child day care: a study of incidence and cost.” Am J Public Health, 1989. 79(4): p. 479-84.
    16. Uhari, M. and M. Mottonen, “An open randomized controlled trial of infection prevention in child day-care centers.” Pediatr Infect Dis J, 1999. 18(8): p. 672-7.
    17. Taylor, M.R. and P. O’Connor, “Resident parents and shorter hospital stay.” Arch Dis Child, 1989. 64(2): p. 274-6.
    18. Navaie-Waliser, S.A., Bonnell, C. and Peng, T. “Informal and formal home health caregivers: the disconnect between providers in patient care systems.” Acad Health Serv Res Health Policy Meeting. 2002. Washington, D.C.
    19. Bull, M.J., “Factors influencing family caregiver burden and health.” West J Nurs Res, 1990. 12(6): p. 758-70; discussion 771-6.
    20. Burton, L.C., et al., “Preventive health behaviors among spousal caregivers.” Prev Med, 1997. 26(2): p. 162-9.
    21. Collins, K.S., Joseph, S., et al., Informal Caregiving. 1999, The Commonwealth Fund.
    22. Nursing Home Task Force Report. 1998, National Hospice Organization: Washington, DC. p. 1-87.
    23. Dunne, G., G. Vugia, C. Schnurr, J. Cahill, and J. Rosenberg, Norovirus in California Long-term Care Facilities. 2008.
    24. Calderon-Margalit, R., et al., “A large-scale gastroenteritis outbreak associated with Norovirus in nursing homes.” Epidemiol Infect, 2005. 133(1): p. 35-40.
    25. Lovell, V., IWPR Analysis of National Health Interview Survey data. 2008.
    26. Gilleskie, D., “A Dynamic Stochastic Model of Medical Care Use and Work Absence.” Econometrica, 1998. 66(1): p. 1-45.
    27. Kneipp, S.M., “The relationships among employment, paid sick leave, and difficulty obtaining health care of single mothers with young children.” Policy, Politics & Nursing Practice, 2002. 3(1): p. 20-30.
    28. Pignone, M., et al., “Cost-effectiveness analyses of colorectal cancer screening: a systematic review for the U.S. Preventive Services Task Force.” Ann Intern Med, 2002. 137(2): p. 96-104.
    29. Coffield, A.B., et al., “Priorities among recommended clinical preventive services.” Am J Prev Med, 2001. 21(1): p. 1-9.
    30. Reisine, S.T., “Dental disease and work loss.” J Dent Res, 1984. 63(9): p. 1158-61.
    31. Dwight-Johnson, M., et al., “Treatment preferences among depressed primary care patients.” J Gen Intern Med, 2000. 15(8): p. 527-34.
    32. Centers for Disease Control and Prevention, U.S. Key Facts About Seasonal Flu. [cited March 6, 2008]; Available from: http://www.cdc.gov/flu/keyfacts.htm.
    33. Molinari, N.A., et al., ‘The annual impact of seasonal influenza in the US: measuring disease burden and costs.” Vaccine, 2007. 25(27): p. 5086-96.
    34. Fields, B., .D. Knipe and P. Howley, Virology. Vol. 1. 2007: Lippincott Williams & Wilkins. 3177.
    35. Centers for Disease Control and Prevention, U.S. Seasonal Flu. September 22, 2006 [cited March 19, 2008]; Available from: http://www.cdc.gov/flu/toolkit/stories/flubreak.htm.
    36. Department of Health and Human Services, U.S. Community Strategy for Pandemic Influenza Mitigation. 2007 [cited Feb. 26, 2008]; Available from: http://www.pandemicflu.gov/plan/community/commitigation.html#V.
    37. Glass, R.J., et al., "Targeted social distancing design for pandemic influenza:’ Emerg Infect Dis, 2006. 12(11): p. 1671-81.
    38. Glass, R.G. and L. Glass, Design of Community Containment for Pandemic Influenza with Loki-Infect. 2007, National Infrastructure Simulation & Analysis Center: Albuquerque, NM. p. 88.



  • Press Coverage

    Study: Sick Leave Measure Would Benefit Public Health
    KPBS, May 12, 2008

    Celebrating Mother’s Day: Help Working Moms Pass California Paid Sick Days Law
    California Progress Report, May 11, 2008