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
• 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
                                   Vaccines
  • FDA approved                       • Not FDA approved
         •    Anthrax                    •   Tulermia
         •    Yellow fever               •   Q Fever
         •    Smallpox                   •   EEE
         •    Plaque                     •   Pentavalent
                                             Botulism toxoid




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