Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.
OCR for page 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 institution' s 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, physician's 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
OCR for page 124
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
OCR for page 125
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 employees' 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:
To commit to developing a detailed knowledge of the occupational haz
OCR for page 126
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.
OCR for page 127
OCCUPATIONAL HEALTH-CARE SERVICES
TABLE 7-2 Assessment of Risk Associated with Animal-Related Research
127
Criterion
Possible
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).
OCR for page 128
128 OCCUPATIONAL HEALTH AND SAFETY OF RESEARCH-ANIMAL WORKERS
arcs of employees and an understanding of the temporal and spatial distribution
of those hazards. These are referred to below as "that knowledge" and "that
understanding."
· To understand the medical presentation of occupational illness and inju-
ries for which employees are at risk.
· 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.
· To apply that knowledge to an understanding of how employment pre-
sents a direct threat to employees' health.
.
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.
· To communicate that understanding to potential and current employees so
that they can decide whether to accept potential hazards.
· 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.
.
To strive to maintain objectivity in the face of conflicts that occur because
of the occurrence of work-related illness or injury.
· To educate employees about early warning signs of occupational illness
or injury that should prompt medical action or evaluation.
.
To provide the institution a considered judgment, based whenever pos
sible on aggregate information, as to the status of occupation-related illness and
. .
nJury among emp oyees.
· 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 provider's 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
OCR for page 129
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 employee's 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 Replacement 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 Replacement 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 institution's 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
OCR for page 130
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
employee's 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 employee's 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 people including repre
OCR for page 131
OCCUPATIONAL HEALTH-CARE SERVICES
131
sentatives of worker compensation, environmental health and safety, personnel
(human resources), and the occupational health-care service should 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.
"Near-miss reports" may be prepared by employees when equipment mal-
function or performance error almost results in an accident or substantial expo
OCR for page 132
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 employee's 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 toxoids such as for hepatitis B. rabies, and tetanus is 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 employee's 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
OCR for page 133
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 employee's
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 institution's 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
OCR for page 134
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:
· Health-care providers tour the facility and are knowledgeable about the
workplace-hazard profile.
· 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.
· Medical histories elicit risk-related events (such as the frequency and
severity of animal bites).
· The health-care service requests consultation from the environmental
health and safety staff in the case of health alterations or occupational disease or
. .
nJury.
· The health-care service participates in the development of activities of the
occupational health and safety program.
· The health-care service provides information to the institution about the
occurrence of work-related illnesses and injuries.
Representative terms from entire chapter:
medical evaluation
