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

Agent Specific Occupational Health & Safety Training

Thomas H. Winters, MD, FACOEM

Medical Director

Occupational & Environmental Health Network

Waltham, MA


Objectives

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

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

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

Levels of Protection

  • OSHA

    • Engineering controls

    • Work practice controls

    • Administrative controls

  • PPE


Pre placement evaluations

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 evaluations1

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

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

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

Vaccinations

  • Exposure specific

  • Many vaccines are investigational


Vaccines

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

Allergies

  • Latex

  • Lab animals

  • Irritant contact dermatitis

    • Frequently related to PPE


Occupational asthma

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

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

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

Respiratory Protection Program

  • Fit testing

  • Education

  • Periodic spirometry

  • Annual questionnaire

    • May trigger physical examination

  • Compliance


Agent specific occupational health safety training

PPE

  • Eye wear, face shields

  • Protective clothing

  • Gloves

    • Nitrile

    • Chemical


Final evaluations

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

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

Post-Exposure Evaluation

  • Employee interview

    • Categorize exposure

  • Medical history

  • Physical exam


Case study

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

Clinical Investigation

  • Past medical history

  • Recent travel

  • Occupation

    • Student

      • Research activities/exposures


Differential diagnosis

Differential Diagnosis

  • Influenza

  • E coli

  • Shigellosis

  • Salmonella

  • Campylobacter jejuni

  • Schistosoma

  • Entamoeba histolytica

  • Ulcerative colitis


Diagnosis

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

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

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

Prevention

  • Lab safety re-education

    • Hand washing

    • Policy/procedure review

    • Rapid reporting of breech in lab proctols


References

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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