IBC: Promoting Optimal Practice Now and In the Future

Occupational Health and Medical Surveillance

June 25, 2009L. Casey Chosewood, MD

Director, Office of Health and SafetyMedical Officer, Strategy and Innovation, Office of the Director

Centers for Disease Control and Prevention

DisclaimerThe views herein represent current approaches and practices of the CDC Office of Health and Safety as described by the author and presenter. Your own workplace may have similar or vastly different needs and requirements. This is not official, cleared guidance from the Centers for Disease Control and Prevention. Such guidance can be found at www.cdc.gov. The mention of organizations and commercial entities and products in this presentation is for illustrative purposes only and does not represent an endorsement by CDC or the US Department of Health and Human Services.

HighlightsCDC Today: An Overview of Current Public Health ChallengesOccupational Health and Worker Protection at CDCScreenings, Medical Clearance and SurveillanceMedical Clearance, Immunization and Serum Banking IssuesOccupational Health Issues of Animal Care WorkersPost-incident and Post-Exposure Management

TsunamiDecember

04-05

West Nile

VirusAug-Nov 02

SpaceShuttle

Columbia Disaster

Feb 03

SARS Mar-Aug 03

Monkeypox June-Aug 03

Northeast Blackout

Aug 03

California Wildfires

Oct-Nov 03

Ricin TularemiaAnthrax Oct-Nov 03

BSE Dec 03

Avian Influenza

Jan-Mar 04

Guam Typhoon

Feb 04

Ricin Domestic Response

Feb 04

Global AIDS Program

Deployments

Hurricanes (Charley, Frances,

Ivan, Jean) Aug-Oct 04

West Nile Virus

Aug-Nov 04

Influenza VaccineShortage

Oct 04-05

World Trade Center

Sept2001

AnthraxAttacksOct-Nov 01

Influenza Sept 03

Hurricane IsabelSept 03

CDC: Health Protection and ResponseHurricane

KatrinaAug. 05 - 2006

Marburg Virus

Mar 05-Sept 05

Hurricane Rita

Sept. 05 - present

HurricaneWilma

Oct 04-Present

H5N1 Response and Pan Flu Prep

Novel H1N1

Response April 2009 -

present

CDC’s Current Global Challenges

Pandemic Influenza PreparednessNovel H1N1 Response

Hien TT et al., New England J Med 2004;350:1179-1188

DAY 5 DAY 7 DAY 10

Emerging Infections and Threats Quiz

CDC’s Current Global Challenges

CDC’s Current Global ChallengesBonus Question: Name This Mystery Virus

SARS

E. coli 0157HPS

CryptosporidiosisCyclospora

GuanaritoDengueCholera

HPS

New variant CJDFoot & mouth disease

Avian influenza

Rift Valley feverEbola HFHIV / TBMalaria

Yellow fever

Nipah virus

PlagueHIV

HIVSARS

Avian influenza

DiphtheriaWest Nile virus

HIVMDR-TB

DengueHendra virus

West Nile virus

MonkeypoxVRSA

AnthraxWest Nile virus

Polio

VISAE. coli 0157

Leptospirosis

CDC’s Global Health Challenges

Emerging and Re-emerging Infectious Diseases

CDC Infrastructure OverviewCDC Director

Chief Operating OfficerChief Operating OfficerOffice of Health and SafetyOffice of Health and SafetyOffice of Security and Emergency PreparednessOffice of Security and Emergency PreparednessBuildings and Facilities OfficeBuildings and Facilities OfficeHuman ResourcesHuman ResourcesEqual Employment Opportunity OfficeEqual Employment Opportunity OfficeFinancial Management OfficeFinancial Management Office

Coordinating Center DirectorsCoordinating Center DirectorsNational Centers, Institutes, OfficesNational Centers, Institutes, Offices

LaboratoriansLaboratoriansAnimal Care and Use ProgramAnimal Care and Use Program

CDC Office of Health and Safety Protects the Health, Safety, and Resilience of the CDC WorkforceApproximately 125 employeesInternal Activities

Physicians (3) MidPhysicians (3) Mid--Levels (3) Nurses (8)Levels (3) Nurses (8)Biosafety Officers and Technicians (5)Biosafety Officers and Technicians (5)Industrial Hygienists (8)Industrial Hygienists (8)Safety and Environmental Engineers (5)Safety and Environmental Engineers (5)Health Physicists (2)Health Physicists (2)Safety and Occupational Health Specialists, Safety and Occupational Health Specialists, Trainers, and TechniciansTrainers, and Technicians

CDC’s Office of Health and Safety at Work

Occupational Health and Safety at CDC

Comprehensive Risk AssessmentsGeneral Job Hazard AnalysesBiological, Chemical, Radiation Risks

Integrated Occupational Health and Safety ProgramsWith Programs (labs, PI’s, response elements)With Support Partners (Animal Care, Facilities, Security)

Interlocked Workplace Safety and Clinical ProgramsRisk Assessments lead clinical screenings and interventions

Aggressive Incident Management and InvestigationEmergency Response ElementSafety Help Desk, Safety Info Line, CDC Clinic Hotline, Worker Injury Reporting

SystemHealth Promotion and Prevention Activities

Safety TrainingQuality of Work Life Initiatives

Continuous Vigilance and Process ImprovementMetrics Review and Program Evolution

Safety Challenges in the High-Containment Lab Environment

People

Processes

Places

Pathogens

The Risk Assessment and Occupational Health

Basis for sound, comprehensive safety decisions and occupational health planningMust be customized and universal for all potentially affected personnelDefine potential exposure and other risks based upon actual job duties Translate outcomes of the assessment to create optimal screening, worker protection and surveillance programs

The Ideal Occupational Health Clinic

Onsite or Near the WorkplaceNear Ambulance AccessElectronic Health RecordsWide Variety of PPE Always AvailableOne-pass Air or Negative Pressure Space*Isolation Room*

Anteroom for donning or doffing PPEAnteroom for donning or doffing PPEShower insideShower insideSurfaces that can be easily decontaminatedSurfaces that can be easily decontaminated

*As determined by risk assessment

The Ideal Occupational Health Clinician

Available and readily accessible 24/7KnowledgeableIntegrated into research programsFamiliar with work, agents, protocolsAble to Access Subject Matter Experts and Consultants when NecessaryGenuine Interest in Laboratory Worker Protection IssuesAgent-, PPE-, Decon-, and Procedure-Savvy

Pre-Placement Medical Screening

Evaluation of past medical history

Medical, surgical, social and family historyMedical, surgical, social and family historyAllergies and sensitivities (latex, dander, drugs, Allergies and sensitivities (latex, dander, drugs, foods)foods)Previous occupational history and activityPrevious occupational history and activityMedications and other treatmentsMedications and other treatmentsActive conditions and review of major body Active conditions and review of major body systemssystemsReview and record past immunization historyReview and record past immunization history

Medical Assessment and Interventions

Targeted physical examination if necessaryFitness for Duty AssessmentBaseline serum collection and storageImmunizationsTiters when indicatedOther lab work when indicated

Serum BankingPros

Helps identify and characterize silent or inadvertent Helps identify and characterize silent or inadvertent infectionsinfectionsMay be useful in assessing risks with novel or emerging May be useful in assessing risks with novel or emerging agentsagentsMay help with a workerMay help with a worker’’s nons non--occupational health issuesoccupational health issuesMay protect the employer from liability related to previouslyMay protect the employer from liability related to previously--acquired infectionsacquired infections

ConsCostly and resource intensiveCostly and resource intensiveStorage, retention and legacy issuesStorage, retention and legacy issuesPrivacy, trust and confidentiality issuesPrivacy, trust and confidentiality issuesMany believe postMany believe post--exposure serum collection adequate for exposure serum collection adequate for baseline purposesbaseline purposes

Medical Assessment and Interventions

Respirator clearance and spirometryRespiratory fit testing and training programsInterventions to protect research animalsRepeat all interventions at appropriate intervals

Additional Risks Related to Work with Laboratory Animals

Animals react variably in lab environmentVariety of job tasks and processes increase riskAnimal handling less automated, “hands on”Fewer engineering and administrative controlsGreater reliance on personal protective equipment, consistent work practices, and personal behaviorTraining levels of animal care staff and lab workers vary widely

Commonly Used Immunizations Hepatitis B SeriesMMR, PolioVaricellaRabiesSmallpox/VacciniaTetanus-DiphtheriaHepatitis A SeriesQ fever, Yellow Fever, JEOthers as Research Warrants

Personal Protective Equipment

Gloves and GownRespiratory ProtectionFace and Eye ProtectionClosed-toe ShoesField Gear and Clothing

Periodic Medical Surveillance

and Evaluation

Assess need for interval surveillance on case-by-case basisUpdate medical screenings in at-risk employeesAssess titers and offer boosters as neededAnnual medical clearance to use respirator, fit testing and training Builds trust and ongoing relationship between lab workers and occ health staff

Never Hesitate to Raise a Red FlagWorkers should understand incubation periods, modes of transmission and clinical symptomsWorkers, supervisors and clinicians should always maintain a high index of suspicion for exposure and a lowthreshold for actionNever discourage reporting of concernsPay attention to work absencesAny fever or illness clustering should lead to prompt evaluationKnow that symptoms of work-acquired infection and natural infection may differ

Medical AlertAttending Physicians

This card holder works at the _______________________ in areas where hazardous biological, chemical or radioactiveagents or materials may be used. In the event of anunexplained illness, please contact the supervisor listed on thereverse side for information on specific agents or materials towhich this person may have been exposed.

Clinic 8 - 16:30 EST xxx.xxx.xxxxAgency Contact xxx.xxx.xxxx

Medical Alert Card

Employee Name _______________________ ______________

_____________________________________________________Employee Emergency Contact Telephone Number

Allergies _____________________________________________

Organizational Unit ____________________________________

1º Supervisor Work Telephone Alternate Telephone_____________________________________________________2º Supervisor Work Telephone Alternate Telephone

Medical Alert Card(back)

Post-Exposure Management

Clinical Focus

Repeat or extend first aid measures if neededEvaluate patient, event and agent-specific risksObtain supervisory, safety, expert or other specialty inputIncrease or expand vigilance (clinical follow-up, education, after-hours contacts)Aggressive use of prophylaxes / interventions where appropriate

Post-Exposure ManagementSafety Focus

Thorough incident investigationAssess risks for multiple victimsAssure control for secondary incidentsAccentuate the “opportunity this presents”not the “failure it represents”Use multi-disciplinary “systems approach”to assure follow-thru with corrective action/prevention efforts

Specialists and In-Patient Management Issues

Plan for seamless transition to specialty care or in-patient management in advanceEstablish a work-specific relationships with specialists and facilitiesSpecialized in-patient units for high-risk agent exposures likely to be increasingly commonInfection control in hospital setting is not newOngoing communication and planning

CDC’s In-patient Management Unit at Emory University Hospital

Protecting High-Containment Laboratory WorkersBasic Tools for Success

Comprehensive Risk Assessments Dictate Essentials for Optimal Occupational HealthInter-locked Workplace Safety and Clinical ProgramsAggressive Incident Management and InvestigationCredible Surveillance and Post-Exposure ManagementHealth Promotion and Prevention ActivitiesContinuous Vigilance and Process Improvement

More information…The 5th Edition of the Biosafety in Microbiological and Biomedical Laboratories is now available online at www.cdc.gov/od/ohs/Extensive Biosafety and Biosecurity risk assessment material is included in this editionNew chapter on Occupational Health