Agent specific occupational health safety training
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Agent Specific Occupational Health & Safety Training. Thomas H. Winters, MD, FACOEM Medical Director Occupational & Environmental Health Network Waltham, MA. Objectives. Describe categories and types of agents and their exposure risks List available vaccines

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Agent Specific Occupational Health & Safety Training

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Agent Specific Occupational Health & Safety Training

Thomas H. Winters, MD, FACOEM

Medical Director

Occupational & Environmental Health Network

Waltham, MA


Objectives

  • Describe categories and types of agents and their exposure risks

  • List available vaccines

  • Identify appropriate steps for exposure including reporting, treatment and follow-up


Risk Assessment

  • BLS 1, 2, 3 or 4

  • Types of exposures

    • Bacterial

    • Viral

    • Toxins

    • Chemical

    • Rickettsial, protozoal, helminth, fungus

  • Risk of disease usually same as exposure risk

    • Inhalation, mucosal contact, or nonintact skin contact

    • Amount of dose

    • Vaccination and antibody titers

    • Virulence of the organism

    • Associated illness or medications

    • Prophylactic antibiotics

Reference: Rusnack et al, 2004, p. 791


Gap Analysis

  • Review of policies

  • Review of procedures

  • Assessment of current training program

  • Evaluation of current protective measures

  • Assessment of expert resources


Levels of Protection

  • OSHA

    • Engineering controls

    • Work practice controls

    • Administrative controls

  • PPE


Pre-Placement Evaluations

  • Obtain accurate job description

    • Speak with direct supervisor if require clarification

  • History

    • General health history

    • Obtain immunization records

    • Previous occupational exposures

  • Physical

    • Focus

      • Cardiac

      • Respiratory

      • Immunologic

      • Skin

  • Baseline lab work-exposure dependent

    • CBC, LFT, Chem-20

    • Titers

    • Serum storageLaboratory personnel

    • Immunizations/monitoring (i.e. Hepatitis B vaccine, baseline serum samples, TB skin testing)

    • Immuno-compromised person evaluation/policy

  • Other exposure dependent testing

    • Chest x-ray

    • EKG

    • PFTs


Pre-Placement Evaluations

  • Baseline lab work-exposure dependent

    • CBC, LFT, Chem-20

    • Titers

    • Serum storage laboratory personnel

    • Immunizations/monitoring (i.e. Hepatitis B vaccine, baseline serum samples, TB skin testing)

    • Immuno-compromised person evaluation/policy

  • Other exposure dependent testing

    • Chest x-ray

    • EKG

    • PFTs


Annual Medical Surveillance

  • Questionnaire

    • Answers may trigger physical and additional testing

  • History

    • Change in job status or exposure type

  • Physical

  • Laboratory testing

    • Exposure specific


Common Agents

  • AGENTS CAUSE HUMAN DISEASE WITH SERIOUS OR LETHAL CONSEQUENCES; INDIGENOUS OR EXOTIC

    • Human cell lines

    • Shigella

    • Borrelia burgdorferi

      • Erlichia (HGE)

      • Babesia microti (human babesiosis)

    • Plasmodium spp (rodent)

    • Plasmodium spp (mosquito born)

    • Mycobacterium Tuberculosis

    • Vaccinia

    • Adenovirus

    • Herpes Simplex virus

    • E Coli

    • Francisella tularensis

    • Hepatitis B, C

    • Poliovirus

    • HIV


Vaccinations

  • Exposure specific

  • Many vaccines are investigational


FDA approved

Anthrax

Yellow fever

Smallpox

Plaque

Not FDA approved

Tulermia

Q Fever

EEE

Pentavalent Botulism toxoid

Vaccines

Ref: Rusnack et al, 2004, p. 793


Allergies

  • Latex

  • Lab animals

  • Irritant contact dermatitis

    • Frequently related to PPE


Occupational Asthma

  • Animal handlers

    • Allergies

      • Pre-existing

        • RAST

          • RAST for other allergens: rabbit, non-human primates, gerbils

        • Prick test

        • Mouse urine antigen, mouse epithelium, bedding

      • Occupationally acquired


Post-Exposure Prophylaxis

  • Bacterial agents

    • Salmonella, Shigella

    • Anthrax

    • Plaque

    • Tularemia

  • Viral agents

    • HIV, Hep B, Hep C

    • Influenza

    • Vaccinia

  • Toxins

    • Few of options

      • ClL. Botulinum-trivalent equine anti-toxin


Employee Training

  • Education

    • Critical to minimize exposure risk

    • Increase understanding to improve rapid reporting to optimize outcomes

    • Employee awareness regarding resources

      • 24/7 expert medical coverage

        • MD, NP


Respiratory Protection Program

  • Fit testing

  • Education

  • Periodic spirometry

  • Annual questionnaire

    • May trigger physical examination

  • Compliance


PPE

  • Eye wear, face shields

  • Protective clothing

  • Gloves

    • Nitrile

    • Chemical


Final Evaluations

  • Written report

    • Pre-placement

      • Fit for duty

      • Fit for duty with restrictions

      • Not fit for duty

      • Medical hold


Assessment of Factors Influencing the Disease Risk After Exposure to an Agent

  • The risk of disease is usually the same as exposure risk or lower if individuals had prior vaccination, exposure to nonpathogenic strain, or given antibiotic prophylaxis.

  • Was there inhalation, mucosal contact, or non-intact skin contact with agent? Was there immediate cleansing with disinfectant (time interval from incident to cleansing)? Immediate cleansing of agent may reduce disease risk.

  • What was the estimated dose of exposure? What is the estimated infective dose/lethal dose of the agent?

  • Was the individual vaccinated against the agent? Do they have protective antibody titers? How effective is the vaccine? Prior vaccination may lower the risk of disease.

  • What is the virulence of the organism? Exposure to non-virulent strains may lower disease risk (i.e. non-virulent Steme strain of B.anthracis).

  • Does individual have an illness or take medications that predispose for higher risk for disease?

  • Are prophylactic antibiotics available against the organism? Post-exposure antibiotic prophylaxis may lower disease risk. Consider investigational antiviral agents in individuals with moderate to high-risk viral exposures who are not vaccinated to lower the risk of disease.

Ref: Rusnak et al., 2006; Heymann, 2004, Winters, 2006


Post-Exposure Evaluation

  • Employee interview

    • Categorize exposure

  • Medical history

  • Physical exam


Case Study

  • 25 yr old female graduate student at a major university presents to University Health Services with a two day history of fever to 103, abdominal pain, bloody/watery diarrhea, shaking chills, nausea, vomiting, anorexia and abdominal pain. She has taken loperamide for the diarrhea and tenesmus which she believes has made her symptoms worse.


Clinical Investigation

  • Past medical history

  • Recent travel

  • Occupation

    • Student

      • Research activities/exposures


Differential Diagnosis

  • Influenza

  • E coli

  • Shigellosis

  • Salmonella

  • Campylobacter jejuni

  • Schistosoma

  • Entamoeba histolytica

  • Ulcerative colitis


Diagnosis

  • Shigellosis

    • Four types of Shigella:

    • S. dysenteriae, S. flexneri, S. boydii, and S. sonnei.

    • Shigella dysenteriae 1 (Shiga toxin)

      • Rare in the U.S. – this finding likely lab related with no travel history

      • Incubation: 1-4 days Duration: 5-7 days

      • Complications may include:

        • Toxic megacolon

        • Intestinal perforation

        • Hemolytic uremic syndrome (HUS)

      • Case fatality rate as high as 20% among hospitalized cases (Heymann, 2004,p. 487)

      • 8% of patients with HUS develop lifelong complications such as HTN, seizures, blindness or paralysis

Ref: http://www.niaid.nih.gov/factsheets/shigellosis.htm


Diagnostic Testing

  • Microscopy of fresh stool (time sensitive- within 2 hours)

  • Stool culture and serotyping

    • Enzyme immunoassay for Stx for S dysenteriae type 1

Ref: http://www.emedicine.com/ped/topic2085.htm


Treatment

  • Most cases resolve within 5-7 days

  • Hospitalized

    • Supportive therapy

    • Intravenous fluids

    • Antipyretics

    • Anti-diarrheals not typically used- may make prolong/worsen course illness

    • Increasing resistance to TMP-SMZ and ampicillin

    • Ciprofloxacin 500mg po x 5 days, or Z-pack

    • Monitor for complications (HUS)


Prevention

  • Lab safety re-education

    • Hand washing

    • Policy/procedure review

    • Rapid reporting of breech in lab proctols


References

  • Cohen, J. and Powderly, W. ( 2004) Infectious diseases, 2nd ed. St. Louis: Mosby.

  • Heymann, D. L. ed. (2004). Control of communicable diseases manual, 18th ed. Washington, DC: American Public Health Association.

  • National Research Council. (1997). Occupational health and safety in the care and use of research animals. Washington, DC: National Academy Press

  • Rusnak, J. M. et al. (2004, August). Management guidelines for laboratory exposures to agents of bioterrorism. JOEM, 46 (8), 791-800.

  • U.S. Department of Health and Human Services. (1999). Biosafety in microbiological and biomedical laboratories, 4th ed. Washington, DC: U.S. Government Printing Office.

    • http://www.cdc.gov/od/ohs/pdffiles/4th%20BMBL.pdf


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