NEWS & COMMENTARY

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References & Links

DOT
dms.dot.gov

OSHA
www.osha.gov

NIOSH
www.cdc.gov/niosh

NHCA
www.hearingconservation.org

The Journal SCIENCE
www.sciencemag.org

OSHA’s Adoption of CDC Recommendations Makes Occupational Medicine Clinics Re-Evaluate their Methods of Treating Previous Hepatitis B Immunization Non-Responders. OSHA’s release last month of the Enforcement Procedures for the Occupational Exposure to Bloodborne Pathogens is forcing occupational medicine clinics to re-evaluate their treatment of employees who do not form antibodies after receiving three doses of Hepatitis B vaccine. In the enforcement procedures, OSHA states that it "requires use of the CDC guidelines current at the time of the evaluation or procedure." It directs providers to the most recent guidelines which "recommend that employees who have ongoing contact with patients or blood and are at on-going risk for injuries with sharp instruments or needlesticks be tested for antibody to Hepatitis B surface antigen, one to two months after the completion of the three-dose vaccination series. Employees who do not respond to the primary vaccination series must be revaccinated with a second three-dose vaccine series and retested. Non-responders must be medically evaluated."

Comment: When we first started immunizing employees against hepatitis B the question arose: "What do we do with the people who don’t form antibodies?" There was no clear answer. Some clinics gave a fourth injection. Some a fifth. With its compliance guidelines, OSHA is requiring that if an employee doesn’t form antibodies, the entire three-injection series must be repeated. Make sure you are in compliance. William L. Newkirk, MD (wln)

OSHA Revises Bloodborne Pathogens Compliance Directive. On November 5, 1999, OSHA issued a revision of the compliance directive for enforcement of the 1991 Bloodborne Pathogens Regulations. The new directive is designed to help minimize serious health risks faced by workers exposed to blood and other potentially infectious materials. The directive guides OSHA’s compliance officers in enforcing the standard that covers occupational exposure to bloodborne pathogens and ensures consistent inspection procedures are followed. It updates an earlier directive issued in 1992 and reflects the availability of improved devices, better treatment following exposure and OSHA policy interpretations.

The revised directive emphasizes the importance of an annual review of the employer’s bloodborne pathogens program and the use of safer medical devices to help reduce needlesticks and other sharps injuries. OSHA does not advocate the use of one particular medical device over another. The directive also highlights basic work practices, personal protective equipment and administrative controls. The emphasis on engineering controls results from OSHA’s request last year for ideas and recommendations on ways to better protect workers from contaminated needles or other sharp objects.

Comment: This is not a new standard. It follows California’s law which took affect on July 1, 1999 mandating safety needles. The makers of these products applauded the news. wln

NIOSH Issues Needlestick Alert. On Tuesday, November 23, 1999, the National Institute for Occupational Safety and Health (NIOSH), part of the Centers for Disease Control and Prevention (CDC), recommended that employers adopt strategic measures to protect the Nation’s 8 million health care workers from job-related injuries caused by needles in syringes, intravenous delivery systems, and related medical devices. "Today’s health care workforce faces a multitude of risks," said NIOSH Director Linda Rosenstock, M.D., M.P.H. "We know that needleless devices and safe needle devices can save lives. We must do everything we can to protect the health care workers who have devoted their lives to keeping America healthy."

NIOSH recommendations for work-related needlestick injuries are outlined in a new bulletin, NIOSH Alert: Preventing Needlestick Injuries in Health Care Settings. Developed in collaboration with other CDC centers and with extensive outside scientific review by diverse industry, labor, and public health organizations, the Alert provides detailed guidance and assistance to employers, workers, and others in reducing needlestick injuries. NIOSH recommends that the use of needles be eliminated where possible. If safe and effective alternatives to needles are not available, devices with safety features such as shields and sheaths should be used. Devices should be selected, used, and evaluated as part of a comprehensive program in which safe work practices, such as prohibiting recapping, are established under written procedures, and workers are trained in those practices.

Each healthcare setting should have its own carefully tailored program, developed with front line worker input and review. Hollow-bore needles such as those used in syringes present the greatest risk for needlestick, but potential for injury exists whenever any sharp device is used, the NIOSH Alert reports. Most reported needlesticks involve nurses, but laboratory staff, doctors, housekeepers, and other health care workers are also injured. The Alert suggests examples of devices that may reduce the risk of needlesticks, but advises that no one device will be appropriate or effective for every workplace.

Comment: On November 5, 1999, OSHA issued a revision of the compliance directive for enforcement of the 1991 Bloodborne Pathogens Regulations. NIOSH’s document follows that directive. The general theme is that it is time to use more engineering changes to prevent needlesticks. This is increasingly important because the triple-drug post-needlestick HIV prophylaxis is so poorly tolerated by most people. wln.

New Study Provides Insight into Chronic Pain. Substance P-Saporin targets delivery of a toxic compound to eliminate those nerve cells that transmit pain messages up the spinal cord to the brain. This precise method allows chronic pain to be permanently stopped without affecting other neurons. This technology, created by San Diego-based Advanced Targeting Systems, creates the springboard for providing a one-time injection of a targeted toxin that could result in permanent relief for those suffering constant pain from cancer and other illnesses.

On Friday, November 19, 1999, University of Minnesota researchers reported in the journal Science the results of an animal study that both helps describe the pathophysiology of chronic pain and offers a new approach to its treatment. Chronic pain appears to arise from fewer than 2 percent of the spinal cord neurons. These neurons have receptors for substance P—a neurotransmitter that is elevated in the spinal fluid of patients with fibromyalgia and other chronic pain conditions. In the study, Patrick Mantyh of the University of Minnesota and the Veterans Affairs Medical Center in Minneapolis and colleagues took advantage of the role of substance P to help control chronic pain. After isolating substance P, they attached a neurotoxin, Saporin. In tests on rats, it killed the neurons responsible for causing severe chronic pain, but did not dull the senses against other forms of pain. Within 45 days, tests showed the rats were completely relieved of the chronic pain, but were fully responsive to other stimuli. When the rats were retested at 200 days, the chronic pain had not returned, suggesting that the substance P-Saporin combination may give permanent relief.

Comment: This is an important study for two reasons: First, it provides further support for the mechanism of chronic pain syndromes, including fibromyalgia, which affect many patients seen in occupational medicine programs. Evidence continues to support the notion that these are central nervous system disorders characterized by elevated levels of substance P in the spinal fluid. The substance P, in turn, attaches to the neurons which transmit chronic pain. Second, this elegant study provides the possibility of a new approach to eliminating chronic pain syndromes—by killing the nerve cells involved in the propagation of the syndromes. We’ve come a long way in understanding these syndromes in the last three years. This study is another big step forward. wln.

National Institutes of Health awarded $16 million for two allopathic institutions to study the effects of natural medicine. Oregon Health Sciences University and Kaiser Permante’s Center for Health Research, both in Portland, Oregon will collaborate with several of Portland’s other natural health institutions to study the effects of how natural medicine (often referred to as CAM) affects neurological illnesses and temporomandibular joint (TMJ) disorder. The studies will investigate the effects of numerous naturopathic approaches, oriental medicine, massage, and yoga on TMJ, Alzheimer’s, multiple sclerosis and other neurodegenerative diseases.

Portland is home to nationally recognized alternative medicine colleges in four disciplines: National College of Naturopathic Medicine; Oregon College of Oriental Medicine; Western States Chiropractic College; and Oregon School of Massage, all of which will participate and have equal billing in the grant.

Provider Based Networks Cheaper for Workers’ Comp Injuries. The Workers’ Compensation Research Institute (WCRI) reported in its study, "The Impact of Workers’ Compensation Networks On Medical Costs and Disability Payments," that medical provider networks produced significantly lower costs — 30-50% lower in fact.

The WCRI examined more than 160,000 closed injured worker cases from three states: California, Connecticut and Texas. Lower costs were attributed to reduced utilization of services such as fewer office visits, ancillary tests, surgeries and therapies. Time off work was not extended. Copies of the study are available by calling (617) 661-9274.

DOT Testing Revisions Aimed at Adulterants. Seeking public comments until April 7th, the DOT has proposed revisions to the 49 CFR 40 that are aimed at widespread use of adulterants to beat tests. The proposed rule change would require labs to test all specimens for adulterants, would hold third parties accountable for providing "appropriate service" supporting the employer’s drug and alcohol program, and would allow the reporting of positive test results to all DOT-regulated employers for whom the employee works—not just the employer ordering the test. Comments to the proposed rule can be made at http://dms.dot.gov and clicking SUBMIT.

Comment: If you do a lot of drug testing, you should review the proposed changes and make comments to the DOT. You will find that the proposals affect urine tests more than they do breath alcohol tests, probably because the urine testing regulations are older. Recognize that these changes are only proposals at this time. They do, however, give us an idea of the future direction of testing requirements. wln

Duration-Toxicity Link Reported by the EPA. The EPA is printing a limited number of reports of its 1998 workshop on the relationship between exposure duration and toxicity. The EPA at its Risk Assessment forum said it "is beginning to examine how dose-duration relationships are or can be incorporated into the risk assessment process for less than lifetime exposure." Currently, scientists assume that the overall daily exposure levels are continuous over a lifetime when assessing risks. Now, they are realizing the exposures can come in "bursts or spikes" and can be intermittent. Requests of the report should be made to (800) 490-9198.

Best Practices in Hearing Loss Prevention, a forthcoming publication from NIOSH, was compiled from a meeting held on October 28, 1999 at Wayne State University with the National Hearing Conservation Association (NHCA).