Agent Specific Agent Specific Occupational Health & Occupational Health &

Safety TrainingSafety TrainingThomas H. Winters, MD, FACOEMThomas H. Winters, MD, FACOEM

Medical DirectorMedical DirectorOccupational & Environmental Health NetworkOccupational & Environmental Health Network

Waltham, MAWaltham, MA

ObjectivesObjectives

• Describe categories and types of Describe categories and types of agents and their exposure risksagents and their exposure risks

• List available vaccines List available vaccines • Identify appropriate steps for Identify appropriate steps for

exposure including reporting, exposure including reporting, treatment and follow-uptreatment and follow-up

Risk AssessmentRisk Assessment• BLS 1, 2, 3 or 4BLS 1, 2, 3 or 4• Types of exposuresTypes of exposures

• BacterialBacterial• Viral Viral • ToxinsToxins• ChemicalChemical• Rickettsial, protozoal, helminth, fungusRickettsial, protozoal, helminth, fungus

• Risk of disease usually same as exposure riskRisk of disease usually same as exposure risk• Inhalation, mucosal contact, or nonintact skin contactInhalation, mucosal contact, or nonintact skin contact• Amount of doseAmount of dose• Vaccination and antibody titers Vaccination and antibody titers • Virulence of the organismVirulence of the organism• Associated illness or medicationsAssociated illness or medications• Prophylactic antibioticsProphylactic antibiotics

Reference: Rusnack et al, 2004, p. 791

Gap AnalysisGap Analysis

• Review of policiesReview of policies• Review of proceduresReview of procedures• Assessment of current training Assessment of current training

programprogram• Evaluation of current protective Evaluation of current protective

measuresmeasures• Assessment of expert resourcesAssessment of expert resources

Levels of ProtectionLevels of Protection

• OSHAOSHA• Engineering controlsEngineering controls• Work practice controlsWork practice controls• Administrative controlsAdministrative controls

• PPEPPE

Pre-Placement Pre-Placement EvaluationsEvaluations• Obtain accurate job descriptionObtain accurate job description

• Speak with direct supervisor if require clarificationSpeak with direct supervisor if require clarification• HistoryHistory

• General health historyGeneral health history• Obtain immunization recordsObtain immunization records• Previous occupational exposuresPrevious occupational exposures

• PhysicalPhysical• FocusFocus

• CardiacCardiac• RespiratoryRespiratory• ImmunologicImmunologic• SkinSkin

• Baseline lab work-exposure dependentBaseline lab work-exposure dependent• CBC, LFT, Chem-20CBC, LFT, Chem-20• TitersTiters• Serum storageSerum storageLaboratory personnel• Immunizations/monitoring (i.e. Hepatitis B vaccine, baseline serum samples, TB skin

testing)• Immuno-compromised person evaluation/policy

• Other exposure dependent testingOther exposure dependent testing• Chest x-rayChest x-ray• EKGEKG• PFTsPFTs

Pre-Placement Pre-Placement EvaluationsEvaluations

• Baseline lab work-exposure dependentBaseline lab work-exposure dependent• CBC, LFT, Chem-20CBC, LFT, Chem-20• TitersTiters• Serum storage lSerum storage laboratory personnel• Immunizations/monitoring (i.e. Hepatitis B vaccine,

baseline serum samples, TB skin testing)• Immuno-compromised person evaluation/policy

• Other exposure dependent testingOther exposure dependent testing• Chest x-rayChest x-ray• EKGEKG• PFTsPFTs

Annual Medical Annual Medical SurveillanceSurveillance

• QuestionnaireQuestionnaire• Answers may trigger physical and Answers may trigger physical and

additional testingadditional testing• HistoryHistory

• Change in job status or exposure typeChange in job status or exposure type• PhysicalPhysical• Laboratory testingLaboratory testing

• Exposure specificExposure specific

Common AgentsCommon Agents AGENTS CAUSE HUMAN DISEASE WITH SERIOUS OR

LETHAL CONSEQUENCES; INDIGENOUS OR EXOTIC• Human cell linesHuman cell lines• ShigellaShigella• Borrelia burgdorferi Borrelia burgdorferi

• Erlichia (HGE)Erlichia (HGE)• Babesia microti (human babesiosis)Babesia microti (human babesiosis)

• Plasmodium spp (rodent)Plasmodium spp (rodent)• Plasmodium spp (mosquito born)Plasmodium spp (mosquito born)• Mycobacterium TuberculosisMycobacterium Tuberculosis• VacciniaVaccinia• AdenovirusAdenovirus• Herpes Simplex virusHerpes Simplex virus• E ColiE Coli• Francisella tularensisFrancisella tularensis• Hepatitis B, CHepatitis B, C• PoliovirusPoliovirus• HIVHIV

VaccinationsVaccinations

• Exposure specificExposure specific• Many vaccines are investigationalMany vaccines are investigational

VaccinesVaccines

• FDA approvedFDA approved• AnthraxAnthrax• Yellow feverYellow fever• SmallpoxSmallpox• PlaquePlaque

• Not FDA approvedNot FDA approved• TulermiaTulermia• Q FeverQ Fever• EEEEEE• Pentavalent Pentavalent

Botulism toxoidBotulism toxoid

Ref: Rusnack et al, 2004, p. 793

AllergiesAllergies

• LatexLatex• Lab animalsLab animals• Irritant contact dermatitisIrritant contact dermatitis

• Frequently related to PPEFrequently related to PPE

Occupational AsthmaOccupational Asthma

• Animal handlersAnimal handlers• AllergiesAllergies

• Pre-existingPre-existing• RASTRAST

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

• Prick testPrick test• Mouse urine antigen, mouse epithelium, Mouse urine antigen, mouse epithelium,

beddingbedding

• Occupationally acquiredOccupationally acquired

Post-Exposure Post-Exposure ProphylaxisProphylaxis

• Bacterial agentsBacterial agents• Salmonella, ShigellaSalmonella, Shigella• AnthraxAnthrax• PlaquePlaque• TularemiaTularemia

• Viral agentsViral agents• HIV, Hep B, Hep CHIV, Hep B, Hep C• InfluenzaInfluenza• VacciniaVaccinia

• ToxinsToxins• Few of optionsFew of options

• ClL. Botulinum-trivalent equine anti-toxinClL. Botulinum-trivalent equine anti-toxin

Employee TrainingEmployee Training

• EducationEducation• Critical to minimize exposure riskCritical to minimize exposure risk• Increase understanding to improve Increase understanding to improve

rapid reporting to optimize outcomesrapid reporting to optimize outcomes• Employee awareness regarding Employee awareness regarding

resourcesresources• 24/7 expert medical coverage24/7 expert medical coverage

• MD, NPMD, NP

Respiratory Protection Respiratory Protection ProgramProgram

• Fit testingFit testing• EducationEducation• Periodic spirometryPeriodic spirometry• Annual questionnaireAnnual questionnaire

• May trigger physical examinationMay trigger physical examination

• ComplianceCompliance

PPEPPE

• Eye wear, face shieldsEye wear, face shields• Protective clothingProtective clothing• GlovesGloves

• NitrileNitrile• ChemicalChemical

Final EvaluationsFinal Evaluations

• Written reportWritten report• Pre-placementPre-placement

• Fit for dutyFit for duty• Fit for duty with restrictionsFit for duty with restrictions• Not fit for dutyNot fit for duty• Medical holdMedical hold

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

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

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

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

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

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

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

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

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

Post-Exposure Post-Exposure EvaluationEvaluation

• Employee interviewEmployee interview• Categorize exposureCategorize exposure

• Medical historyMedical history• Physical examPhysical exam

Case StudyCase Study

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

Clinical InvestigationClinical Investigation

• Past medical historyPast medical history• Recent travelRecent travel• OccupationOccupation

• StudentStudent• Research activities/exposuresResearch activities/exposures

Differential DiagnosisDifferential Diagnosis

• InfluenzaInfluenza• E coliE coli• ShigellosisShigellosis• SalmonellaSalmonella• Campylobacter jejuniCampylobacter jejuni• Schistosoma• Entamoeba histolytica • Ulcerative colitisUlcerative colitis

DiagnosisDiagnosis• ShigellosisShigellosis

• Four types of Four types of Shigella:• S. dysenteriae, S. flexneri, S. boydii, and S. sonnei. • Shigella dysenteriae 1 (Shiga toxin)Shigella dysenteriae 1 (Shiga toxin)

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

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

• Complications may include:Complications may include:• Toxic megacolonToxic megacolon• Intestinal perforationIntestinal perforation• Hemolytic uremic syndrome (HUS)Hemolytic uremic syndrome (HUS)

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

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

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

Diagnostic TestingDiagnostic Testing

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

• Stool culture and serotypingStool culture and serotyping• Enzyme immunoassay for Stx for Enzyme immunoassay for Stx for S

dysenteriae type 1 type 1

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

TreatmentTreatment

• Most cases resolve within 5-7 daysMost cases resolve within 5-7 days• HospitalizedHospitalized

• Supportive therapySupportive therapy• Intravenous fluidsIntravenous fluids• AntipyreticsAntipyretics• Anti-diarrheals not typically used- may make Anti-diarrheals not typically used- may make

prolong/worsen course illnessprolong/worsen course illness• Increasing resistance to TMP-SMZ and Increasing resistance to TMP-SMZ and

ampicillinampicillin• Ciprofloxacin 500mg po x 5 days, or Z-pack Ciprofloxacin 500mg po x 5 days, or Z-pack • Monitor for complications (HUS)Monitor for complications (HUS)

PreventionPrevention

• Lab safety re-educationLab safety re-education• Hand washingHand washing• Policy/procedure reviewPolicy/procedure review• Rapid reporting of breech in lab Rapid reporting of breech in lab

proctolsproctols

ReferencesReferences• Cohen, J. and Powderly, W. ( 2004) Cohen, J. and Powderly, W. ( 2004) Infectious diseases, Infectious diseases,

22ndnd ed ed. St. Louis: Mosby.. St. Louis: Mosby.• Heymann, D. L. ed. (2004). Heymann, D. L. ed. (2004). Control of communicable Control of communicable

diseases manualdiseases manual, 18, 18thth ed. Washington, DC: American ed. Washington, DC: American Public Health Association.Public Health Association.

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

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

• U.S. Department of Health and Human Services. (1999). U.S. Department of Health and Human Services. (1999). Biosafety in microbiological and biomedical laboratoriesBiosafety in microbiological and biomedical laboratories, , 44thth ed. Washington, DC: U.S. Government Printing Office. ed. Washington, DC: U.S. Government Printing Office.• http://www.cdc.gov/od/ohs/pdffiles/4th%20BMBL.pdf