American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
Objectives
– Understand the scope and practice of OM – Name 2 historical OM figures – Identify significant laws – Name one major preventive health initiative in which OM plays an important role – Enumerate OM services delivery methods Scott C. Jones, DO, MPH, FAOCOPM – Explain the essential and elective components of St. Petersburg, Florida an OM practice March 14, 2012
American Osteopathic College of Occupational and Preventive Medicine
Definition of Occupational Medicine Why Occ Med?
• The ONLY medical specialty trained in the • The branch of medicine that deals with the interaction between the worker and the work prevention and treatment of occupational injuries place! and diseases. • OccDocs MUST know the work environment of • An occupational disease is one that is associated their patients! with a particular occupation and occurs in the workplace. • Companies MUST know their OccDocs! • Some occupations confer specific risks, such as the prevalence of black lung in coal miners. Now for some Occ Med History…
History of Occupational Medicine Pliny the Elder 23 - 79 AD
• “The fumes from silver mines • Mirrors the history of medicine are harmful to all animals…” • “…when well shafts have • Hippocratic teaching (460-377 BC) about observation been sunk deep, fumes of and balance, not superstitious sulfur or alum rush up to – “Observe the patient’s condition and their response to meet the diggers and kill disease, rather than the disease itself.” them.” • Animal bladder “veils” to protect miners
A-1 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
Galen 131 - 200 AD Rhazes c850 - 923
• Physician to the gladiators • Documented occupations of under Marcus Aurelius patients • Accomplished surgeon, wrote – Cotton merchant about procedures and – Cloth merchant instruments – Goldsmith – • Wound treatment in the work bookseller place • Observations of mine workers exposed to acid mists
Bernardino Ramazzini 1633 - 1714 “Disease of Scribes and Notaries”
• “To the questions • “An acquaintance of mine, a notary by recommended by Hippocrates, profession, still living, used to spend his whole he [physician] should ask one life continually engaged in writing, and he more – What is your made a good deal of money from it; first he occupation?” began to complain of intense fatigue in the • Pioneered field of Ergonomics whole arm, but no remedy could relieve this, … • Visited workers and workplaces
“Disease of Scribes… ” Recommended Reading
• “…and finally the whole right arm became • Lancet article: Lancet 19999;354:858-61 completely paralyzed. In order to offset this infirmity he began to train himself to write with the left hand, but it was not very long before it too was attacked by the same malady.”
A-2 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
Percival Pott 1714 - 1788 Thomas Morrison Legge 1863 - 1932 • First medical inspector of • Scrotal cancers in chimney factories in England sweeps • Lead Poisoning and Lead • “pioneer of observational Absorption epidemiology” • Recommended banning indoor • “Father” of environmental lead paint carcinogenesis • Occ med in medical school curriculum
Alice Hamilton 1869 - 1970 Alice Hamilton Award
• pioneer of toxicology From CDC/NIOSH Website: • 1919 first woman appointed to faculty at Harvard Medical • Alice Hamilton Awards School, Department of Industrial The Alice Hamilton Awards for Occupational Safety and Health recognize the scientific excellence of technical and instructional materials by NIOSH Medicine scientists and engineers in the areas of biological science, engineering and • national expert on exposures to physical science, human studies, and educational materials. toxic chemicals in the workplace, • The Awards honor Dr. Alice Hamilton (1869 - 1970), a pioneering especially lead researcher and occupational physician, and are presented each year by NIOSH on the basis of rigorous reviews by panels of scientific experts from • active role in exposing the 1924 outside the Institute. Ethyl leaded gasoline and 1928 "radium girls" industrial disasters
http://www.cdc.gov/niosh/hamilton/defa ult.html
Scott C. Jones, DO, MPH 1959 - present
• Board Cert. Occ Med • DOCPCMS • Medical Director – BJC CHS – St. Louis Metro Police Dept – St. Louis County Police Dept – Metro Bistate • Compensation Systems – State WC – FELA – Jones/Longshoremans’
A-3 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
Historical Events Historical Events
• Factory Act of 1867 • Worker Compensation Laws – Restricted hours during – No fault insurance coverage for injured workers which children, young – Early 1900’s workers and women – State based programs and laws were permitted to labor – Employee right-to-choose; right-to-know – Any contested cases are adjudicated by state compensation boards – Burden of proof on worker
Historical Events Historical Events
• Occupational Medicine became specialty 1954 • EPA established 1970 – • OSHA established 1970 – safe working environment – Regulates pesticides, • NIOSH established 1970 – research agency – Enforces Toxic Substance Control Act (TSCA) – Noise Control Act – And many more since then
Occupational Health Services Team Approach
• Physician • Safety Officers • • What does one do in occupational medicine? • Occupational Health Industrial Hygienist Nurse • Management (plant • What is the scope of services? • PAs and NPs manager, HR dept) • Ergonomic team • Physical Therapist • Environmental team • Quality Care: Clinical v. Occ Med • Case Manager • TPAs – Internal • Insurance Cos. – External
A-4 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
Types of Services Clinical Services
• Clinical • Examinations • Ancillary – Pre-placement – Return to work • Preventive – Fitness for duty • Health Promotion Programs – Respirator clearance • Health and Productivity Management – Periodic Surveillance • Worker Health as force for National Health – Disability examinations Policy reform – IME • Injury Care
Ancillary Services Preventive Health Services
• Audiometric • Health Promotion Programs – Smoking cessation • Spirometry – Stress reduction • Visual testing – Nutritional counseling • Laboratory testing – Mental Health and Depression – Sedentary Lifestyle interventions • X-rays • Periodic evaluations • Physical Therapy – Risk assessment • MRO Drug Testing – Lifestyle factors – Appraisals of health (HRAs)
Healthy People 2020 Healthy People 2020
Access Health Services Family Planning Lesbian, Gay, Bisexual, and Transgender Preparedness New Adolescent Health New Food Safety Health New Public Health Infrastructure Arthritis, Osteoporosis, and Chronic Back Genomics New Maternal, Infant, and Child Health Respiratory Diseases Conditions Global Health New Medical Product Safety Sexually Transmitted Diseases Blood Disorders and Blood Safety New Health Communication and Health Mental Health and Mental Disorders Sleep Health New Cancer Information Technology Nutrition and Weight Status Social Determinants of Health New Chronic Kidney Disease Healthcare-Associated Infections New Occupational Safety and Health Substance Abuse Dementias, Including Alzheimer’s Disease Health-Related Quality of Life & Well- Older Adults New Tobacco Use New Being New Oral Health Vision Diabetes Hearing and Other Sensory or Physical Health Disability and Health Communication Disorders Early and Middle Childhood New Heart Disease and Stroke Educational and Community-Based HIV Programs Immunization and Infectious Diseases Environmental Health Injury and Violence Prevention Topics marked "New" are topic areas that were not included in Healthy People 2010. * http://www.healthypeople.gov/2020/topicsobjectives2020/default.aspx http://www.healthypeople.gov/2020/topicsobjectives2020/default.aspx
A-5 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
Types of Occ Med Practices Basic Function of Occ Physician
• Multi-specialty group practices • Provide high-quality medical services • Corporate-based clinics – i.e. give good EBM care • Private practice • Understand company’s objectives • Hospital based programs – Medical conscience for employers • University/ Teaching/ Residency • Aid in regulatory compliance – • Primary care offices OSHA, EPA, DOT • Marketing and billing
Work-Site Visit Work-Site Visit
• First impressions count • Observe workers working • Number of employees • Observe workers arriving, on breaks and leaving • Number of shifts • Physical environment: temp., odor, vibration, noise • Union or non-union shop • General safety – machine guards, safety showers, • Health/medical services available signs, trip hazards • Essential Functions in Job Descriptions • Eating area, wash room • Review the Material Safety Data Sheet – MSDS • Ergonomic issues – heavy lifting, repetitive motion, • General housekeeping (spills, cleanliness) awkward positions
Work-Site Visit Assisting Employer
• Chemical, physical, biological hazards • OSHA compliance • Dermal exposures – Respiratory Protection Program • Respiratory exposures – Hearing conservation programs • Use of PPE – DOT requirements • Ventilation/ exhaust systems, administrative controls
A-6 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
Evidence Based Medicine Approach to Occ Injury & Illness
"the conscientious, explicit and judicious use of • Subjective information current best evidence in making decisions – History of present illness or injury about the care of the individual patient. It • In patient’s own words…”xyz” means integrating individual clinical expertise – Job history: past and present with the best available external clinical – Exposure history: work, hobbies, environmental evidence from systematic research." (e.g. Doe Run) Dr. David Sackett, 1996 – ROS for temporal relationships – History of Present Injury/Illness
Approach to Occ Injury & Illness Work Relatedness
• Objective • “Definitive causation assessments should be – Physical examination, functional testing based on considerably more information than – Lab and x-ray – Work place visit preliminary assessments.” • Assessment – diagnoses, opinion on WR • Objective vs. Subjective • Plan – “straight shooter” – Medication: OTC v. Rx – “nice person” – Restrictions: based on injury NOT work – – HEP, Physical Therapy, exercise prescription Did YOU witness the incident? – Care plan, manage expectations, recheck
Case Management Timeline
DOI ARTW RTW Closure
Injury Disability Management Management
OMP (Out of Medical Process)
A-7 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
Injury Management Disability Management Review Records for Abilities Doctors On-Call Second Opinion Exam Functional Testing On Call Physician Vocational Counseling Managers, Co-workers, Communication of Expectations Observe Safety & Productivity
DOI ARTW ARTW RTW Closure
Interventions more effective Interventions less effective
Ideally, ARTW=RTW date
OMP
Tools of Evidence Based Medicine
• MOI Investigation • ICD-9 (ICD 10) • ACOEM Occupational Medicine Treatment Guidelines • Official Disability Guidelines • Medical Disability Advisor • AMA Guides to the Evaluation of Permanent Impairment
ACOEM Occupational Medicine Treatment Guidelines I. Foundations of Occupational Medicine Practice 1. Prevention 2. General Approach to Initial Assessment 3. Initial Approaches to Treatment 4. Work Relatedness 5. Cornerstones of Disability Management 6. Case Management: Prevention and Management of Delayed Functional Recovery 7. Pain Behavior, Inconsistent Findings and Motivation for Self-Care and Recovery 8. Consultations and Independent Medical Examinations 9. Reintegration and Reconditioning after Testing or Surgery
A-8 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
Prevention Strategies Delayed Recovery
• Primary – avoid incident • Exam findings – Safe work place – Fit worker • Functional data in chart • Secondary – avoid disability – Rehab – Proper Treatment • Disability duration guides – BIC • • Tertiary – avoid recurrence FCE – FFD • Natural history of condition – Fit work to worker • surveillance Involve your Occ Doc!
ACOEM Occupational Medicine Treatment Guidelines II. Presenting Complaints 10. Neck and Upper Back 11. Shoulder 12. Elbow 13. Forearm, Wrist and Hand 14. Low Back 15. Knee 16. Ankle and Foot 17. Acute Eye Complaints 18. Stress-Related
Practical Application ODG: Official Disability Guidelines
ICD 9Diagnosis • RTW data and Best Practices • Causality Likelihood 724.5 Backache • Medical Costs 726.1 Rotator Cuff Syndrome Shoulder • Case Management Triage 845.0 Ankle Sprain or Strain – Levels I, II, III and inflection point • Physical Therapy Guidelines • DD Adjustment Factors by Age
A-9 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
Strategies for a successful Workers’ Compensation Program
Commitment 1.Gain support of administration for consistent P from 1.Consistent enforcement of P&P enforcement of P&P R leadership and 2.Participation in routine meetings to review 2.Meet with key stakeholders at least once a year health and discuss issues. to report on compliance. E providers V Effective 1.Understand how P&P are developed and policies and 1.Clear processes for work related injuries, approved in the organization. E procedures illnesses and exposures 2.Work with HR, Legal, Finance to create P&P that N 2.Policies address key components supports goals. 3.Ongoing communication of P&P 3.Develop and deliver material at new employee T orientation, ongoing supervisor training. I Ongoing 1.Frequency and severity compared to past and analysis of 1.Monthly and annual comparisons against similar organizations O data past experiences & industry data 2.Interdisciplinary effort to identify and address N 2.In depth analysis of problem areas high risk issues unique to the organization Interventions 1.Identify responsible party for the program targeted at 1.Use data and risk assessment to create 2.There will be a positive ROI for funding targeted high risk targeted initiatives interventions issues 2.Implementation of intervention plan (e.g. ergonomics) Access to 1.Create direct communication line with medical C timely 1.Employer communicates key information to providers. O evidenced medical provider. 2.Insist that medical providers practice evidence based care 2.Data is generated, communicated and based medicine. N incorporated into plan of care. T Disciplined 1.Evaluation by OM specialist with attention to oversight of 1.Management begins at the point of work status, medications and follow up. R medical discovery. 2.Use of pain charts, Official Disability Guidelines process 2.Consistent application of Evidence Based (ODG), etc O Medicine. 3. Develop expertise in use of ODG. L Ongoing education for claims adjustors and 4.Share expertise with key players. case managers.
A-10 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
Objectives
o Define Epidemiology and how it explains disease patterns. o Explain the differences between epidemiology and clinical medicine. o Identify the types of epidemiologic studies. o Describe common measures of association between factors and outcomes. o Identify desired screening test characteristics.
American Osteopathic College of Occupational and Preventive Medicine
Epidemiology Individual Characteristics o Study of: o Demographic o patterns of disease occurrence and the factors o age, sex, race, sexual orientation that influence these patterns. Social and economic o distribution and determinants of health-related o events. o income, occupation, education o 3 Pillars: o Personal o Time o tobacco, alcohol, drug use, diet, physical exercise o Place o Person
Biostatistics Statistics
• Science of applying descriptive and inferential • Descriptive statistics to biological and medical data. – Central tendency – Dispersion – Frequencies • Inferential – Correlation – Causation
B-1 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
The Connection? Purposes of Epidemiologic Studies o Biostatistics o Etiology o The mathematical association o Preventive services o Epidemiology o Public health services o The logical and biological association o Public health messaging
Epidemiology vs Clinical Medicine Study Designs o Epidemiology • Prospective o Groups – Cohort – Experimental o The ill and well • Retrospective Identify exposures, reduce risk o – Cohort – Case-control o Clinical Medicine • Other o Individuals – Cross-sectional o Primarily the ill o Improve diagnoses, treat disease
Prospective Retrospective
• Cohort • Cohort – Classify individuals by exposure – Classify individuals by exposure • Experimental • Case-control – Assign individuals to exposure groups – Identify cases and controls, examine multiple exposures
B-2 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
Other Bias
• Cross-sectional • Systematic error resulting in over- or under- – Use group data to identify exposure and outcome estimation of the association. simultaneously • Two major types: – Selection – Observation/Information
8/23/2010 AOCOPM 2010 13
Types of Bias Other Reasons for Error
• Selection • Confounding
• Observation/Information • Random error – recall bias – interviewer bias – follow-up bias – misclassification bias
Causality Measures of Morbidity
• Hill’s Criteria • Incidence Rate – Strength of association – Consistency – Specificity • Prevalence Rate – Temporality – Biological gradient – Plausability – Coherence – Experiment – Analogy
B-3 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
Incidence Prevalence
• Proportion of total population which is • Occurrence of new cases of disease in a diseased. population over a specified time frame.
• P = # existing cases in population • I = # new cases in population Total population Total population
Connection of I and P Measures of Association
• Measures of • Estimates of Comparison Comparison Incidence – Absolute Measures • Odds Ratio • Risk Difference Prevalence • Population Attributable Risk – Relative Measures • Relative Risk Cure or Death
Measures of Association 2 x 2 Table by Study Design • Prospective • Retrospective – Relative Risk – Odds Ratio Outcome+ Outcome - – Attributable Risk
Factor + a b a + b
Factor - c d c + d
a+c b+d a+b+c+d
B-4 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
Relative Risk Attributable Risk
• RR = Riskexposed • Incidence of disease in exposed group Riskunexposed eliminated if exposure is removed. • RR = a / (a + b) c / (c + d) • AR = Incidenceexposed - Incidenceunexposed • The higher the RR, the greater the risk of disease for exposed individuals. • AR = (a / (a + c)) – (b / (b + d))
Odds Ratio Group Exercise #1
• OR = Oddsexposed • Cluster of an unknown skin disease in an Oddsunexposed urban area. • OR = ad bc • What is some information we want to know • The higher the OR, the greater the odds of first? exposure for diseased individuals.
Group Exercise #1: Group Exercise #1: Population and Symptoms Work Place Practices • Controls • Population – Latex gloves used with 97% of patients – 5 of 47 dental hygienists/assistants in last year – 1% latex-allergic patients – Large multi-site dental practice – 4.8% patients had oral sores • Cases • Symptoms – Latex gloves used with 83% of patients – 3.5% latex-allergic patients – Burning, itching, swelling; localized to fingers in cases – 5% patients had oral sores
• Dental tools reused after manual cleaning throughout all clinics • What might you want to know about population? • What else do we want to know them?
B-5 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
Group Exercise #1: Group Exercise #1: Lab work and Examination The Study
• Examination • Guesses on disease? – 4/5 Cases develop vesicles at area of inflammation – 1/42 Controls experience itching only • Prospective or retrospective? • Blood work – identify pathogens • Study Design?
• Measure of Association?
http://www.dent.ucla.edu/pic/visitors/herpes/page1.html
Group Exercise #1: Group Exercise #2 Epidemiology vs Clinical Medicine
Epidemiology Clinical Medicine • Interested in studying connection between • Identifying groups’ • Diagnose patients hepatitis and occupational risk. symptomology • Begin with a non-diseased recent HS grads in several counties in state X. • Infectious control via work • Infection control via place practices and hygiene medications and personal • Study will follow participants for 5 years. hygiene • Further occupational safety mandates, messaging
Group Exercise #2: Group Exercise #2: Questions Questions • What kind of study design is this? • What are some known occupations at risk for hepatitis infection? • What is our outcome of interest? • Name some symptoms of hepatitis. • What is our risk of interest? • What is the duration of symptom onset?
B-6 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
Group Exercise #2: Group Exercise #2: Numbers Numbers • The following results are found: • RR = a / (a + b) c / (c + d)
Hepatitis + Hepatitis - Hepatitis + Hepatitis -
Exposed to 34 b 154 Exposed to 34 120 154 bodily fluids bodily fluids
Not exposed to c 245 c + d Not exposed to 10 245 255 bodily fluids bodily fluids
44 b+d a+b+c+d 44 365 409
Group Exercise #2: Group Exercise #2: Numbers Numbers • RR = a / (a + b) • What do we calculate if we want to estimate c / (c + d) the percent of cases caused by exposure at • RR =34/154 =0.22 = 5.5 work? 10/255 0.04
• Express this risk in epi lingo.
Group Exercise #2: Group Exercise #2: Numbers Numbers • AR = (a / (a + c)) – (b / (b + d)) • AR =(34 / 44) – (120 / 365) =0.77 – 0.33 = 0.44 x 100% = 44% Hepatitis + Hepatitis -
Exposed to 34 120 154 • Express this info in epi lingo. bodily fluids
Not exposed to 10 245 255 bodily fluids
44 365 409
B-7 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
Screening tests Validity
• What tests do we use to identify Herpatic • The right measurement for disease/disorder whitlow and Hepatitis? status? – Measurement validity • Small cell lung carcinoma? • Ability to differentiate cases and controls. – • Thoracic Outlet Syndrome? Can the test results be trusted? • Sensitivity and Specificity
Sensitivity and Specificity Sensitivity
• Used to evaluate screening test accuracy. • Sensitivity =# of ppl test positive x 100% # of ppl with disease
• Sensitivity • a/(a+c) x 100% – Probability of correctly classifying those with disease
• Specificity – Probability of correctly classifying those without disease
Specificity Sensitivity and Specificity
# of ppl test negative • Specificity = x 100% # of ppl without disease Test Disease+ Disease -
• Positive + A B d/(b+d) x 100% (true positives) (false positives)
Negative - C D (false negatives) (true negatives)
Totals A+C B+D
B-8 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
Sensitivity and Specificity: Sensitivity and Specificity: Calculations Calculations • Sensitivity = a/(a+c) x 100% • Sensitivity = a/(a+c) x 100% • Specificity = d/(b+d) x 100% = 21/23 x 100% = 91.3%
Test Disease+ Disease - • Specificity = d/(b+d) x 100% Positive + 21 4 (true positives) (false positives) = 45/49 x 100% = 91.8%
Negative - 2 45 (false negatives) (true negatives)
Totals 23 49
Screening Test: Predictive Value Feasibility • Validity established, but feasible? • PPV – Predictive Value – Proportion of individuals with a positive test who • Positive Predictive Value (PPV) have the disease • Negative Predictive Value (NPV) • NPV – Proportion of individuals with a negative test who do not have the disease
PPV & NPV What else can we learn?
# of ppl test positive and have disease • False Positive Rate • PPV= x 100% # of ppl who test positive – Proportion of disease free individuals who test positive • PPV= a/(a+b) – b/(b+c) # of ppl test negative without disease • False Negative Rate • NPV= # of ppl who test negative x 100% – Proportion of diseased individuals who test negative • NPV= d/(c+d) – c/(a+c)
B-9 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
Questions?
B-10 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
Occupational Medicine Residency at WVU • 2 Year program (after internship) • AOA & ACGME Accredited – Only AOA program in OEM • Includes MPH (or soon MOH) degree Carl Werntz, D.O., MPH Residency Program Director • Based in Morgantown, WV West Virginia University • NIOSH (DRDS, DSR, and HELD) on campus • Clinically oriented residency
American Osteopathic College of Occupational and Preventive Medicine
Learning Objectives DEFINITION • Collection, Analysis, & Dissemination of medical data on groups of exposed For Medical Monitoring Programs, people the Learner will: Monitoring for: • List 3 reasons for establishing a program • Development of “expected” diseases • Describe 3 different regulatory programs • Effectiveness of existing control measures • List 5 steps in creating a program • Baseline data for future testing • Discuss the rationale and ethical issues to be • Safety assurance of new substances or considered creating a program novel exposures
Not covered in this lecture Venues of “Medical Surveillance”?
• Employee Wellness programs
Monitor Program to • Workplace screening for community diseases Program Decrease Risk (think SARS or Bird Flu) Known Disease Effectiveness Risk Secondary Inherent Risk Prevention • Preventative health screenings Exposure Initiate Program Monitor – Unknown Risk for Diseases Blood Pressure, Diabetes, Cholesterol, etc. Population Identified
• Fitness for duty examinations
C-1 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
Reasons to monitor Examples for this class • Early recognition of expected disease
• Monitoring effectiveness of control systems •Coal Worker’s Pneumoconiosis (Black • Safety of new materials Lung) •Lead (Pb) • Protecting Customers •Beryllium (Be) •Nanomaterials
Examples of each
Noise-Induced Hearing Loss Hearing conservation
• Accepted: Exposure Disease pathway • Is there a change in hearing?
• If so, employer can address issue? • Program entry criteria based upon measured – Better prevention noise levels – Reassigning “sensitive” worker
• Annual Hearing Test (Screening) • Sounds Simple! • Good for Everyone
What type of program is PHASES OF PROGRAM Hearing Conservation? • Primary Prevention • Needs assessment • Secondary Prevention • Goals & targets • Tertiary Prevention • Choosing testing modalities Secondary Prevention • Interpretation of data •Detection of the earliest signs of • Intervention based on results disease •So further exposure can be limited
C-2 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
NEEDS ASSESSMENT GOALS & TARGETS
• Review Industrial Processes • Health Effects From Exposure • Screening for Disease • Review Exposure Potential – Occupational (Noise, Pneumoconiosis, – Review Material Toxicology Bladder Cancer, etc.) • Be selective – Available Guidelines • Gear towards population at risk • OSHA • NIOSH • Detect in latent phase, not just symptoms • ACGIH – Medical literature, texts, & databases
Hearing Protection GOALS & TARGETS
• Sound levels measured in workplace – Sound Pressure Meter • Screening for Disease (cont.) – Sound Dosimeter (TWA) – Occupational – Usually done by industrial hygienist • Test should be valid & reliable – Must look at both peak and TWA noise • Longitudinal studies required • Benefit should outweigh cost • If > 85 dBA – then must have program & make • Early treatment should be available & effective hearing protection devices available • If > 90 dBA – must use hearing protection
CHOOSING TESTING MODALITIES Issues for Workers
• Intrusiveness of the test • Physical Examination – Breath – Effectiveness in screening is limited – Urine – Signs are late finding – X-Rays – Should be directed toward target organ(s) – Blood – Perceived benefit to patient – CT/MRI – Allows counseling & motivation – Pathology specimens • Who learns Results • Potential impacts on employment
C-3 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
CHOOSING TESTING MODALITIES CHOOSING TESTING MODALITIES
• Questionnaires • Pulmonary Function Tests – Directed toward symptoms associated with agent – Integral part of “obstructive” occupational – No good commercially available, standardized lung disorder monitoring forms – Best when compared longitudinally – Impacted by cigarette smoking & non- occupational medical conditions (asthma, COPD) – ACOEM Position Paper
CHOOSING TESTING MODALITIES Coal Worker’s Health Program
• Chest X-Ray (TB, Silicosis, Asbestosis) • History of program (1969) – Baseline – Variable disease penetrance – Not frequently (usually every 5-10 years) – Discord between health-based recommendations and engineering capacity of the day – Done after review of symptoms +/- pulmonary functions • Screening CXR – Every 5 years with NIOSH- provided B-reading • If Positive: – Transfer to “low-dust” job – Preserved pay and benefits
Coal Worker’s Health Program CHOOSING TESTING MODALITIES
• About 5,000 films per year – ~400 positive for CWP • Biological Monitoring – 10-15% of positives ever apply to MSHA for – Assesses exposure transfer rights – Effectiveness of controls ? • Formal vs Informal program – Not diagnostic – Who gets results? – Agent presence does not prove disease (exception: Pb) – Are actions mandatory? • Risk to worker of using transfer rights
C-4 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
CHOOSING TESTING MODALITIES Lead (OSHA 1910.1025) Measure Disease • Biological Monitoring (cont.) • Whole Blood Lead Assess control measures – Appropriate specimen critical • Measures agents or metabolites • Measures direct effect • Zinc Protoporphyrin (ZPP) Catch Chelators – RBCs - lead – Beta 2 microglobulin - protein losing nephropathies – Cholinesterase - carbamates or organophosphates • BUN, Cr, UA Monitor for • CBC End-Organ • (ZPP) Damage
CHOOSING TESTING MODALITIES CHOOSING TESTING MODALITIES • Cancer Risk Screening – Assessment of Exposure Tests • monitor mutagens in body fluids • Cancer Screening – Urine is only reliable assay • Carcinogens bind to body chemicals (DNA or – Cytological morphology Hemoglobin) • Can detect cancers before symptoms – Cytogenetic monitoring • May not change survival rate • Measures chromosomal aberrations – Cell surface antigens • Immunological studies of exfoliated cells – Bladder Cancer (Benzene) • Currently ONLY research tools, none in – Cervical Cancer (HPV) regulatory exams or common clinical practice
CHOOSING TESTING MODALITIES Analyzing Results
– Specimen levels may not be associated with health effects (exception: inorganic lead) • Cancer Risk Screening – Timing critical – Oncogene activation determination • Average level • Detects protein products coded by genes • Peak level early in malignant process • Worst case scenario • Promising but not yet useful • Employee presence at collection • Half life of agent
C-5 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
Hearing Conservation INTERPRETATION OF DATA Data Analysis • How much change in test results is important? • Nonspecific testing abnormalities • What is normal annual variation? – Example: liver function tests • Can retesting be done? – “Normal variant” • What about other otologic diseases? – Caused by non-occupational factors • Isn’t hearing loss with age “normal”?
Standard Threshold Shift When has hearing changed?
• Math to identify when “enough” hearing loss • Accuracy of the test has occurred for company to pay attention – Accuracy of the machine – Average in dB at 2000, 3000, and 4000 Hz – Precision of each annual measurements – Compare with “Baseline” • What is acceptable inter-test variability in the data? – If average loss >10 dB, then a “threshold shift” – Worker Learning Curve
• But this threshold is arbitrary • Temporary threshold shifts – Concerts, races, ATVs, motorcycles, lawnmowers
Hearing Protection INTERVENTION BASED ON RESULTS
• If Positive (OSHA criteria): – Retesting allowed within 30 days • Abnormality decisions – Medical evaluation allowed (noise vs ENT Disease) – Caused by or aggravated by work – Recordable on OSHA 300 Log conditions? – If Noise-related hearing loss: – Additional workplace testing needed? • Failure in prevention program? – Consequence of lifestyle or non- – Unidentified exposure occupational factors? – Failure of PPE • Epidemiolgical approach helps – Improperly quantified exposure • Understand occupational toxicology • Non-work noise exposures?
C-6 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
IDENTIFICATION OF OVER-EXPOSURES & DISEASE PATTERNS ANALYSIS OF GROUP DATA • Epidemiologist & clinician interaction • Index case investigation • Reporting overexposures may be more – Single case could be indicative comfortable in clinical setting • Case clusters – Physician role to depersonalize – May warrant further investigation • Occupational sentinel health events • Temporal or geographic trends may provide clues of a developing – May show significant pattern pattern of illness • Association with exposure status – Link exposure data with medical data
COMMUNICATION OF COMMUNICATION OF RESULTS RESULTS
• Worker • Worker representative – Timely & understandable – Very Limited access to medical data – Access to data – Could access aggregate data with outliers • Management • Government – Medical opinion - avoid specific medical – Certain circumstances information (exception: Pb levels) • OSHA 300 log • NIOSH HHE (part of CDC) • other agencies (depending on worksite)
Releasing Data to workers Beryllium
• Must include interpretation and explanation in • Complicated disease – Genetic component (with test) language appropriate to the population – Sensitization test available (WBC Lymphocyte Proliferation Test) • Fair PPV, NOV • Give worker option to further disseminate (or – Sensitization can occur without disease not) • What to do with genetic testing (Base pair changes) – Who is tested? • Worker must understand risks of sharing data – Who learns results • – Any impact of results Should not be coerced to divulging results • Testing that reveals sensitization, but NOT disease • Only notify employer if safety concerns (and – Who is tested? – Who Learns Results? tell worker you will do so) – Impact of results?
C-7 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
PROGRAM EVALUATION PROGRAM EVALUATION
• Good Quality Control • Lead to interventions that decreased risk rates – Lab tests • Cost of the program – Physiological tests (PFTs)
• Appropriateness of target population – Percentage at risk tested? • Other diseases identified (and associated cost – Workers not at risk tested savings)
EXAMPLES OF MEDICAL SURVEILLANCE Nanomaterials • What are they like? • New Commercial Substance – Titanium Dioxide – Nanoparticles / Nanomaterials – Carbon Black • No OSHA standards – Not much hollow at that diameter • No NIOSH criteria documents – Asbestos-like? • No ACGIH TLVs established • What Health problems are associated with these? • No known diseases • What body systems would most likely be affected? • What acceptable testing is possible
Issues for Companies TIP OF THE ICEBERG
• Cost of testing/evaluation • Time away from work • Impact on “Injury Rates” • Outcomes: – Restrictions for worker – Worker’s comp claim? – Lawsuit? – Regulatory agency “problems”
C-8 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
Ergonomics
Work Related Musculoskeletal Disorder [MSD] – Term used by OSHA – Includes injuries to: Nerves A Physician’s Guide Tendons AOCOPM Basic Course Muscles & Supporting Structures of Joints
American Osteopathic College of Occupational and Preventive Medicine
Ergonomics Ergonomics Common Areas of Injury Learning Objectives: Hands Shoulders – Able to define Ergonomics & Work Related Wrists Neck Musculoskeletal Disorder Elbows Low Back – Able to define the Elements of an Ergonomics Process – Able to define Ergonomic Risk Factors – Able to discuss Causation issues – Able to define Intervention Strategies
Ergonomics Ergonomics Process
Definitions: Management/Leadership Support – Ergonomics Employee Involvement Ergo = Work Training Nomo = Laws or Study of Ergonomics = study of people & their work Hazard Identification Process Implementing Solutions – Cumulative Trauma Disorder [CTD] Evaluate Impact Cumulative = Building up or Accumulation Trauma = Injury Disorder = Condition or Dysfunction [Plan-Do-Check-Act (PDCA) Process]
D-1 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
Management Support Employee Involvement
Critical to successful implementation Request Feedback on changes Visible to employees Utilize employee groups to: – Consistently communicating the importance of – Identify Problems employee safety & health – Analyze Tasks – Assign process owners & Communicate the – Recommend Solutions responsibilities of process owners – Commit adequate resources – Integrate production processes & improvements with H&S concerns – Accountability
Employee Involvement Training
Benefits: General Ergonomic Training – Additional problem solving capabilities – Ensures employees are informed about ergonomic issues & how to decrease the risk of injury – Hazard Identification assistance – Provided by individuals with experience in ergonomics & – Improves acceptance of changes company’s processes – Provided in a manner & language that all employees can understand – Provide Training for: Managers, Supervisors, Engineers & Maintenance Personnel, and Health Care Providers
Employee Involvement Training
Prompt & early MSD reporting process General Ergonomics Training Engage employees in: – Should include: – Design of work, equipment & procedures Reporting Procedures [Req. by 29 CFR 1904] Company’s Ergonomics Process – Reporting of workplace hazards How to identify ergonomic risk factors – Training Policies & Procedures for avoiding injuries – including Establish a procedure designed to allow proper work practices & equipment employees to raise ergonomic issues without How to recognize early indications of a MSD fear of reprisal Advantages of addressing MSD in their early stages
D-2 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
Training Training
Employees at Risk for MSD Engineers & Maintenance Personnel – Hands-on ergonomics training prior to starting their – How to prevent & correct ergonomic problems full-time production job through proper: – Care, Use & Handling of special tools Job & Workstation Design – Proper use of safety equipment, including PPE Maintenance of equipment related to MSD prevention [e.g. gloves] – Training on ergonomic issues associated with their – Use of proper lifting techniques & devices tools & job tasks
Training Training
Managers Health Care Providers – Training in: – Familiar with the company’s ergonomics process Preventive strategies & their specific responsibilities Early recognition Evaluation Treatment – Sufficient training in ergonomic issues associated Rehabilitation of MSD with their areas, so they can effectively implement the processes – Familiar with the high risk jobs and the types of problems employees may face
Training Hazard Identification
Supervisors 3 Step Process – Receive same training as employees – Analyze existing data – Additional training on: – Conduct initial workplace surveys Recognition of hazardous work practices – Conduct job specific hazard analyses Correction of hazardous work practices Implementation of the ergonomic process How to track ergonomic corrections How to determine whether employees need training on safe work practices How to monitor workers on restricted duty
D-3 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
Hazard Identification Ergonomic Risk Factors
Analysis of existing data Other less common ergonomic risk factors are: – Sources: – Vibration OSHA 300 & 301 reports – Cold First Aid logs Analysis of Workers’ Compensation claims Jobs with multiple risk factors have a higher Incident/Near-miss reports probability of causing MSD Insurance claim reports Employee interviews & surveys
Hazard Identification Job Hazard Analysis
Initial Workplace Survey Observe the operation – Ergonomics Checklist Videotape the process [# reps/min] Assists in identifying relevant risk factors Discuss the work process with the operator – Important ergonomic risk factors are: Force – Amount of physical effort required to perform a Ask yourself two questions – Would I do the task or maintain control of a piece of equipment or tool job this way? & Would I want a loved one Frequency – repetition of the same motion or series of doing this job? motions continually or frequently Posture – Awkward & Static postures
Hazard Identification Intervention Strategies
Ergonomic Risk Factors Engineering Controls – Awkward or Static Postures – examples Work Practices Working above chest/shoulder height Kneeling Administrative Controls Squatting Leaning or frequent Forward Bending Torso rotation, esp. while lifting Sometimes the solution is a “Blinding Flash of Forceful grasping of hand tools Common Sense” Tools held in a non-neutral or fixed position Pinch-grip
D-4 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
Work Practices and Administrative Engineering Controls Controls 1. Most effective. Worker Selection 2. Most costly. – Harmful job demands remain unchanged 3. Industry specific applications of general – May be a discriminatory practice principles Essential Job Function must be clearly defined Any screening/testing must be directly related to the – Lift tables EJF – Hoist/mechanical lift devices Selection criteria must be uniformly applied – Counter Balanced tools
Work Practices and Administrative Work Practices and Administrative Controls Controls Training Worker rotation – Skill training – Common strategy – Proper biomechanics for job tasks – Need to involve different muscle-tendon groups to – Proper tool selection be effective – Correct sequencing of job tasks – Slower, or self-paced-increases worker autonomy – Frequent rest breaks, reduces the frequency factor – Job enlargement-internal job rotation
Work Practices and Administrative Work Practices and Administrative Controls Controls Work Hardening Regular Maintenance: Clean and sharp – Minimum evidence of efficacy instruments reduce required force – Starting new employees at a slower pace Good housekeeping – Warm-up exercises/stretching program
D-5 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
Causation Ticket Counter Complex question: •Extended – Is the report of injury accurate? reaches can – Has job analysis been performed? cause back – Is there a videotape of the process and shoulder – Can you directly observe the operation? injuries. – Are there underlying medical conditions? – Are others having the same problem? – Exacerbation vs. Aggravation
Causation Computer Workstations
Helpful criteria Good working positions include neutral body – Temporally correct relationships positioning which is a comfortable working posture in which your joints are naturally aligned. – Strength of Association This reduces stress and strain on the muscles, – Consistency of Association tendons, and skeletal system and reduces the risk of – Specificity of Association developing a musculoskeletal disorder (MSD). – Biological plausibility
Ticket Computer Counter Workstations •Agents often •The user’s stand for long torso and periods of time leading to neck are fatigue. vertical. •Lifting heavy •Thighs are luggage can lead to ergonomic horizontal hazards. •Lower legs are vertical
D-6 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
Selecting Workstation Components Mouse OSHA has eTools that •Keep mouse close explains how to select to keyboard. and arrange workstation •Alternate hands to components like operate mouse. keyboards, mouse, •Use keyboard wrist/palm supports, shortcuts to reduce chairs, etc. extended use. OSHA website: http://www.osha.gov/SLTC/etools /computerworkstations/compone nts.html
OSHA Computer Workstation Keyboards •Proper placing of Checklist keyboard helps reduce Checklist can help create a safe and exposure to awkward positions, repetition and comfortable computer workstation. contact stress. Has sections on •Consider keyboard - Working Postures •Height •Distance -Keyboard/Input device •Design and use -Monitors -Chairs -Document Holders, etc Website:http://www.osha.gov/SLTC/etools/computerworkstations/checklist.html
Delivery Chairs Trucks •Backrest should conform to curvature •Employees must of spine. perform •Seat should allow repeated feet to rest flat on the elevated reaches floor or footrest. which can result •Armrests should in ergonomic allow elbows to stay hazards. close to body.
D-7 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
Delivery Trucks •Possible solution would be a pullout bar.
Delivery Trucks •Pullout bar reduces stress to shoulders and back.
D-8 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
Objectives Participants will be able to: • Evaluate the impact that various governmental and private sector organizations have upon employers in their management of environmental issues. • Determine the degree to which a broad range of occupational health laws and regulations directly impact clinical practice in occupational medicine • Apply new changes to existing laws which affect occupational medicine practice • Implement an effective clinical program in the Worker Compensation environment Liz Clark, DO, MPH & TM, FAOCOPM • Employ the use of the internet as a valuable resource MY 2012 in the practice of occupational medicine
American Osteopathic College of American Osteopathic College of Occupational and Preventive Medicine Occupational and Preventive Medicine
Occupational Health and Safety Unique Features • Significant Legal and Regulatory Interface • Certain knowledge of association between Introduction EXPOSURE and HEALTH EFFECTS – Lack of uniqueness of manifestations of occupational disease – Long latency periods of many occupational diseases • Emphasis on Prevention in occupational medicine
American Osteopathic College of American Osteopathic College of Occupational and Preventive Medicine Occupational and Preventive Medicine
Definitions Definitions • Laws, Statutes and Acts • The Code of Federal Regulations (CFR) is the – Enacted by Federal or State Legislature codification of the practices and procedures – Provide a guide by which Standards are written of federal administrative agencies published • Regulations and Rules in the Federal Register. Divided into 50 Titles – Promulgated by Federal Agencies representing broad areas subject to federal – Carry “Force of Law” regulation – Promulgated by federal entities such as DOL, DOT, OSHA, EPA
American Osteopathic College of American Osteopathic College of Occupational and Preventive Medicine Occupational and Preventive Medicine
E-1 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
Regulations and Rules • Title 10 - Energy 42 - Public Health • 14 - Aerospace and Space Chapter 1: Public • 21 - Food and Drugs Health Service, • 29 - Labor Dept. HHS Regulatory and – Chapter 4: Wages and 49 - Transportation Hour Advisory* Bodies – Chapter 5: EEOC – Chapter 6: OSHA • 32 - National Defense • 40 - Environment
American Osteopathic College of American Osteopathic College of Occupational and Preventive Medicine Occupational and Preventive Medicine
Governmental Departments Governmental Departments • Department of Labor (DOL) – Equal Employment Opportunity Commission – Occupational Health and Safety Administration • Created under Title VII of Civil Rights Act of 1964 (OSHA) – Provides technical assistance of those subject to provision • Promulgates standards – Intervenes in civil actions of aggrieved parties • Develops regulations • Conducts inspections and investigations – Bureau of Labor Statistics • Issues citations and proposes penalties – Wages and Hour Division – Mining Safety and Health Administration: similar to OSHA – National Institute of Occupational Health and Safety (NIOSH) • Research arm of OSHA: workplace safety, hazardous chemicals • Technical assistance and training
American Osteopathic College of American Osteopathic College of Occupational and Preventive Medicine Occupational and Preventive Medicine
Governmental Departments Governmental Departments • Department of Transportation (DOT) – Major Administrations and Agencies of DOT – Regulate forensic urine drug testing • Office of Drug and Alcohol Policy and Compliance (ODAPC) – Classifies hazardous material transportation • Federal Motor Carrier Safety Administration (FMCSA) • Compressed gas, flammables, oxidizers, corrosives, explosives, • Federal Highway Administration poisons, radioactive materials • Federal Aviation Administration (FAA) – Reviews and comments on environmental impact • Federal Railroad Administration (FRA) studies of major transportation projects • US Coast Guard (USCG) – Regulate interstate transportation • Pipeline and Hazardous Materials Safety Administration (PHMSA) • Federal Transit Administration (FTA)
American Osteopathic College of American Osteopathic College of Occupational and Preventive Medicine Occupational and Preventive Medicine
E-2 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
Governmental Departments Governmental Departments • Health and Human Services (HHS): – Substance Abuse and Mental Health Services – Public Health Service - one of four divisions of HHS Administration (SAMHSA) • Agency for Toxic Substances and Disease Registry (ATSDR) • Implements state-of-the art practices for addictive and mental – Mission: Health related responsibilities of Comprehensive health disorders Environmental Response, Compensation and Liabilities Act – Agency for Toxic Substances and Disease Registry (CERCLA) – Collects, maintains, analyzes and disseminates information – National Toxicology Program (NTP) relating to exposure to toxic or hazardous substances • Coordinates chemical testing and toxicology programs among • Centers for Disease Control and Prevention (CDC) various agencies, including NIOSH – Leadership in control of preventable conditions and responding to public health emergencies – National Institute of Health (NIH) – Collects, maintains, analyzes and disseminates national data on health status and health services • Food and Drug Administration (FDA) – Establishes mandatory standards for food, drug and cosmetics
American Osteopathic College of American Osteopathic College of Occupational and Preventive Medicine Occupational and Preventive Medicine
Governmental Departments Governmental Departments • Environmental Protection Agency (EPA) • Department of Homeland Security (DHS) – Regional Administrators work closely with state – Federal Emergency Management Agency governments • Incident Command System - multi-agency coordination – Goal: to coordinate effective government action to » OSHA - incident command system etool protect the environment through systematic » NFPA - adopted standards abatement and control of pollution » USDA Forestry Service • Emergency Management Institute - Training – Research, monitoring, standard-setting, and – National Incident Management System (NIMS) activities protecting air and water and addressing » Five year training plan hazardous waste disposal and other environmental » Integrated Emergency Management Course threats » Six required online courses for individuals and organizations to be NIMS compliant : ICS: 100, 200, 300, – Issue citations 400, 700, 800
American Osteopathic College of American Osteopathic College of Occupational and Preventive Medicine Occupational and Preventive Medicine
Other Agencies, Institutes Other Agencies, Institutes • American National Standards Institute • National Labor Relations Board - an – Standards for Personal Protective Equipment independent federal agency with no statutory – Some standards incorporated into OSHA regulations enforcement authority • International Agency for Research on Cancer – National Labor Relations Act of 1935, amended by (UN) Taft-Hartley Act of 1947: governs relations between – Provides information on suspected carcinogens employers and unions whose operations involve – Classifications based on evidence of carcinogenicity interstate commerce • National Fire Protection Association - NFPA – Secret balloting 1582 – Unfair practices • American Conference of Governmental – Enforcement through US Court of Appeals Industrial Hygienists
American Osteopathic College of American Osteopathic College of Occupational and Preventive Medicine Occupational and Preventive Medicine
E-3 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
Environmental Protection Agency • Clean Air Act – Established National Ambient Air Quality Standards (NAAQS) • Ozone, carbon monoxide, sulfur dioxide, nitrogen dioxide, particulates and lead – National Emission Standards for Air Pollutants (NESHAPS) • Radon, mercury, beryllium, vinyl chloride, arsenic, benzene, Laws and Related radionuclides • Source categories: dry cleaners, gas distribution points, organic chemical manufacturers Enactments • Clean Water Act – Regulates discharges from industrial and municipal point sources – Discharges into public treatment works • apply best available technology: BAT – Discharges into surface waters • apply best practicable control technology: BPT
American Osteopathic College of American Osteopathic College of Occupational and Preventive Medicine Occupational and Preventive Medicine
Environmental Protection Agency Environmental Protection Agency • Safe Water Drinking Act • Resource Conservation and Recovery Act (RCRA) – EPA to regulate waste management and disposal practices – Each state required to establish standards and restrict – “Cradle to Grave” regulation of generation, storage, transport, pollution treatment and disposal of hazardous waste – Household and commercial sewage • CERCLA: “Superfund” – Comprehensive Environmental Response, Compensation and – Secondary treatment of municipal wastewater prior to Liability Act discharge – Authorizes EPA response to hazardous contamination sites – Addressed legacy of abandoned waste sites • Superfund Amendment and Reauthorization Act (SARA) – Authorizes EPA to respond to environmental emergencies – Emergency Planning and Community Right-to-Know Act (EPCRA): Title III of SARA: emergency response planning
American Osteopathic College of American Osteopathic College of Occupational and Preventive Medicine Occupational and Preventive Medicine
Environmental Protection Agency Department of Labor • Toxic Substances Control Act: ToSCA • Family Medical Leave Act (FMLA)- highlights of – “Cradle to Grave” identification and control of chemicals that pose risk to human health or environment changes – Manufacture, processing, distribution, use and disposal – Military Family Leave – Provides EPA overall picture of chemicals use in US • Military Caregiver Leave - 26 weeks • Qualifying Exigency Leave - 12 weeks • Federal Insecticide, Fungicide and Rodenticide Act • Clarification of questions on new forms for providers (FIFRA) • Clarification of six serious health conditions for employers – Requires toxicological studies – Registration: governs use and distribution • Marine Protection, Research and Sanctuaries Act • Uranium Mill Tailings Radiation Control Act
American Osteopathic College of American Osteopathic College of Occupational and Preventive Medicine Occupational and Preventive Medicine
E-4 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
Department of Labor Department of Labor • Americans with Disabilities Act: ADA-AA • Occupational Safety and Health Act – Effective January 1, 2009 • 15 or more employees – Agency responsibility: enforcement • Question of whether one qualifies should not demand excessive • Inspections, investigations, citations analysis • Expands number entitled to protection – Employer responsibilities • More difficult for employer to defend against claims • Management commitment and employer involvement – Definition of “Disability” construed in favor of broad coverage to maximum extent under terms of ADA • Worksite analysis – Expanded list of “Major Life Activities” and introduces major • Hazard prevention and control body functions • Training for employees, supervisors and managers – Loosens “Substantially Limits” requirement • Reporting and recordkeeping : OSHA 300 logs • Includes episodic impairments and those in remission • Without regard to mitigating measures • Loosens “Substantially Limits” Requirement
American Osteopathic College of American Osteopathic College of Occupational and Preventive Medicine Occupational and Preventive Medicine
Department of Transportation Department of Labor Federal Motor Carrier Safety Administration – Employee responsibilities: compliance, but no enforcement – Physician responsibilities • Physical Qualifications: 49 CFR Part 391.41 • Familiar with OSHA standards • Provide examinations as required by OSHA • Drug and Alcohol Testing: 49 CFR Part 391.11 • Provide information for OSHA recordkeeping • Responsibilities of Medical Examiners: 49 CFR Part • Permit employee access to employee medical records 391.43 • Right to access of chemical information on MSDS • Assist employers in hazard identification – National Registry of Certified Medical Examiners – General Duty Clause – Skill Performance Evaluations (SPE) • Furnish employment and place of employment free from recognized – Medical Expert Panels hazards likely to cause death or serious harm • Frequent source of citations – Exemption Programs – Numerous standards: respiratory, noise, asbestos, others
American Osteopathic College of American Osteopathic College of Occupational and Preventive Medicine Occupational and Preventive Medicine
Guideline and Interpretations • Issued by Agencies to direct or clarify compliance issues with their regulations • Do not have the “Force of Law” – ADA-AA Technical Assistance Manual Worker Compensation – OSHA Compliance Directives – Record Keeping Guidelines (Bureau of Labor Statistics)
American Osteopathic College of American Osteopathic College of Occupational and Preventive Medicine Occupational and Preventive Medicine
E-5 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
Worker Compensation Act Worker Compensation Act • Adopted in 1912 to replace Tort system • Certain federal employees not covered • “No fault” – Postal workers – State operated system – VA hospital workers – Legal standard - not scientific standard – Interstate Railroad workers: Federal Employers Liability Act • Limits amount an employee can recover – Seaman: Merchant Marine Act of 1920 – Longshoremen: Longshoremen’s and Harbor Workers – Wage loss benefits Compensation Act – Cost of medical treatment – Most agricultural workers and very small employers exempt – Rehabilitation services – No punitive damages, pain or suffering
American Osteopathic College of American Osteopathic College of Occupational and Preventive Medicine Occupational and Preventive Medicine
Worker Compensation Act Recent changes • Notice Concerning the Lilly Ledbetter Fair Pay Act of 2009 • HIPPA final rule 164.512 (1) states “a covered • On January 29, 2009, President Obama signed the Lilly Ledbetter Fair Pay Act entity may disclose protected health information of 2009 ("Act"), which supersedes the Supreme Court's decision in Ledbetter v. (PHI) as authorized by and to the extent necessary Goodyear Tire & Rubber Co., Inc., 550 U.S. 618 (2007). Ledbetter had required a compensation discrimination charge to be filed within 180 days of a to comply with laws that provide for work-related discriminatory pay-setting decision (or 300 days in jurisdictions that have a local injuries or illness without regard to fault”. or state law prohibiting the same form of compensation discrimination). – Treatment • The Act restores the pre-Ledbetter position of the EEOC that each paycheck that delivers discriminatory compensation is a wrong actionable under the federal – Operations EEO statutes, regardless of when the discrimination began. As noted in the Act, – Payment it recognizes the "reality of wage discrimination" and restores "bedrock principles of American law." • Under the Act, an individual subjected to compensation discrimination under Title VII of the Civil Rights Act of 1964, the Age Discrimination in Employment Act of 1967, or the Americans with Disabilities Act of 1990 may file a charge within 180 (or 300) days of any of the following:
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Lilly Ledbetter case Sex Discrimination
• ROBERTSON SANITATION TO PAY $475,000 IN EEOC LAWSUIT CHARGING IT FAILED TO HIRE • when a discriminatory compensation decision or other discriminatory practice FEMALE DRIVERS affecting compensation is adopted; • Trash Removal Company Hired Less Qualified Males, EEOC Charged • when the individual becomes subject to a discriminatory compensation decision • ATLANTA – Robertson Sanitation, a Phoenix-based trash hauling, recycling and or other discriminatory practice affecting compensation; or disposal company that operates in Georgia, will pay $475,000 to settle a sex • when the individual's compensation is affected by the application of a discrimination lawsuit brought by the U.S. Equal Employment Opportunity discriminatory compensation decision or other discriminatory practice, including Commission (EEOC), the agency announced today. each time the individual receives compensation that is based in whole or part • According to the EEOC’s suit, Jeanine Moore applied for a truck driver position on such compensation decision or other practice. with Robertson at its Winder, Ga., facility in August 2005. Although she was • The Act has a retroactive effective date of May 28, 2007, and applies to all more qualified than a number of male applicants who were hired, Moore was claims of discriminatory compensation pending on or after that date. never interviewed and never received an offer. The EEOC said that the job applications for the Winder location between January 2005 and September • Notice to Potential Charging Parties: If you are aware of unexplained differences 2006 shows that some of the men hired were less qualified than Moore, between your own compensation and coworkers' compensation and believe that including six males who the agency claims lacked Robertson’s minimum the difference is because of your race, color, religion, sex, national origin, age, qualifications for the truck driver position. Investigation of or disability, you should call 1-800-669-4000 or 1-800-669-6820 (TTY) for more information on filing a charge with the EEOC.
American Osteopathic College of Occupational and Preventive Medicine
E-6 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
Sexual Discrimination • Moore’s allegations revealed a class of similarly qualified women who, like Sexual Discrimination Moore, were also rejected despite their qualifications. The EEOC said the • The decree has a term of four years and requires Robertson to submit a report each year identifying the name, sex and employer subjected female applicants to discriminatory hiring practices at the qualifications of all qualified applicants for truck driver positions, the persons offered positions, and the persons hired. Winder facility as well as the Austell, Ga., facility. Robertson shall also maintain all driver applications for the duration of the decree for inspection, and provide an explanation for each time a qualified female applicant is not offered a position. The EEOC will have the right to review • The consent decree settling the suit provides for $475,000 in monetary relief to Robertson's compliance with the requirements of the decree through, among other things, inspection of all documents used or considered in the hiring process. the class of qualified female applicants who were discriminatorily rejected for • The decree also provides that Robertson shall not discriminate against qualified applicants on the basis of gender, nor employment between January 1, 2005 and October 31, 2006. Moore will retaliate against any person who opposed discriminatory practices or participates in proceedings under Title VII. The decree also includes provisions for equal employment opportunity training, reporting, and posting of notices. In the suit receive $ 70,000 in damages while the remaining funds will be distributed and consent decree, Robertson Sanitation denied any liability or wrongdoing. among the remaining qualified claimants whose eligibility will be determined by • “We are pleased with the employer’s efforts to quickly resolve this dispute, while taking affirmative steps to remain in a procedure set forth in the decree. compliance with the law in the future,” said Robert Dawkins, regional attorney for the EEOC’s Atlanta District Office. “The decree takes into consideration the fact that Robertson hired seven female drivers after the discrimination charge • In addition to the monetary relief, Robertson Sanitation, a division of Republic was filed. The hiring goals are designed to ensure that the employer continues hiring qualified women in the future.” Services of Georgia, has agreed to exercise good faith in offering employment to • The EEOC is responsible for enforcing federal laws prohibiting employment discrimination based on race, color, gender (including sexual harassment and pregnancy), religion, national origin, age, disability and retaliation. Further qualified female applicants for residential, commercial, industrial and roll-off information about the EEOC is available on its web site20at www.eeoc.gov. truck driver positions at the Winder and Austell facilities. According to the • PRESS RELEASE decree, “good faith will be measured against the standard of offering 2-12-09 employment to at least 70% of the females in the qualified applicant pool.”
American Osteopathic College of Occupational and Preventive Medicine
Pregnancy Discrimination • MOVIE PRODUCTION COMPANIES RESOLVE PREGNANCY DISCRIMINATION CASE WITH EEOC Pregnancy Discrimination • ‘Stranger Than Fiction’ Production Companies to Pay $75,000 to Pregnant Job Applicant • CHICAGO – Crick Pictures, L.L.C., and Mandate Pictures, L.L.C., will pay $75,000 to settle a federal pregnancy discrimination suit brought by the U.S. Equal Employment Opportunity Commission (EEOC), • The consent decree settling the suit, signed by Judge Gottschall of U.S. District Court in Chicago today, the agency announced today. The EEOC’s suit had charged that movie production companies Crick and provides that the defendants will pay the pregnant applicant and her attorneys a total of $75,000, less Mandate refused to hire a pregnant job applicant, Cynthia Castillo-Hill, for a position as an extras applicable taxes. The decree enjoins the companies from future pregnancy discrimination and casting assistant after they learned that she was expecting a baby. Castillo-Hill sought work on the film retaliation. It also requires the defendants to provide training to their managers about the obligation to Stranger Than Fiction, which stars Will Ferrell. avoid discrimination. The EEOC suit was originally filed and captioned EEOC v. Crick Pictures, et al., • “The EEOC’s evidence in this case – which included an e-mail from the hiring supervisor – showed that Case No. 08 cv 5005, N.D. Illinois E. Div. the defendants believed that Castillo-Hill’s pregnancy would prevent her from being able to handle the • EEOC Trial Attorney Deborah Hamilton, who worked on the matter, said, “The Pregnancy Discrimination stress and long hours associated with the job though her own doctor had indicated that the job was Act makes clear that pregnant job applicants must be judged on the basis of their job skills and appropriate,” explained EEOC Chicago District Office head Jack C. Rowe. abilities, not on the basis of their pregnancy. We are pleased that the defendants have joined in a • EEOC Regional Attorney John Hendrickson, who oversees all litigation for Chicago District Office, added, voluntary resolution of this suit. All parties thus have saved further time and expense” “It is just this sort of stereotypical decision making by an employer that is prohibited by federal law, and • EEOC Supervisory Trial Attorney Gregory Gochanour, who managed the agency’s litigation of the case, for good reasons.” Pregnancy discrimination violates Title VII of the Civil Rights Act of 1964, as added, “Ms. Castillo-Hill will receive meaningful compensation, and through the consent decree, amended by the Pregnancy Discrimination Act of 1978. protections are in place to ensure that future discrimination is avoided.” • Federal Magistrate Judge Jeffrey Cole in Chicago had presided over a settlement conference that led to the resolution of this case. • The EEOC is responsible for enforcing federal laws prohibiting employment discrimination based on race, color, gender (including sexual harassment and pregnancy), religion, national origin, age, American Osteopathic College of disability and retaliation. Further information about the EEOC is available on its web site at Occupational and Preventive Medicine www.eeoc.gov
Sex Discrimination Sexual Discrimination • LA WEIGHT LOSS SETTLES NATIONWIDE SEX DISCRIMINATION LAWSUIT WITH EEOC • Comp any Refused to Hire Men into Weight Loss Counselor and Other Jobs, Agency Alleged • Requires Pure Weight Loss to use an electronic applicant tracking system for each person hired and for • BALTIMORE – The U.S. Equal Employment Opportunity Commission (EEOC) announced today that it has any person who submits an application, and to provide specific information on applicants by sex and resolved its pattern or practice sex discrimination lawsuit against LA Weight Loss Centers, Inc., other categories defined by the EEOC; and (renamed Pure Weight Loss, Inc., in early 2007), for $20 million and other significant relief. • According to the EEOC’s suit (WDQ-02-CV-648), filed in the U.S. District Court for the District of • Mandates that Pure Weight Loss create a discrimination complaint procedure, post its commitment to Maryland, Pure Weight Loss had a nationwide policy of not hiring qualified males into the positions of equal opportunity and a diverse workforce, and report compliance to the EEOC. counselor/sales, medical assistants, assistant managers, center managers, area supervisors, trainers, • Additionally, the consent decree requires hiring of rejected male applicants and includes numerical and other field positions. Former Area Trainer Kathy Koch was disciplined and fired in retaliation for complaining about the company’s policy of not hiring men and for interviewing male candidates, the benchmarks for hiring and/or promoting men to the positions from which they had been previously EEOC also alleged. excluded; requires Pure Weight Loss to conduct quarterly reviews to assess attainment of its hiring • Pure Weight Loss discontinued its business operations in January 2008 and filed a voluntary petition goals; and, at the EEOC’s option, requires Pure Weight Loss to employ an outside expert to examine the under Chapter 7 of the United States Bankruptcy Code on January 11, 2008, in the U.S. Bankruptcy hiring process to assist in achieving any unmet hiring goals. Court for the Eastern District of Pennsylvania (Case No. 08-10315-JKF). The bankruptcy trustee has agreed to the terms of the consent decree, which was approved by the bankruptcy court. • “We brought this lawsuit to advance the legal right to a workplace free of sex discrimination and to • Refusing to hire qualified applicants because of their gender, maintaining sex-specific job remind employers that they must make employment decisions based on the applicant’s ability to classifications, and retaliating against employees who protest unlawful discriminatory practices violate perform the duties of the job,” said EEOC Philadelphia Regional Attorney Jacqueline McNair, whose Title VII of the Civil Rights Act of 1964. Pursuant to the consent decree and as approved by the jurisdiction includes Maryland. bankruptcy trustee, the EEOC will have a claim in bankruptcy court of $20 million -- $16,842,656 in back pay and $3,157,344 in punitive damages -- payable to men whom the EEOC determined were • “EEOC will strongly pursue employers who choose to flagrantly disregard federal law by engaging in subjected to hiring discrimination because of their sex during the period January 1, 1997, through the systemic gender discrimination,” said EEOC Supervisory Trial Attorney Tracy Hudson Spicer. Added entry of the decree. The portion of the settlement, if any, that the EEOC will be able to obtain through EEOC Senior Trial Attorney Ronald L. Phillips, “The EEOC’s systemic initiative was undertaken to combat its pending bankruptcy court claim is presently unknown. Koch settled with Pure Weight Loss in company-wide discriminatory employment practices like this one.” November 2005. • Along with the monetary relief to the class members, the 10-year consent decree provides for • The EEOC’s Baltimore Field Office litigation team included EEOC attorneys Tracy Hudson Spicer, Ronald significant injunctive relief. The decree applies to all Pure Weight Loss centers or to any successor L. Phillips, Corbett Anderson and Cecile Quinlan. Applying the Commission’s national law firm model, resuming business operations. The decree: the Baltimore team was also assisted in this case by attorneys from EEOC's New York, Boston, St. • Prohibits Pure Weight Loss from discriminating against job applicants or employees because of sex and Louis, Pittsburgh, Indianapolis, Dallas, and Chicago offices. retaliating against any of its employees or applicants; • The EEOC enforces federal laws prohibiting employment discrimination. Further information about the EEOC is available on its web site at www.eeoc.gov. American Osteopathic College of Occupational and Preventive Medicine
E-7 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
Laws and Acts Legal update • Employers And Other Entities Covered By EEO Laws • Title VII of the Civil Rights Act of 1964 and the Americans with Disabilities Act (ADA) cover all Employers with less than 25 employees may private employers, state and local governments, and education institutions that employ 15 or more individuals. These laws also cover private and public employment agencies, labor qualify for a tax credit 35% of premium costs for organizations, and joint labor management committees controlling apprenticeship and training. • The Age Discrimination in Employment Act (ADEA) covers all private employers with 20 or more providing health coverage to their employees, state and local governments (including school districts), employment agencies and labor organizations. employees(PPACA) • The Equal Pay Act (EPA) covers all employers who are covered by the Federal Wage and Hour Law (the Fair Labor Standards Act). Virtually all employers are subject to the provisions of this Those with 50 or more employees (starting in Act. • Multinational Employers 2014) required to pay 60% of minimal essential • U.S.-based companies that employ U.S. citizens outside the United States or its territories, and multinational employers that operate in the United States or its territories, are covered under coverage or pay penalty of $2,000 per EEO laws, with certain exceptions. For answers to common questions about how EEO laws apply to multinational employers, please see: employee • The Equal Employment Opportunity Responsibilities of Multinational Employers • Employee Rights When Working for Multinational Employers
American Osteopathic College of American Osteopathic College of Occupational and Preventive Medicine Occupational and Preventive Medicine
Patient Protection Act 2010 Tax on Insurance • Imposes nondeductible flat dollar amount • Dan aged 40 elects family coverage penalty of $95 per person w/o minimal • Major medical, dental essential coverage (2014) • Value $37,000 $325 in 2015 • This is 9,500 above threshold $695 in 2016 • Dan’s employer would report $9,500 as * This currently is being legally contested 2 separate taxable to insurer suits surrounding the government mandating • Insurer calculates the tax and pays IRS purchase of private insurance is unconstitutional
American Osteopathic College of American Osteopathic College of Occupational and Preventive Medicine Occupational and Preventive Medicine
“Must See” Occ Med TV • Drug and Alcohol – http://www.dol.gov/workingpartners/welcome.html – http://www.dot.gov/ost/dapc • Federal Motor Carrier Safety Administrator Websites – http://www/fmcsa.gov • OSHA – http://www/osha.gov • National Fire Protection Association – http://www.nfpa.org/index.asp • NIOSH – http://www.cdc.gov/NIOSH
American Osteopathic College of American Osteopathic College of Occupational and Preventive Medicine Occupational and Preventive Medicine
E-8 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
The End With special thanks to Dr. Tim Eckstein
Liz Clark, DO, MPH & TM, FAOCOPM [email protected] 210-289-8607
American Osteopathic College of Occupational and Preventive Medicine
E-9 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
Ralph M. Sutherlin, DO, MPH, CPE, FACOEM St Luke’s Occupational Medicine Department Chair Boise, Idaho
• Occupational Medicine • Aerospace Medicine • Public Health & Community Medicine Mid Year Seminar • Family Medicine March 14, 2012 St. Petersburg, FL • (Independent Medical Examiner) • (Medical Review Officer) • FAA (Senior Aviation Medical Examiner) American Osteopathic College of Occupational and Preventive Medicine
Objectives Responsible Staff and Facilities
• Develop a strategy for conducting a workplace walk- • Health and Safety Measures through survey – Safety Officer • Organize a format for recording essential – Nursing staff observations – Medical equipment • Consider unique characteristics of various industries – First aid stations • Consider applicable governmental regulations – Emergency response • Discuss resources – Record storage
Important Documents Relevant OSHA Standards
• Material Safety Data Sheets (MSDS) • Respirator Program • Job Descriptions • Record Keeping • Policies and Procedures • Hazard Communication • Hearing Conservation • Others – Asbestos – Cadmium – Lead – Blood borne pathogens • General Duty Clause
F-1 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
Hazardous Substances Toxic Substance
• Inhalation • Toxic Substances Control Act • Ingestion – Storage • Skin contact – Labeling – Disposal
Disaster/Violence Response Exposures
• SARA, title III • Ergonomic • Humidity – Emergency response and community right- to- know law • Radiation • Noise • Office of Homeland Security • Heat/cold • Dusts • Critical Incident Response • – Defusing • Vibration Illumination – Debriefing • Infection
Hazards Control Measures
• Engineering controls • Slip, trip and fall hazards • Administrative Controls – Oil drips • – Waxed floors Personal Protective Equipment – Debris – Loose grates – Gravel – Uneven terrain – Assembly line bridges – Icy parking lots and sidewalks
F-2 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
Monitoring and Surveillance Training Procedures
• Industrial Hygiene • Lockout / tagout – Monitoring procedures • Confined space entry – Historical data • Welding and cutting – Record storage • Medical Surveillance • Compressed gas line repair – Procedures • PPE storage and care – Historical data • Critical incident response – Record storage
Substance Abuse Corporate Culture
• Corporate policies • Union presence • Drug and alcohol testing programs – Collective bargaining agreements – DOT compliance • Absenteeism/tardiness – Non-DOT programs • Turnover – MRO services • Age of workforce • Employee Assistance Program (EAP) • Employee ownership • Employee autonomy • Management style
NAVY HEALTH PROMOTIONS Services and Facilities
• Shower, wash and restroom facilities FORGE THE FUTURE MISSIONMISSIONVISIONVISION • Cafeterias The Health Promotion Program The Mission of the Health • of NAVMARCORESCEN Grand Promotion Committee is to Food and water source and handling Rapids will enable attainment of promote optimal health for • Break areas the highest level of readiness the entire Naval Community achievable in the Naval Reserve. by providing comprehensive, • Garbage and waste disposal high quality Health Promotion activities which will reduce preventable disease and injury.
F-3 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
Other Operations Traffic Control
• Off-production maintenance procedures • In-plant • Water purification plant – Avenues of entrance and egress • Local industrial partners – Foot and forklift traffic lanes • Parking lot – General design – Signals, entrances and exits – Surface maintenance
Resources
• NIOSH Safety Checklist Program for schools – 1-800-35-NIOSH • The Workplace Walk-Through, by James P. Kornberg, Lewis Publishers, 1992 • Work Site Risk Assessment – D.H. Cordes, D. F. Rea Ralph M. Sutherlin, DO, MPH, CPE, FACOEM (208)409-0609 – Primary Care, Vol 21, No. 2, 1994 [email protected]
F-4 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
LECTURE OBJECTIVES
• Understand the definition of “toxicology” • Identify various aspects of chemical exposure • Identify methods & common applications of toxicology in chemical-induced illness • Understand routes & degree of exposure, absorption, & metabolism • Understand exposure-dose response relationship, duration, frequency, distribution, affect on target organ, metabolism, & routes of excretion
American Osteopathic College of Occupational and Preventive Medicine
TOXICOLOGY DEFINITION IDENTIFIES VARIOUS ASPECTS OF CHEMICAL • The scientific study of the: EXPOSURE VIA… Mechanisms of action (adverse effects) caused by exogenous agents (chemical) to the study of • Assessment of Actual Health Damage molecular biology with • Determination of Dose/Response Assimilation of knowledge & techniques from chemistry, mathematics and physics and Relationships Application of this discipline to safety evaluation • Determination of Acceptable and risk assessment. Exposure Limits
METHODS Common Applications • Controlled clinical studies • Controlled clinical studies • Epidemiologic studies (e.g. cohort, case • Epidemiologic studies (e.g. cohort, case control, cross sectional, etc.) control, cross sectional, etc.) • Animal/cell system testing (assumes • Animal/cell system testing (assumes underlying end target cells in either model underlying end target cells in either model is equivalent to humans) is equivalent to humans)
G-1 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
Chemical-Induced Exposure Routes Illness • Lungs – inhalation Need practical understanding of a chemical’s • GI tract – ingestion Exposure Routes • Skin – absorption & penetration Absorption (parenteral administration) Metabolism • Subcutaneous • Intravenous Distribution • Intramuscular Excretion • Intraperitoneal
Dose Response Exposure Routes Relationship Potency and Response Rates in • Toxicity usually worsens with increasing Decreasing Order dose – Intravenous – Often determined through animal models – Inhalation – common occupational Not always valid in diseases – Intraperitoneal e.g., hypersensitivity pneumonitis antigen – Intradermal dose needed for symptoms may be small after – Oral initial sensitization – Dermal – common occupational •
Exposure Duration Exposure Frequency
• Single Dose • Smaller doses intermittently may allow for • Short term ~ 1 week full or partial repair of damage • Subchronic ~ 3 months • Long term ~ 2+ years - may influence types of effects seen, e.g., immediate effect vs. delayed effects
G-2 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
Absorption Absorption - Lung
• Process by which material passes through • Gases (H2S, CO) body membranes (defenses) & enters • Particulates (silica, asbestos) blood stream – Absorption is usually in alveoli (large surface • Administration affects area 50-100 sq meters) – Rate of absorption – Concentration of toxicant at target tissues over time
Absorption - Lung Absorption - Skin
• Key determinants • Route of entry - substance must pass – Solubility through either epidermal cells, sweat – Concentration glands, sebaceous glands, or hair follicles – Rate and depth of respiration • Epidermal cells: most important as it – Cardiac output constitutes the largest surface area – Particle size • >5 µm – nasopharyngeal • 2-5 µm tracheobronchiolar • 1 µm or below alveolar
Absorption - Epidermis Absorption - Epidermis
• Must first pass through the stratum • Substances usually readily diffuse due to corneum (rate limiting membrane barrier) structure (porous, nonselective, watery) – Passive diffusion with different mechanisms for • Allows entry to capillaries ionized vs non-ionized materials • Animal skin models differ from humans • Differences in skin thickness - degree of permeability in various body regions, e.g., – Guinea pig, pig, monkey - very similar scrotum vs. abdomen vs. foot – Rat/rabbit - more permeable – Cat - less permeable • Compromised by injury (abrasion, burn, etc.)
G-3 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
Skin - Role of Water Absorption - GI Tract
• Normal skin - About 90 grams H2O per gram of • Important in dry tissue – Food chain toxicants., e.g., mercury • With additional water contact get a 2-3x – Young children, e.g., lead increase in permeability (wearing of work gloves – Accidental poisoning, e.g., workers eat/smoke & perspiration) with contaminated hands • Certain bipolar solvents, e.g., dimethyl sulfoxide • Less frequent than dermal or inhalation routes (DMSO) can facilitate penetration of toxicants through skin
Absorption - GI Tract Absorption - GI Tract
• Key determinants • Most toxicants cross body membranes by simple – Solubility (lipid) diffusion lipid solubility along with concentration gradient impact rates – Active transport mechanisms (GI membranes) • GI Membrane specialized transport systems – GI motility (ph & ionization state) impacts absorption rates of some toxicants – Physical properties of the toxin • Non-ionized molecules - more lipid soluble – Age • pH - Gastric juice or neutrality of GI contents – Nutritional state may influence ionized or non-ionized states of materials
Absorption - GI Tract Absorption Routes of Administration • Motility – If decreased often increases absorption – If increased often decreases absorption • Route of administration impacts: • Particle size & water solubility play a role – Rate of absorption – Large particles or water insoluble not as likely to – Concentration of toxicant at organ/target readily absorb tissues over time • Metals - may alter absorption of other metals – Cadmium decreases absorption of zinc & copper • Intraperitoneal – Calcium decreases cadmium • Subcutaneous – Zinc decreases copper – Magnesium decreases fluoride • Intramuscular • Intravenous - direct to blood
G-4 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
Distribution to Target Organ Distribution to Target Organ
• Via blood or reticuloendothelial system • If one agent displaces a protein-bound • Target organ impact depends on toxicant may see significant impact, for chemical’s ability to pass through cell example: membranes & tissue affinity for substance – Sulfonamide drug given to patient • Plasma bound chemicals may bind with taking oral hypoglycemic may displace protein (albumin) & not be significantly oral hypoglycemic drug causing toxic until unbound chemicals saturate hypoglycemic coma protein diffuse through capillaries
Distribution to Target Organ Distribution to Target Organ
• Lipid soluble molecules with a molecular • When material accumulates in weight of 50 or less readily permeate cell toxicologically inactive sites (e.g., adipose membranes tissue) may result in initial protective mechanism • Water soluble diffuse through aqueous • When excreted a delayed impact on target channels or through active transport cells may be seen - e.g., inorganic lead – May concentrate in some areas more than symptoms may be seen some time after others exposure due to slow release from bone & other areas
Target Organ - Examples Target Organ - Examples • Brain - often less because: – Capillary endothelial cells tightly joined • Asbestos & radioactive dusts accumulate lungs – Capillaries surrounded by astrocytes – Lungs become target organ for toxic impact – CNS interstitial fluid has lower protein • Liver & Kidney concentration than other body areas • Materials that do enter the brain are generally: – Concentrate more toxicants due to high – Lipid soluble capacity to bond chemicals along with active – Non-protein bound transport & protein binding capabilities – Non-ionized – Small molecular size
G-5 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
Target Organ - Examples Metabolism
• Fetus • Enzymatic chemical transformations of compounds – Placenta less effective than CNS barriers – Mainly in liver – Some in intestine, kidney, lung, brain & skin Simple diffusion most common mechanism for – • Biotransformation rates impacted by chemicals, viruses, etc. – Age – Sex – Underlying disease – Nutritional status – Presence of enzyme inducing or activating agents (e.g., phenobarbital P450 can rates of transformation of other substances)
Metabolism Excretion - Routes
• Types of metabolism • Kidney (primary) – Catabolic – Oxidations (P-450 mono oxygenases) • Liver & biliary – Reduction – Hydrolysis • Lungs – Synthetic conjugation reactions (joining parent • Sweat material with another to form a third substance) • Glucuronic acid conjugated to: • Tears – Aliphatic & aromatic alcohols – Mercaptans • Breast milk – Certain acids – 1º and 2º aliphatic and aromatic amines
Excretion – Kidney Factors Excretion – Liver Factors
• Passive glomerular filtration • GI tract • Passive tubular diffusion – Blood passes through liver before reaching • Active tubular secretion systemic circulation • Urine pH impacts ionic/non-ionic form of • Liver chemical – Can remove chemicals, biotransform • Lipid solubility chemicals, & lessen reabsorption after bile • Particle size excretion to intestine • Protein binding • Active transport
G-6 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
Excretion - Liver Excretion - Lung Biotransformation • Important for materials that are in the gas • Organic compounds transformed to polar metabolites make them less lipid soluble for GI phase of body temperature or that have reabsorption high vapor pressures • Protein bound chemicals become fully available for biliary excretion – Lead, arsenic, manganese - rapidly concentrated & excreted in bile – Zinc, iron, gold, chromium - poorly concentrated in bile.
Excretion - Breast Milk Excretion - Other
• Primarily lipid soluble compounds • Elimination through sweat, saliva, skin, (e.g., DDT, polycholorinated & hair, & nails polybrominated biphenyls) – Quantitatively of minor importance – May play role in biologic monitoring
Toxicologic Testing Methods Obtaining Toxicology Data
• Influenced by Toxic Substances Control • Methods Act (TSCA) - 1976 – Epidemiologic – EPA requires chemical data 90 days before – In vitro assays production begins • Mutagenic effects – Laboratory animals • Carcinogenic effects • Teratogenic effects • Synergistic effects • Behavioral effects
G-7 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
Animal Testing Toxicity Rating
• In general, if the absorption, distribution, metabolism, & excretion of a material is similar in humans & a particular animal species, test results in that species generally are predictive of human toxicity – Assumes that underlying end-target cells are equivalent
Acute Toxicology Studies Obtaining Toxicology Data
• Animal model • Dermal Irritation, Sensitization, Phototoxicity • One-time dose – Rabbit model (irritation studies) – Evaluate for effects over hours/days/weeks • Patch testing - scores skin change – Helps determine LD 50 (lethal dose 50%) • Phototoxicity – uses UV to irradiate skin – Inhalation studies use LC 50 (lethal – Guinea pigs (sensitization studies) concentration 50%) • Eye irritation – Rabbits often used • Substance put in lower conjunctival sac & eye observed over 3 days
Obtaining Toxicology Data - Obtaining Toxicology Data – Subchronic Exposure Bioassays (Evaluate Carcinogenicity) • Assess mutagenesis/teratogenesis effects on reproduction • Usually rats & mice • Daily administration for 3-4 months – Usually 3 groups (1 for each exposure; 50 • Use human exposure routes animals each) • Usually uses 2 animal models – Control group of 50 • Observe mortality, weight, oral food intake, – Exposure length blood, & chemistries • Generally 30 months for rats • Gross & microscopic evaluation at study end • 24 months for mice
G-8 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
Obtaining Toxicology Data - Obtaining Toxicology Data - Mouse Skin Bioassays In Vitro Assays
• Applied to shaved skin of mice • Use cell cultures & bacterial systems • 2-3X per week outside of animal • Population usually 50 male mice • Use to assess mutagenicity • Single dosage level • Ames assay uses Salmonella typhimurium • Assay for dermal tumors
Tools & Resouces For Tools & Resouces Addressing Potential
Exposure / Effects • ASTDR (Agency for Toxic Substances & • MSDS Disease Registry) • Med line • Toxnet • Tox line • TOMES • IARC Monographs – International Agency for Research on Cancer • ACGIH TLV’s (threshold limit values)
Example Areas for Board Review CASE STUDY
• Occupational Renal, Liver, Lung, • Mercury • 56-year-old homemaker seen at your office has a 3- Cardiovascular, Skin disease • Lead month history of chronic, nonproductive cough with chest pain associated with the cough. The cough has • Vibration effects • Organophosphates recently become unresponsive to OTC liquid cough • Fluorocarbons • Silica suppressants. She denies: • Carbon disulfide • Aluminum – Shortness of breath • Asbestos • Hydrocarbons – Wheezing • Nitroglycerine • Arsenic – Hemoptysis • Enzymatic detergents • Isocyanates – Fever • Platinum salts • Nickel – Chills • Beryllium • Cadmium – Sore throat • Acrylonitrile • Radiation – Hoarseness • Alcohol – Postnasal drip
G-9 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
– Cough • Independent of time of day, physical activity, weather conditions, or exposure to dust or household cleaning agents • Daughter's cigarette smoke does not seem to aggravate the cough – Fatigue – Weight loss - lost 18 pounds over past 6 months without dieting – Physical examination (including HEENT • PMH noncontributory & chest) is normal – Nonsmoker; nondrinker – No contact with known chemical substances or irritants other • No cyanosis than typical household cleaning agents • Family medical history • No clubbing of extremities X4 – Father - died age 65 of myocardial infarction • No palpable lymph nodes – Mother - breast cancer at age 71 – First husband died of CVA 3 years ago – Newly remarried to retired shipyard worker. She & current husband live with 28-year-old daughter & 9 y/o grandson in New Hampshire home – Has not been outside the New England area X5 years.
– Diagnostic tests • CBC - normal. INITIAL CHECK QUESTIONS (Choose the • Chemistry panel – normal with exception of a total one best answer) serum calcium level of 12.7 mg/dL (normal range: 9.2 - 11.0 mg/dL). Given the clinical findings to this point, which of • Chest radiograph - a non-calcified, non-cavitary the following is most likely part of the 3.5 centimeter (cm) mass within parenchyma adjacent to right hilum. No other radiographic differential diagnosis? abnormalities appear. A. Chronic obstructive pulmonary disease (COPD) • Urinalysis results are normal. B. Angina • Purified protein derivative (PPD) skin test for C. Pulmonary tuberculosis tuberculosis negative. D. Primary pulmonary malignancy
The differential diagnosis for the patient's radiographic The following increase the likelihood of a pulmonary solitary pulmonary nodule would include: malignancy: • Primary pulmonary malignancy • Radiographic appearance of the lesion (size & lack of • Metastatic malignancy calcification) • Age • Granulomatous disease (e.g., tuberculosis, coccidioidomycosis, histoplasmosis, nocardiosis) • Sex (current or former women smokers are at higher risk) • Symptoms of cough & weight loss • Arteriovenous (AV) malformation • Hypercalcemia • Pulmonary hamartoma • Absence of residence in or travel to an area endemic for • Bronchial adenoma coccidioidomycosis (southwest USA) or histoplasmosis • Pulmonary abscess (Ohio/Mississippi Valley) • Pseudonodule (e.g., nipple shadow, superficial skin lesion) • Absence of fever or evidence of infectious disease • Sarcoidosis • Negative PPD skin test - does not rule out TB but makes less likely
G-10 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
What further testing might you order? NOTE A. Search for previous chest radiographs for comparison At this point, referral to a specialist such as a B. Low-dose, computerized tomography (LDCT) pulmonologist with expertise and clinical experience diagnosing, treating, and managing lung disease would scan of the lungs be reasonable. C. Lateral chest X-ray D. Sputum studies for cytology and cultures Additional testing and care based on the specialist’s (standard pathogens, fungus, acid-fast bacilli) assessment and recommended treatment plan may include further testing with additional referral E. All of the above (depending on the findings) to an oncologist, a chest surgeon, or both.
Initially, one or more of the following tests might be Which environmental causes have been appropriate: associated with this patient's probable disorder? • Search for previous chest radiographs for comparison • Sputum studies for cytology & cultures (standard pathogens, fungus, acid-fast bacilli) A. Daughter’s smoking. • Lose-dose lung CT scan B. Exposure to increased levels of radon gas • Fiber optic bronchoscopy with bronchial brushings & C. Persistent organic pollutants specimens for cytology/culture. D. Exposure to pesticides from the home’s foundation • If primary lung cancer is detected metastatic work-up E. Toxic products in the patient’s drinking water (scans of the brain, liver, adrenals, and bones) might be indicated. Again, this would be guided by specialist care and recommendations.
Environmental causes of lung cancer may NOTE include: • Arsenic see http://www.atsdr.cdc.gov/csem/arsenic/ As previously mentioned, referral to & consultation with a • Asbestos specialist with expertise & experience diagnosing, treating, & • Chloromethyl ethers managing lung disease should guide treatment options. Referral options might include recommendations for any additional • Chromium referrals to an oncologist, a chest surgeon, or both. Depending on • Ionizing radiation (alpha, beta, gamma, or x-radiation) histological type, local extension into adjacent anatomical • Nickel structures, presence of metastases, & the general health of the • Polycyclic aromatic hydrocarbons patient, treatment options might include surgical excision, • Radon radiation therapy, chemotherapy, & possibly immunotherapy. Again, specialist care and a recommended treatment plan should • Tobacco smoke guide the choice of options.
G-11 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida
RADON
Which route of exposure would most Radon is a radioactive element. Two of its isotopes (radon-220 & radon-222) are progeny in two decay likely have been associated with this chains that begin with naturally occurring thorium and patient's disorder? uranium, respectively, in rock, soil, water, and air. A. Intravenous B. Inhalation Radon is a noble gas. It is colorless, odorless, tasteless, & imperceptible to the senses. Radon gas moves freely C. Intraperitoneal through the air, groundwater, & surface water. The main D. Intradermal source of indoor radon gas infiltration is from soil into buildings. The growing popularity of CT scans and E. Oral nuclear medicine in medical radiation have replaced F. Dermal radon as the primary source of ionizing radiation exposure.
TIP OF THE ICEBERG
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