ANTHRAX: What Every Clinician Should Know

Bioterrorism & Disaster Planning

United States PHS Updates Guidelines for Occupational Exposure to Bloodborne Pathogens

OSHA Delays Recordkeeping Rule Relating to Hearing Loss & Musculoskeletal Disorders

New Report on the American Workforce 2001

A web broadcast, initially aired October 18th, presents clinical guidelines and procedures for the early recognition, diagnosis, treatment, and reporting of anthrax exposure. A panel of experts from the Centers for Disease Control and Prevention provides an overview of clinical, laboratory, and public health preparedness. Provided by the University of North Carolina School of Public Health: www.sph.unc.edu/about/webcasts/bioter_10-18_stream1.htm.

Bioterrorism & Disaster Planning

The Department of Labor has a FAQ for participants, beneficiaries, and plan sponsors regarding issues arising from the September 11th attacks: http://askpwba.dol.gov. Other resources pertinent to occupational health include: www.cdc.gov, www.aaohn.org, www.acoem.org, and www.osha.gov.

United States PHS Updates Guidelines for Occupational Exposure to Bloodborne Pathogens

On June 29th the U. S. Public Health Service (PHS) released "Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis."

The reports states: "Occupational exposures should be considered urgent medical concerns to ensure timely postexposure management and administration of HBIG, hepatitis B vaccine, and/or HIV PEP."

In 1998, the PHS published guidelines for the management of HIV exposures that included considerations for postexposure prophylaxis (PEP). Since publication of these guidelines, several new antiretroviral agents have been approved by the Food and Drug Administration (FDA), and more information is available about the use and safety of HIV PEP. As a result, in September, 1999, the CDC convened a meeting of a PHS interagency working group and expert consultants to issue updated recommendations for the management of occupational exposure to HIV. In addition, the report was to include recommendations for the management of occupational HBV and HCV exposures so that a single document could comprehensively address the management of occupational exposures to bloodborne pathogens.

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The report updates and consolidates all previous PHS recommendations for the management of health-care personnel (HCP) who have occupational exposure to blood and other body fluids that might contain hepatitis B virus (HBV), hepatitis C virus (HCV), or human immunodeficiency virus (HIV).

HBV: Recommendations for HBV postexposure management include:

• Initiation of the hepatitis B vaccine series to any susceptible, unvaccinated person who sustains an occupational blood or body fluid exposure.

• PEP with hepatitis B immune globulin (HBIG) and/or hepatitis B vaccine series should be considered for occupational exposures after evaluation of the hepatitis B surface antigen status of the source and the vaccination and vaccine-response status of the exposed person.

HCV: Immune globulin and antiviral agents (e.g., interferon with or without ribavirin) are not recommended for PEP of hepatitis C. For HCV postexposure management, the HCV status of the source and the exposed person should be determined, and for HCP exposed to an HCV positive source, follow-up HCV testing should be performed to determine if infection develops.

HIV: Recommendations for HIV PEP include a basic 4-week regimen of two drugs (zidovudine [ZDV] and lamivudine [3TC]; 3TC and stavudine [d4T]; or didanosine [ddI] and d4T) for most HIV exposures and an expanded regimen that includes the addition of a third drug for HIV exposures that pose an increased risk for transmission. When the source person’s virus is known or suspected to be resistant to one or more of the drugs considered for the PEP regimen, the selection of drugs to which the source person’s virus is unlikely to be resistant is recommended.

[Comment: This is MUST reading for occupational health providers who manage workplace exposures to bloodborne pathogens. – William L. Newkirk (wln), MD, FACPM  Note: Reach PHS at www.cdc.gov. Also, new algorithms for bloodborne pathogen exposures have been posted at www.systoc.com.]

OSHA Delays Recordkeeping Rule Relating to Hearing Loss & Musculoskeletal Disorders

On October 12th the Occupational Safety and Health Administration (OSHA) announced that it will delay for one year the effective date of provisions of its recordkeeping rule that relate to the criteria for recording cases of work-related hearing loss and the definition of "musculoskeletal disorders" (MSDs).

The criteria for recording work-related hearing loss. Section 1904.10 of the final recordkeeping rule requires employers to record, by checking the "hearing loss" column on the OSHA 300 Log, a case in which an employee’s audiogram reveals that a Standard Threshold Shift (STS) has occurred. An STS is defined as "a change in hearing threshold, relative to the most recent audiogram for that employee, of an average of 10 decibels (dB) or more at 2000, 3000, and 4000 hertz in one or both ears."

The old recordkeeping rule contained no specific threshold for recording hearing loss cases. In 1991, OSHA issued an enforcement policy on the criteria for recording hearing loss cases, to remain in effect until new criteria were established by rulemaking. The 1991 policy stated that OSHA would cite employers for failing to record work-related shifts in hearing of an average of 25dB or more at 2000, 3000, and 4000 hertz in either ear.

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The debate about the new recordkeeping rule has been whether a 10dB threshold shift constitutes a health condition serious enough to warrant recording. This is necessary because the final rule no longer requires recording of minor or insignificant health conditions. OSHA announced on July 3rd that it intended to delay implementation of the 10dB standard because it felt there was evidence that a 10dB shift may not be a serious health problem, particularly for employees who have not previously sustained hearing loss, and that a 10dB shift may not be a reliable criterion for recording purposes because of normal variations in audiometric measurement.

OSHA will delay implementation of the recording requirements for a 10dB shift for a year while it reconsiders the criteria for recording hearing loss cases. Given this decision, employers will continue to record hearing loss cases during 2002 using the 25dB criterion articulated in OSHA’s 1991 enforcement policy.

The definition of "musculoskeletal disorder." Section 1904.12 provides that if an employee experiences a recordable musculoskeletal disorder, the employer must record it on the OSHA Log and must check the MSD column.

OSHA’s purpose in including an MSD column on the Log was to gather data on "musculoskeletal disorders" as that term is defined in Section 1904.12. Two months after publication of the new recordkeeping rule, Congress disapproved OSHA’s ergonomics standard under the Congressional Review Act. Following Congressional disapproval of the ergonomics standard, OSHA announced that it intends to develop a comprehensive plan to address ergonomics hazards. One of the key issues to be considered in connection with the comprehensive plan is the definition of an ergonomic injury.

Consequently, in July, 2001, OSHA announced that it would be premature to implement the new definition of MSD in Section 1904.12 before considering the views of business, labor, and the public health community on the problem of ergonomic hazards and that implementing such a definition might cause confusion and uncertainty if the definition differs from that adopted under the comprehensive plan.

OSHA is modifying the introduction to Section 1904.12 to inform employers of the policy that will be in effect during 2002. The note also informs the employer that, instead of checking the column on the 300 Log for MSDs (since this column is being removed from the log), the employer is to check the column for "injury" or "all other illness," depending on the circumstances of the case.

New Report on the American Workforce 2001

The Department of Labor, Bureau of Labor Statistics has a new report on the U.S. workforce. Copies may be requested by calling 202.691.5200 or via e-mail at blsdata_staff@bls.gov. The publication may also be viewed on-line at www.dol.gov.

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