Gary Rischitelli

The risk of acquiring hepatitis B or C among public safety workers

CONTEXT Determination of the occupational risk of hepatitis B and C to public safety workers is important in identifying prevention opportunities and has significant legal and policy implications. OBJECTIVES Characterize the risk of occupationally acquired infection: (1) risk of exposure to blood and body fluids, (2) seroprevalence of hepatitis B and C in the source population, and (3) risk of infection after exposure. DATA SOURCES Electronic search of MEDLINE (1991-1999), HealthStar (1982-1999), and CINAHL (1975-1999) supplemented by selected reference citations and correspondence with authors of relevant articles. STUDY SELECTION Peer-reviewed journal articles (N=702) that addressed the transmission of hepatitis B and C in law enforcement, correctional, fire, emergency medical services, and healthcare personnel were identified. One hundred five (15.0%) articles were selected for full-text retrieval; 72 (68.6%) were selected for inclusion. DATA ABSTRACTION Articles selected for inclusion were abstracted by two reviewers and checked by a third reviewer, using a standard reporting form. DATA SYNTHESIS Evidence tables were constructed, using the standardized abstracts. The tables were designed to summarize data for the key elements of the risk analysis. CONCLUSIONS Data suggest that emergency medical service (EMS) providers are at increased risk of contracting hepatitis B, but data have failed to show an increased prevalence of hepatitis C. EMS providers have exposure risks similar to those of hospital-based healthcare workers. Other public safety workers appear to have lower rates of exposure. Urban areas have much higher prevalence of disease, and public safety workers in those areas are likely to experience a higher incidence of exposure events.

Screening for Elevated Lead Levels in Childhood and Pregnancy: An Updated Summary of Evidence for the US Preventive Services Task Force

BACKGROUND. In 1996, the US Preventive Services Task Force provided recommendations for routine screening of asymptomatic children and pregnant women for elevated blood lead levels. This review updates the evidence for the benefits and harms of screening and intervention for elevated blood lead in asymptomatic children and pregnant women. METHODS. We searched Medline, reference lists of review articles, and tables of contents of leading pediatric journals for studies published in 1995 or later that contained new information about the prevalence, diagnosis, natural course, or treatment of elevated lead levels in asymptomatic children aged 1 to 5 years and pregnant women. RESULTS. The prevalence of elevated blood lead levels among children and women in the United States, like that in the general population, continues to decline sharply, primarily because of marked reductions in environmental exposure, but still varies substantially among different communities and populations. Similar to the findings in 1996, our searches did not identify direct evidence from controlled studies that screening children for elevated blood lead levels results in improved health outcomes, and there was no direct evidence identified from controlled studies that screening improves pregnancy or perinatal outcomes. No new relevant information regarding the accuracy of screening for lead toxicity was identified during the update, and we did not identify evidence that demonstrates that universal screening for blood lead results in better clinical outcomes than targeted screening. Substantial new relevant information regarding the adverse effects of screening and interventions was not identified. CONCLUSIONS. There is no persuasive evidence that screening for elevated lead levels in asymptomatic children will improve clinical outcomes. For those children who are screened and found to have elevated levels, there is conflicting evidence demonstrating the clinical effectiveness of early detection and intervention.

Hepatitis C in urban and rural public safety workers.

A sample of 719 Oregon public safety personnel (police officers, firefighters, and corrections officers) was tested for hepatitis C virus (HCV) antibody after completing a risk questionnaire. Seven of nine positive enzyme immunoassay tests (78%) were confirmed with recombinant immunoblot assay, yielding confirmed prevalence estimates of 1.2% (95% confidence interval, 0.4 to 2.8%) among the 406 firefighters and emergency medical technicians, and 0.7% (95% confidence interval, 0.1 to 2.6%) in 274 corrections personnel. No cases were observed in the 29 participating police officers. Self-reports of the number of workplace exposures to blood were not associated with HCV positivity, and the number of years of public safety employment seemed to be slightly less for HCV-positive subjects. Two of the seven (28.6%) HCV-positive individuals reported having at least one nonoccupational risk factor (odds ratio, 4.3; 95% confidence interval, 0.4 to 27.1), suggesting the greater relative importance of nonoccupational exposures.

Dermatitis in a printed‐circuit board manufacturing facility

Dermatitis complaints are frequently encountered among workers in the microelectronics industry and have been associated with a variety of physical, chemical and psychosocial causes. Employees working in the silk‐screening and kiln‐drying areas of a printed‐circuit board manufacturer complained of recurrent itching and rashes. This case report describes those symptoms and the results of a brief survey of the affected employees, which provided useful data regarding the likely aetiology. A brief epidemiological survey instrument was used to gain information regarding the pattern, duration and frequency of employee symptoms. Data from the survey were used to identify seasonal variations in symptoms that correlated with specific environmental factors in the plant. A brief epidemiological investigation using a self‐reported symptom survey was an efficient tool to catalogue the character, pattern, duration and frequency of complaints that correlated with specific environmental factors in the plant (temperature and low humidity), which were likely causes of the outbreak.

Career risk of hepatitis C virus infection among U.S. emergency medical and public safety workers.

OBJECTIVE A probabilistic model was used to analyze the cumulative risk of occupational hepatitis C virus (HCV) infection among U.S. public safety workers. METHODS A model for the career risk of HCV was developed using the frequency of parenteral exposures to blood, the population seroprevalence of HCV, and the risk of seroconversion after exposure. Estimates of key input variables were obtained from published studies. RESULTS Calculated estimates of the 30-year risk of infection ranged from <0.1% for police, firefighters, and corrections officers to 1.9% among paramedics and emergency department personnel in high-risk communities. Infrequent exposure to high-risk blood seems to present a greater risk of infection than more frequent contact to low-risk populations. CONCLUSIONS Use of a probabilistic risk assessment model using published data can assist in policy decisions designed to protect the health and safety of workers. Further efforts to document the frequency of occupationally acquired HCV are needed.

The future of environmental medicine in Environmental Health Perspectives: where should we be headed?

Rounds in Environmental Medicine” as a regular feature (Hu 1998; Hu and Woolf 2003). This soon led to an expanded Environmental Medicine section that aimed to regularly publish articles in the Grand Rounds format as well as reviews, commentaries, case reports, and research articles, all of relevance to environmental medicine, with a focus mainly on clinical practice. The Grand Rounds series has been a resounding success, as reflected by the wide range of environmental medicine topics, the diversity of reporting sources, and the increased physician readership of the journal. Howard Hu served as the first Medical Editor from 1996 to 2004 and was then succeeded by Brian Schwartz; also in 2004, the journal appointed two Associate Medical Editors: Howard Hu and Gary Rischitelli. With this change in medical editorship, we wish to take the opportunity to present our views on the scope of the “environment” and “environmental medicine” and what we believe is the expanding nature of the field. We present this as a sounding board for ideas and not in any way as a definitive discussion of these issues. Our overall goal is to increase physician readership of the journal and engage EHP ’s audience on a wide variety of environmental medicine topics relevant to both clinical and public health practice; this editorial is a first step in achieving this goal. We are in a changing world. The world’s population continues to grow and the proportion of the elderly is increasing, with recognition of the susceptibility to health risks not only in early life but also in late life. The United States, once the greatest manufacturing nation in history, has become primarily a service economy. Many of the high-intensity hazardous exposures that were the traditional focus of early environmental and occupational health practitioners and social reformers are not the threat to large U.S. populations that they once were. Some exposures of concern remain as pockets of high-intensity hazards or as widespread chronic low-level hazards; new threats are being identified; and environmental factors and gene–environment interactions are thought to play a greater role in the etiology of many diseases than previously believed (Newton and Schwartz 2005; Schwartz 2005a, 2005b). We are quickly approaching a global economy, in which there is free movement of capital, goods, information, and services, if not free movement of labor. A great deal of manufacturing has shifted to developing countries, accompanied by levels of hazardous exposures not seen in the developed world in decades (LaDou 1994, 2002, 2003), and these countries frequently have few occupational or environmental health resources to address such hazards (LaDou 2002, 2003). With this global economy, we have witnessed a global movement of exposures and other environmental hazards. Toxicants released in one geographic area can influence health at great distances, and agents not previously considered to be pollutants, such as carbon dioxide, are having profound impacts on global climate patterns. Global environmental health threats now include not only climate change but also ecosystem decay, species loss, deforestation and desertification, sea level rise, fisheries decline, and stratospheric ozone depletion, to name but a few. Traditionally, environmental health specialists have thought about the ways that the environment can influence human health in terms of the hazardous agents, sources, and routes of exposure. This led to a focus on how human activities have resulted in contamination of air, food, water, and soil, and, in turn, how the contaminants can adversely affect human health. The purview of environmental health has more recently been expanded to bear on the potential impact on health of other components of the environment and on multiple scales, from local to global. Although the definition of “environment,” as it pertains to environmental health, is not our main focus in this editorial, it has clearly been evolving and needs to be articulated, so its effects on human health and medical practice in relation to each other can be articulated more clearly. To that end, we discuss the environment in terms of four main domains: the natural, anthropogenic, social, and cultural environments. The natural environment includes those features that did not arise from human activities, and can include radon; earthquakes, volcanism, and other natural disasters; cosmic ionizing radiation; certain infectious diseases; and other similar hazards. The anthropogenic environment is what has been created or altered by humans; it includes hazards from toxicants—the traditional practice core of environmental medicine—as well as the built environment, and how this may influence health-related behaviors. In contrast to declines in manufacturing and traditional hazardous exposures in the United States, land use has been dramatically outstripping population growth in most parts of the country (Frumkin et al. 2004). A growing literature describes how urban sprawl and the local food environment can influence health (Ewing 2005; Ewing et al. 2003a; Ewing et al. 2003b; Handy et al. 2002). The social environment involves the interactions between people in various places, and can include factors such as social disorganization, safety, physical disorder, commercial vitality, and economic deprivation, measured at the neighborhood level. A growing literature has documented a contextual effect of the social environment on a variety of health outcomes after control for critical individual-level risk factors (Pickett and Pearl 2001); perhaps more important, the social environment may affect several underlying biologic pathways that can modify how the body responds to toxicants or other traditional environmental hazardous exposures (McEwen 2000a, 2000b, 2000c, 2002). Finally, the cultural environment is important because, for example, cultural norms can influence an individual’s interaction with the environment; if the cultural norm is to engage in physical activity, it is more likely that individual community members will also do so. Without consideration of this influence, for example, studies of land use and physical activity could reach erroneous conclusions. Clearly, as the concept of “environment” evolves from the traditional notions of hazards to the built, social, and cultural environments on several scales, it has expanded or created new interfaces with the fields of individual and social behavior, psychology, sociology, ecology, land use, architecture, and other disciplines. This suggests to us that the role of physicians in environmental health and medicine must also evolve if they are to remain relevant and for physicians to have an impact in addressing individual and population health threats that can arise from these old and new environmental challenges.

Assessing data sources for state-level occupational fatality rates: Oregon, 2003–2007

BACKGROUND This study assesses state-level data sources for numerators and denominators in occupational fatality rates. Data from Oregon Fatality Assessment and Control Evaluation, 2003-2007, are used to assess numerators, and to produce fatality rates using different data sources for denominators. METHODS Data sources for state-level occupational fatalities and the employed population are described. A statistical test for interrater reliability is applied in the comparison to Census of Fatal Occupational Injuries data. Odds ratios are calculated in the presentation of incident rates by age. RESULTS Comparison of occupational fatality data sources demonstrates substantial differences. Acquiring appropriate state-level denominator data are limited, particularly for stratified groups. CONCLUSIONS Although not decisive, occupational fatality rates may help confirm areas of concern to guide necessary field work. This assessment of data sources and identification of several priority areas of concern in Oregon may help state researchers direct their own efforts to target priorities for effective interventions.

Defining critical safety behaviors in a point-of-view video observation study of tree fallers at work

Abstract This study aimed to characterize the use of five critical safety behaviors by tree fallers at different skill levels, and to test the feasibility of using a helmet camera to observe work activities directly in a remote environment. Small cameras were mounted on standard hardhats. Video data were obtained for pairs of fallers at four different skill levels, from beginning students to professional fallers. Critical action steps during tree episodes were coded and compared. Critical action steps for fallers were successfully distinguished during work activities. Notable differences were observed among fallers in different skill categories and between individual fallers. This study found that the helmet camera worked well for observing faller work behavior, and that point-of-view video observation may be used to evaluate student loggers and training programs. We also found that professional fallers may have been exposed to increased hazard; care should be observed with helmet cameras designed for professionals.