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OCCUPATIONAL HEALTH-CARE SERVICES 123 7 Occupational Health-Care Services Part of the mission of an occupational health and safety program is to foster the prevention of occupationally acquired illnesses and injuries, the early recog- nition of health alterations due to occupational exposures, and the treatment and management of occupationally acquired illnesses and injuries. Ideally, the occu- pational health element of the occupational health and safety program encom- passes a multifaceted occupational health-care service that complements the over- all program and meets the institutionâs need for productivity and cost effectiveness. The occupational health-care service works within the occupa- tional health and safety program to ensure that risks associated with the use of research animals are kept to an acceptable minimum. The wide variety of acceptable arrangements for providing occupational health-care services reflects the variation in institutional needs and resources, including the size of the animal care and use program, the nature of the risks, and access to occupational health-care services. The services are provided by groups or individuals that have training or experience in occupational health. The pro- viders include physicians, nurse practitioners, physicianâs assistants, and nurses. Each institution should select or contract for appropriate professional guidance and occupational health-care services to meet the occupational-health needs of its employees. This chapter focuses on occupational health-care services appropriate for employees engaged in the care and use of research animals. The term employee is used as a functional term and refers to all persons whose duties place them near research animals, their derived products, and their tissues. The term is intended to include animal-care personnel, investigators and their technical staff, students 123
124 OCCUPATIONAL HEALTH AND SAFETY OF RESEARCH-ANIMAL WORKERS and other trainees, volunteers, engineers, housekeepers, security officers, and maintenance personnel as appropriate. The occupational health-care services needed for employees vary with the health risk associated with their animal- related research or support activities. Institutions should strive for consistency in the occupational health-care services provided for employees at comparable risk. Institutions often do not provide occupational health-care services for con- tract employees who participate in an animal care and use program. If an institu- tion does not provide services, it should confirm that contractors understand and accept their responsibility for the health and safety of contract workers. The contractor should provide occupational health-care services to its employees that are consistent with those provided by the institution to its employees. The institu- tion with responsibility for the space where the contract workers work is obliged to communicate to the contractor the hazards and risks present in the worksite and rules and procedures for the maintenance of a safe environment, and the contractor is obliged to follow and enforce safe work practices. FEDERAL REQUIREMENTS AND GUIDELINES FOR OCCUPATIONAL HEALTH-CARE SERVICES The Occupational Safety and Health Act mandates that employers provide a safe and healthful workplace for their employees. Occupational health-care ser- vices might be required for the institution to meet its responsibilities under the general-duty clause of the act and those specified in health standards promulgated by the Occupational Safety and Health Administration (OSHA). For example, an institution would be required under the OSHA bloodborne-pathogens standard (29 CFR 1910.1030) to provide hepatitis B vaccinations to employees who handle blood, organs, or other tissues from experimental animals infected with HBV and to make available to an employee a confidential medical evaluation immediately after exposure to animal tissues that are contaminated with a bloodborne patho- gen. The OSHA standard on occupational exposure to hazardous chemicals in laboratories (29 CFR 1910.1450) requires medical surveillance when exposure- monitoring reveals an exposure routinely above the action level for an OSHA- regulated substance, e.g., a time-weighted average (TWA) of 0.75 ppm or a short- term exposure level (STEL) of 2.0 ppm for formaldehyde (29 CFR 1910.1048). However, OSHA action levels are unlikely to be exceeded in an animal care and use setting. The Public Health Service Policy on Humane Care and Use of Laboratory Animals, which was revised in response to the Health Research Extension Act of 1986, requires institutions that receive federal funds to provide occupational health-care services to employees who work in laboratory animal facilities and have substantial animal contact. The National Institutes of Health Guidelines for Research Involving Recombinant DNA Molecules (NIH 1994) requires institu- tions that receive NIH support for recombinant-DNA research to provide occupa-
OCCUPATIONAL HEALTH-CARE SERVICES 125 tional health-care services to employees engaged in animal research involving viable recombinant-DNA-containing microorganisms that need biosafety level 3 or greater containment. The NIH guidelines suggest that, for this level of risk, occupational health-care services would include records of agents handled, active investigation of relevant illnesses, and maintenance of serial serum samples for monitoring serological changes that might result from employeesâ work experi- ence. Specific occupational health-care services are recommended in Biosafety in Microbiological and Biomedical Laboratories (CDC-NIH 1993) for employees engaged in research programs that involve experimentally or naturally infected vertebrate animals. These services are summarized in Table 7-1. This authorita- tive source should be consulted for further detail and guidance regarding the application of these recommendations to specific research situations. ASSESSMENT OF HEALTH RISKS Employees who are involved in the care and use of research animals might face health risks for which specific health-care services should be provided. In most cases, effective use of good animal-care and occupational health and safety practices will be sufficient to protect the health of employees. But some work activities create higher risks of occupational injury and illness (such as handling of heavy cages, e.g., back injuries; direct handling of macaques, e.g., B-virus exposure; and removing litter from cages, e.g., increased exposure to allergens). Institutions are obliged to determine which activities and positions place employ- ees at higher risks and to provide the necessary health-care services for them. Substantial contact with research animals or their tissues is an important consideration in assessing health risks, although it is inadequate as the sole crite- rion for assessing risk. Several aspects of a job merit consideration, including exposure intensity, exposure frequency, the hazards associated with the animal being handled, the hazardous properties of the agents that are used in research, the susceptibility of the individual, and the occupational-health history of previ- ous employees. Ultimately, the determination of risk and of the need for health- care services is a matter of professional judgment, especially when the frequency and intensity of exposures to hazards are borderline. Risk associated with the care and use of research animals can be assessed in accordance with the criteria, classifications, and kinds of information listed in Table 7-2. RESPONSIBILITIES OF AN OCCUPATIONAL HEALTH-CARE SERVICE An occupational health-care service has various important responsibilities: â¢ To commit to developing a detailed knowledge of the occupational haz-
126 OCCUPATIONAL HEALTH AND SAFETY OF RESEARCH-ANIMAL WORKERS TABLE 7-1 Federal Recommendations for Occupational Health-Care Services for Research Programs That Involve Experimentally or Naturally Infected Vertebrate Animals Practice Recommendation Limiting access Employees who are highly susceptible to infection with the agent under study or for whom infection might be unusually hazardous should not work in areas where the agent is handled or where vertebrate animals that are experimentally or naturally infected with the agent are used and cared for. Collection and storage Biosafety level 2: of baseline serum samples When appropriate, considering the agents handled (e.g., where there is substantial risk of occupationally acquired infection with the agent under study and methods are available to measure immunologic response to the agent). Biosafety level 3: For all employees who have access to areas where the agent under study is handled or where vertebrate animals that are experimentally or naturally infected with the agent are used and cared for and where methods are available to measure immunologic response to the agent. Serological surveillance Periodic collection and testing of serum samples for at-risk employees is recommended where there is substantial risk of occupationally acquired infection with the agent under study and methods are available to measure immunologic response to the agent. Testing of the sample should be conducted at each collection and the results communicated to the employee. Immunization Immunizations are recommended for clearly identified at-risk employees where a safe and effective vaccine or toxoid exists (e.g., vaccines against hepatitis B, yellow fever, rabies, and poliomyelitis, and toxoids against diphtheria and tetanus). Decisions for giving less-efficacious vaccines, those associated with high rates of local or systemic reactions, or those which produce increasingly severe reactions with repeated use should be carefully considered. Screening tests Skin testing with purified protein derivative (PPD) of previously skin-test-negative at-risk employees is recommended. Source: CDC-NIH 1993.
OCCUPATIONAL HEALTH-CARE SERVICES 127 TABLE 7-2 Assessment of Risk Associated with Animal-Related Research Possible Criterion Classifications Information Sources Exposure intensity High Job profile, environmental health and Medium safety assessment, employee history Low Absent Exposure frequency 8 h/wk or more Job profile, environmental health and Less than 8 h/wk safety assessment, employee history No direct contact Never Hazards posed by animals Severe illness Institutional veterinarian Moderate illness Mild illness Illness unlikely Hazards posed by materials Severe illness Material-safety data sheets; CDC-NIH used in or with animals Moderate illness agent summary statements; Mild illness radiation-, chemical-, and Illness unlikely biological-safety committees; environmental health and safety staff Susceptibility of employee Direct threata Medical evaluation, review of Permanent increase personal medical records Temporary increase Expected incidence or High Published reports, industry experience prevalence Medium Low Absent History of occupational Severe Worker-compensation reports, illness or injury in the Moderate OSHA 200 log position or workplace Mild None Regulatory requirements Required for any Environmental health and safety contact office, consultants, risk managers Professional judgment permitted aReasonable probability of substantial harm. Americans with Disabilities Act of 1990 (PL 101- 336).
128 OCCUPATIONAL HEALTH AND SAFETY OF RESEARCH-ANIMAL WORKERS ards of employees and an understanding of the temporal and spatial distribution of those hazards. These are referred to below as âthat knowledgeâ and âthat understanding.â â¢ To understand the medical presentation of occupational illness and inju- ries for which employees are at risk. â¢ To understand the characteristics of the workforce, the nature of sensitiv- ity or susceptibility factors among members of the workforce, and how these factors affect the ability of employees to perform their tasks. â¢ To apply that knowledge to an understanding of how employment pre- sents a direct threat to employeesâ health. â¢ To communicate that understanding to the health, safety, and manage- ment teams to assist them in making program decisions that are based on the best available medical knowledge. â¢ To communicate that understanding to potential and current employees so that they can decide whether to accept potential hazards. â¢ To communicate the necessary medical information in the event of an occupational illness or injury in a timely fashion to persons with a need to know, including human-resources, worker-compensation, health and safety, and super- visory personnel. â¢ To strive to maintain objectivity in the face of conflicts that occur because of the occurrence of work-related illness or injury. â¢ To educate employees about early warning signs of occupational illness or injury that should prompt medical action or evaluation. â¢ To provide the institution a considered judgment, based whenever pos- sible on aggregate information, as to the status of occupation-related illness and injury among employees. â¢ To participate in the identification of employees at high risk because of animal-related research. The effectiveness with which those responsibilities are carried out depends on the health-care providerâs knowledge of the employee health risks associated with the care and use of research animals at the institution. It also depends on the opportunity to foster genuine collaboration among all program activities of the institution that manage, support, and conduct the animal care and use program. There is a major need for a basic, accessible body of knowledge about health risks to employees. Health-care providers need to have appropriate training and experience to establish and maintain an effective health-care service as part of an occupational health and safety program for employees involved in the care and use of research animals. The information needed to conduct an occupational- health program is typically acquired from many sources. It is essential that veteri- narians, investigators, and environmental health and safety professionals partici- pate in the orientation and continuing training of health-care providers about zoonoses, exposures, illnesses, and other health risks associated with the care and
OCCUPATIONAL HEALTH-CARE SERVICES 129 use of research animals. Infectious-disease specialists, allergists, dermatologists, and pulmonologists might also have to be consulted about aspects of employee health. ACTIVITIES OF AN OCCUPATIONAL HEALTH-CARE SERVICE The selection of occupational health-care services is based on knowledge of occupational hazards, the nature of health risks associated with animal care and use activities at the institution, and the diversity of employees, the work environ- ment, and the mission of the institution. An occupational health-care service that provides comprehensive health-care services to all employees engaged in the care and use of research animals without consideration of employee risks is expensive and might not convey the understanding that employees must have to minimize occupational-health risks. Greater value comes from occupational health-care services that are selectively and judiciously based on work activities that place employees at risk of occupational injury or illness. For example, a preplacement medical evaluation usually consists of a review of functional de- mands of a position, hazards associated with the animal species involved, poten- tial experimental hazards, and the employeeâs medical history. Such an evalua- tion makes good sense if an employee is being assigned duties that require heavy lifting, the handling of animals that are known to be potential sources of zoonotic infections, the cleaning of cages, or the handling of bloodborne pathogens. But it would not be prudent or cost-effective to perform preplacement evaluations of employees only on the basis of substantial contact with research animals, because resources would be directed where hazards do not exist. The occupational health-care services can include preplacement medical evaluations, periodic health evaluations, episodic health evaluations, analyses of adverse health outcomes, medical management of worker-compensation cases, immunizations, medical recordkeeping, serum-banking, exit evaluations, and nonoccupational health care. The value and relevance of those activities for em- ployees at risk are discussed in the sections that follow. No activity should be selected for inclusion in an institutionâs occupational health-care service without consultation with environmental health and safety professionals and discussion with representatives of the research and animal care and use programs. Identification of Persons at High Risk The institution should identify employees at risk because of animal-related research and determine who should participate in the various activities provided by the health-care service. Categories of employees whose activities should be reviewed are investigators, technicians, animal-facility operators, clerical and other support personnel, students, trainees, visitors, maintenance and housekeep-
130 OCCUPATIONAL HEALTH AND SAFETY OF RESEARCH-ANIMAL WORKERS ing personnel, engineers, and facility-management technicians. The service com- ponents that are needed vary with the nature and intensity of the risk. Interaction with Environmental Health and Safety Staff Interaction between occupational health-care service staff and environmen- tal health and safety staff is necessary to develop workplace-exposure informa- tion needed for health-care services. Such interaction constitutes a process for alerting environmental health and safety professionals to hazards that might re- quire additional control. This interaction is also important for assessing risks associated with activities related to animal research and helps to establish criteria for selecting employees who will routinely receive health-care services. Preplacement (Preassignment) Medical Evaluations The preplacement evaluation serves several functions in the occupational health-care service. Every employee who is identified to participate in various activities of the health-care service and is subject to substantial risk in the animal care and use program should undergo a preplacement medical evaluation. It establishes baseline health information on employees before exposure to the risks associated with animal-related research. Pre-existing conditions that can affect an employeeâs capability to perform the essential functions of his or her position without risk of substantial harm might be identified. Another function is to dis- cuss medical conditions that might alter an employeeâs exposure-risk profile; these could include current conditions (such as tuberculosis) and possible future conditions (such as pregnancy in women of child-bearing age). Medical condi- tions that could temporarily alter fitness for duty or require on-site emergency treatment (such as diabetic hypoglycemia and epileptic seizures) can be noted, and appropriate contingency plans can be made. The preplacement medical evalu- ation also presents an opportunity for education about potential hazards in the workplace, the need for accommodation or personal protection, and medical symptoms that should prompt an employee to seek occupational-health evalua- tion between routine visits. Periodic Health Evaluations Scheduled, periodic health evaluations are often a key component of occupa- tional-health programs. They are most useful when carefully designed to obtain information that can be used to verify the success of the occupational health and safety program in reducing occupational illness and injury. The components and frequency of evaluations depend on the nature of potential hazards. Symptoms of health alterations that are of insufficient severity to be labeled disease can prompt preventive measures. Knowledgeable and experienced peopleâincluding repre-
OCCUPATIONAL HEALTH-CARE SERVICES 131 sentatives of worker compensation, environmental health and safety, personnel (human resources), and the occupational health-care serviceâshould determine the need for and design of periodic health evaluations. There should be a schedule for the re-evaluation of previous decisions, the interval for which depends on changes in exposure or workforce characteristics, injury and illness experience, and the availability of new guidance regarding good occupational-health prac- tice. Physical examinations need not be a routine part of periodic medical evalu- ations. Periodic workplace physical examinations are typically performed on healthy persons and rarely alter judgments about their fitness for duty. Resources can be better spent on aggregating and analyzing health-status information, per- forming worksite tours, and tailoring health programs to be specific to the cir- cumstances of each worksite. The time spent with an employee in a medical evaluation might be better spent in taking a careful history based on a knowledge of worksite risks, informing the employees of the nature of hazards and the means of protecting against them, and warning signals of illness. Episodic Health Evaluations Persistent symptoms, symptoms that indicate the onset of a work-related illness, or the occurrence of a work-related injury should prompt appropriate medical evaluation and care. A physical examination focused on the chief com- plaint is typically needed as a routine part of an episodic health evaluation. The results of some evaluations (such as the finding of an eye injury) are referred directly to specialists, and a mechanism is needed to make the health-care service staff and the environmental health and safety staff also aware of them. As a general rule, any event that leads to medical evaluation and any loss of work time that is thought to be work-related should be reported to the occupational-health information system (BLS 1986). Recognition, Evaluation, Recording, and Followup of Adverse Health Outcomes The incidence and prevalence of medical symptoms, injuries, or illnesses should be assessed periodically. Several mechanisms are used to recognize ad- verse health risks and adverse health outcomes. Incident reports are completed when medical symptoms occur as the result of a workplace event or exposure. They should be reviewed by the health-care service to determine whether medical evaluation is needed; the information should also be reviewed by the environ- mental health and safety staff to determine whether their involvement is needed. âNear-miss reportsâ may be prepared by employees when equipment mal- function or performance error almost results in an accident or substantial expo-
132 OCCUPATIONAL HEALTH AND SAFETY OF RESEARCH-ANIMAL WORKERS sure. Near-miss reports are usually kept by the environmental health and safety staff but can be reviewed by health-care providers. Medical Management of Worker-Compensation Cases The management and treatment of worker-compensation cases by the occu- pational health-care service might be an effective way to reduce incidence, sever- ity, and costs of occupational injuries and illnesses (McGrail and others 1995). This service can provide closer monitoring of an employeeâs ability to return to work than an outside provider unfamiliar with the work setting. Return-to-work examinations allow for review of injuries and illnesses (work-related or personal) not being followed by the occupational health-care service and can facilitate an appropriate and safe return to the worksite. Immunization Immunization programs are an accepted method of protecting people from some infectious diseases. The decision to immunize an employee should be made because of a clearly defined, recognized risk at the time of preplacement, peri- odic, or episodic health evaluations (guidance for administration of specific vac- cines and toxoidsâsuch as for hepatitis B, rabies, and tetanusâis provided by the Public Health Service Advisory Committee on Immunization Practices (IPAC 1996). Medical Recordkeeping It is the responsibility of the employer to maintain medical records related to an employeeâs participation in a health-care service activity. Many employers delegate that responsibility to a contract medical service, but there should be a provision for transfer of records if the contractual arrangement terminates. Aggregation of occupational-health data is commonly overlooked. Preplace- ment and periodic health evaluations are performed on many workers, but their results are seldom analyzed in the aggregate for informational purposes. The information derived from aggregate data can be of great use in guiding program decisions. Consultation with epidemiologists can be useful because they under- stand how and why information should be aggregated. Serum-Banking Serum-banking is the collection and frozen storage of serum samples drawn from employees who might be at risk for occupationally acquired infection. Typically, the purpose of the program is to give the institution the ability to compare serum obtained after an acute illness or exposure with serum obtained
OCCUPATIONAL HEALTH-CARE SERVICES 133 before the illness or exposure began. Although serum-banking has generally been regarded as a standard component of occupational-health programs, it should be conducted only when there is a clear reason for obtaining the specimens and there is a plan to analyze the data as part of a risk-assessment strategy. CDC and NIH (CDC-NIH 1993) recommend serum-banking and serologic surveillance when a substantial risk of occupational illness is associated with an agent under study and methods are available to measure immunologic response to the agent (see Table 7-1). Substantial issues should be considered in advance of instituting a serum- banking program, including chain of custody, confidentiality, identification and handling of samples, retention, potential deterioration of sample quality over time, and cost. The program should include informed consent of employees and allow them to decline to participate. The collection and storage of employee serum should not be performed in the absence of a functioning occupational health and safety program. Exit Evaluations An exit evaluation is defined as a medical evaluation performed when an employee terminates employment. Its purpose is to determine the employeeâs health status when exposure to potential hazards ceases. Such an evaluation has potential value for medical and legal reasons. As a practical matter, however, few employees are interested in undergoing evaluations when they leave an em- ployer; after the final paycheck has been disbursed, there are few incentives for the employee to return. It is unlikely that information useful to an occupational health and safety program will be obtained from exit interviews. Nonoccupational Health Care The occupational health-care service should not be the source of primary medical care for employees. Its use as such a source is discouraged because it diverts resources from aspects of the program aimed at reducing workplace health risks. Some employers choose to use the occupational health-care service for gen- eral health promotion, such as blood-pressure measurement, cholesterol screen- ing, and education about healthy lifestyles. The enthusiasm for that kind of pro- motion should be tempered by an honest assessment of the institutionâs resources that are available for occupational health. PROGRAM EVALUATION Evaluation of the adequacy of a health-care service should focus on whether the health-care providers meet legal requirements and ethical guidelines, accom-
134 OCCUPATIONAL HEALTH AND SAFETY OF RESEARCH-ANIMAL WORKERS plish the mission of the occupational-health program, recognize the essential elements of the health-care service, and deliver the appropriate components of the service. The following conditions are indicators that a program is adequate: â¢ Health-care providers tour the facility and are knowledgeable about the workplace-hazard profile. â¢ The health-care service is aware of the occupational-health profiles of employees as reflected in the worker-compensation claims experience, the OSHA 200 log, first-aid reports, and incident reports. â¢ Medical histories elicit risk-related events (such as the frequency and severity of animal bites). â¢ The health-care service requests consultation from the environmental health and safety staff in the case of health alterations or occupational disease or injury. â¢ The health-care service participates in the development of activities of the occupational health and safety program. â¢ The health-care service provides information to the institution about the occurrence of work-related illnesses and injuries.