Design of a systematic approach to workplace exposure medical surveillance protocols

Current toxic tort cases have increased national awareness of health concerns and present an important avenue in which public health scientists can perform a vital function: in litigation, and in public health initiatives and promotions which may result. This review presents a systematic approach, using the paradigm of interactive public health disciplines, for the design of a matrix framework for medical surveillance of workers exposed to toxic substances. The matrix framework design addresses the required scientific bases to support the legal remedy of medical monitoring for workers injured as a result of their exposure to toxic agents. A background of recent legal developments which have a direct impact on the use of scientific expertise in litigation is examined in the context of toxic exposure litigation and the attainment of public health goals. The matrix model is applied to five different workplace exposures: dental mercury, firefighting, vinyl chloride manufacture, radon in mining and silica. An exposure matrix designed by the Department of Energy for government nuclear workers is included as a reference comparison to the design matrix. ^

Using the results of routine laboratory workplace surveillance activities to assess compliance with recommended biosafety guidelines

The biological safety profession has historically functioned within an environment based on recommended practices rather than regulations, so summary data on compliance or noncompliance with recommended practices is largely absent from the professional literature. The absence of safety performance outcome data is unfortunate since the concept of biosafety containment is based on a combination of facility based controls and workplace practices, and persistent failures in either type of controls could ultimately result in injury or death. In addition, the number of laboratories requiring biosafety containment is likely to grow significantly in the coming years in the wake of the terrorist events of 2001. In this study, the outcomes of 768 biosafety level 2 (BSL-2) safety surveys were analyzed for commonalities and trends. Items of non-compliance noted were classified as facility related or practice related. The most frequent item of noncompliance encountered was the failure to re-certify biosafety cabinetry. Not surprisingly, the preponderance of the other frequent items of non-compliance encountered were practice related, such as general housekeeping orderly, changes in compliance levels, as well as establish trends in the elements of items of non-compliance during the sequential survey period. The findings described in this study are significant because, for the first time, the outcomes of compliance with recommended biosafety practices can be characterized and thus used as the basis for focused interventions. Since biosafety is heavily reliant on adherence to specific safety practices, the ability to focus interventions on objectively identified practice-related items of non-compliance can assist in the reduction of worker risk in this area experiencing tremendous growth. The information described is also of heighten importance given the number of workplaces expected to involve potentially infectious agents in the coming years. ^

The population health performance of medical students at two medical schools

Public Health and medicine are complimentary disciplines dedicated to the health and well-being of humankind. Worldwide, medical school accreditation bodies require the inclusion of population health in medical education. In 2003, the Institutes of Medicine (IOM) recommended that all medical students receive basic public health training in population-based prevention. The purpose of this study was to (1) examine the public health clinical performance of third-year medical students at two independent medical schools, (2) compare the public health clinical practice performance of the schools, and (3) identify underlying predictors of high and low public health clinical performance at one of the medical schools. ^ This study is unique in its analysis and report of observed medical student public health clinical practices. The cohort consisted of 751 third-year medical students who completed a required clinical performance exam using trained standardized patients. Medical student performance scores on 24 consensus public health items derived from nine patient cases were analyzed.^ The analysis showed nearly identical results for both medical schools at the 60%, 65%, and 70% pass rate. Students performed poorly on items associated with prevention, behavioral science, and surveillance. Factors associated with high student performance included being from an underrepresented minority, matching to a primary care residency, and high class ranking. A review of medical school curriculum at both schools revealed a lack of training in four public health domains. Nationally, 32% of medical students reported inadequate training in public health in the year 2006.^ These findings suggest more dedicated teaching time for public health domains is needed at the medical schools represented in this study. Finally, more research is needed to assess attainment of public health knowledge and skills for medical students nationwide if we are to meet the recommendations of the IOM. ^

The normal range of the leukocyte count: Implications for surveillance of occupational and environmental exposure and the practice of preventive medicine

Leukopenia, the leukocyte count, and prognosis of disease are interrelated; a systematic search of the literature was undertaken to ascertain the strength of the evidence. One hundred seventy-one studies were found from 1953 onward pertaining to the predictive capabilities of the leukocyte count. Of those studies, 42 met inclusion criteria. An estimated range of 2,200cells/μL to 7,000cells/μL was determined as that which indicates good prognosis in disease and indicates the least amount of risk to an individual overall. Tables of the evidence are included indicating the disparate populations examined and the possible degree of association. ^

Lab animal allergy surveillance at a private medical school in three dissimilar animal research facilities

Very few studies have described MUP-1 concentrations and measured prevalence of Laboratory Animal Allergy (LAA) at such a diverse institution as the private medical school (MS) that is the focus of this study. Air sampling was performed in three dissimilar animal research facilities at MS and quantitated using a commercially available ELISA. Descriptive data was obtained from an anonymous laboratory animal allergy survey given to both animal facility employees and the researchers who utilize these facilities alike. Logistic regression analysis was then implemented to investigate specific factors that may be predictive of developing LAA as well as factors influencing the reporting of LAA symptoms to the occupational health program. Concentrations of MUP-1 detected ranged from below detectable levels (BDL) to a peak of 22.64 ng/m3 . Overall, 68 employees with symptoms claimed they improved while away from work and only 25 employees reported their symptoms to occupational health. Being Vietnamese, a smoker, not wearing a mask, and working in any facility longer than one year were all significant predictors of having LAA symptoms. This study suggests a LAA monitoring system that relies on self-reporting can be inadequate in estimating LAA problems. In addition, efforts need to be made to target training and educational materials for non-native English speaking employees to overcome language and cultural barriers and address their specific needs. ^

Prevalence and risk factors of methicillin-resistant Staphylococcus aureus in critically-ill hospitalized patients in a tertiary care center in Houston, Texas: An active surveillance pilot project

Objective. The objective of this study is to determine the prevalence of MRSA colonization in adult patients admitted to intensive care units at an urban tertiary care hospital in Houston, Texas and to evaluate the risk factors associated with colonization during a three month active-screening pilot project. Design. This study used secondary data from a small cross-sectional pilot project. Methods. All patients admitted to the seven specialty ICUs were screened for MRSA by nasal culture. Results were obtained utilizing the BD GeneOhm™ IDI-MRSA assay in vitro diagnostic test, for rapid MRSA detection. Statistical analysis was performed using the STATA 10, Epi Info, and JavaStat. Results . 1283/1531 (83.4%) adult ICU admissions were screened for nasal MRSA colonization. Of those screened, demographic and risk factor data was available for 1260/1283 (98.2%). Unresolved results were obtained for 73 patients. Therefore, a total of 1187/1531 (77.5%) of all ICU admissions during the three month study period are described in this analysis. Risk factors associated with colonization included the following: hospitalization within the last six months (odds ratio 2.48 [95% CI, 1.70-3.63], p=0.000), hospitalization within the last 12 months, (odds ratio 2.27 [95% CI, 1.57-3.80], p=0.000), and having diabetes mellitus (odds ratio 1.63 [95% CI, 1.14-2.32], p=0.007). Conclusion. Based on the literature, the prevalence of MRSA for this population is typical of other prevalence studies conducted in the United States and coincides with the continual increasing trend of MRSA colonization. Significant risk factors were similar to those found in previous studies. Overall, the active surveillance screening pilot project has provided valuable information on a population not widely addressed. These findings can aid in future interventions for the education, control, prevention, and treatment of MRSA. ^

Youth population's health issues in Comal County, Texas

This study assesses adolescent's health issues in Comal County, TX. Adolescents are defined as youth between the ages of 12 to 17 years of age, who resided in Comal County during the time period of 2000 to 2007. The analysis focused on high risk behaviors including use of gateway drugs—tobacco and alcohol; illegal substance use; and reproductive health related indicators, including sexual activity, sexually transmitted diseases, and pregnancy. This study is based on the primary and secondary data collected as part of the 2008 Comal County Community Assessment. It compares findings from the primary data sources to extant data from four secondary data sources including: (1) The Centers for Disease Control & Prevention (national) Healthy People 2010; (2) The Centers for Disease Control & Prevention, Youth Risk Behavior Surveillance Survey, 2007; (3) The Texas Department of State Health Services, 2000 to 2007; and The Pride Survey (Local and Statewide). The methods are drawn from the literature on "rapid epidemiologic appraisal" (Annett H. & Rifkin S. B., 1988). The study focus on corroborating the perceptions, subjective concerns, opinions and beliefs of the Comal County key stakeholders and community participants with qualitative and quantitative indicators of health and well being. The value of this approach is to inform community leaders using a public health perspective and evidence in their decisions about priority setting and resources allocation activities for prevention of high risk behaviors and promotion of adolescent health and well being. ^

Use of pulsed-field gel electrophoresis in surveillance of Salmonella in Houston, Texas

Background. Pulsed-field gel electrophoresis (PFGE) is a laboratory technique in which Salmonella DNA banding patterns are used as molecular fingerprints for epidemiologic study for "PFGE clusters". State and national health departments (CDC) use PFGE to detect clusters of related cases and to discover common sources of bacteria in outbreaks. ^ Objectives. Using Houston Department of Health and Human Services (HDHHS) data, the study sought: (1) to describe the epidemiology of Salmonella in Houston, with PFGE subtype as a variable; and (2) to determine whether PFGE patterns and clusters detected in Houston were local appearances of PFGE patterns or clusters that occurred statewide. ^ Methods. During the years 2002 to 2005, the HDHHS collected and analyzed data from routine surveillance of Salmonella. We implemented a protocol, between May 1, 2007 and December 31, 2007, in which PFGE patterns from local cases were sent via e-mail to the Texas Department of State Health Services, to verify whether the local PFGE patterns were also part of statewide clusters. PFGE was performed from 106 patients providing a sample from which Salmonella was isolated in that time period. Local PFGE clusters were investigated, with the enhanced picture obtained by linking local PFGE patterns to PFGE patterns at the state and national level. ^ Results. We found that, during the years 2002 to 2005, there were 66 PFGE clusters, ranging in size from 2 to 22 patients within each cluster. Between different serotypes, there were marked differences in the sizes of PFGE clusters. A common source or risk factor was found in fewer than 5 of the 66 PFGE clusters. With the revised protocol, we found that 19 of 66 local PFGE patterns were indistinguishable from PFGE patterns at Texas DSHS. During the eight months, we identified ten local PFGE clusters with a total of 42 patients. The PFGE pattern for eight of the ten clusters matched the PFGE patterns for cases reported to Texas DSHS from other geographic areas. Five of the ten PFGE patterns matched PFGE patterns for clusters under investigation at PulseNet at the national level. HDHHS epidemiologists identified a mode of transmission in two of the ten local clusters and a common risk factor in a third local cluster. ^ Conclusion. In the extended-study protocol, Houston PFGE patterns were linked to patterns seen at the state and national level. The investigation of PFGE clusters was more efficacious in detecting a common transmission when local data were linked to state and national data. ^

Racial disparities in CD4 counts at initial HIV-1 diagnosis: Analysis of the Adult Spectrum of HIV disease dataset and public health implications

Introduction. The HIV/AIDS disease burden disproportionately affects minority populations, specifically African Americans. While sexual risk behaviors play a role in the observed HIV burden, other factors including gender, age, socioeconomics, and barriers to healthcare access may also be contributory. The goal of this study was to determine how far down the HIV/AIDS disease process people of different ethnicities first present for healthcare. The study specifically analyzed the differences in CD4 cell counts at the initial HIV-1 diagnosis with respect to ethnicity. The study also analyzed racial differences in HIV/AIDS risk factors. ^ Methods. This is a retrospective study using data from the Adult Spectrum of HIV Disease (ASD), collected by the City of Houston Department of Health. The ASD database contains information on newly reported HIV cases in the Harris County District Hospitals between 1989 and 2000. Each patient had an initial and a follow-up report. The extracted variables of interest from the ASD data set were CD4 counts at the initial HIV diagnosis, race, gender, age at HIV diagnosis and behavioral risk factors. One-way ANOVA was used to examine differences in baseline CD4 counts at HIV diagnosis between racial/ethnic groups. Chi square was used to analyze racial differences in risk factors. ^ Results. The analyzed study sample was 4767. The study population was 47% Black, 37% White and 16% Hispanic [p<0.05]. The mean and median CD4 counts at diagnosis were 254 and 193 cells per ml, respectively. At the initial HIV diagnosis Blacks had the highest average CD4 counts (285), followed by Whites (233) and Hispanics (212) [p<0.001 ]. These statistical differences, however, were only observed with CD4 counts above 350 [p<0.001], even when adjusted for age at diagnosis and gender [p<0.05]. Looking at risk factors, Blacks were mostly affected by intravenous drug use (IVDU) and heterosexuality, whereas Whites and Hispanics were more affected by male homosexuality [ p<0.05]. ^ Conclusion. (1) There were statistical differences in CD4 counts with respect to ethnicity, but these differences only existed for CD4 counts above 350. These differences however do not appear to have clinical significance. Antithetically, Blacks had the highest CD4 counts followed by Whites and Hispanics. (2) 50% of this study group clinically had AIDS at their initial HIV diagnosis (median=193), irrespective of ethnicity. It was not clear from data analysis if these observations were due to failure of early HIV surveillance, HIV testing policies or healthcare access. More studies need to be done to address this question. (3) Homosexuality and bisexuality were the biggest risk factors for Whites and Hispanics, whereas for Blacks were mostly affected by heterosexuality and IVDU, implying a need for different public health intervention strategies for these racial groups. ^

The impact of 1995--1996 health sector reforms in the effectiveness of malaria control program in the state of Orissa, India

Malaria poses a significant public health problem worldwide. The World Health Organization indicates that approximately 40% of the world's population and almost 85% of the population from the South–East Asian region is at risk of contracting malaria. India being the most populous country in the region, contributes the highest number of malaria cases and deaths attributed to malaria. Orissa is the state that has the highest number of malaria cases and deaths attributable to malaria. A secondary data analysis was carried out to evaluate the effectiveness of the World bank-assisted Malaria Action Program in the state of Orissa under the health sector reforms of 1995-96. The secondary analysis utilized the government of India's National Anti Malaria Management Information System's (NAMMIS) surveillance data and the National Family Health Survey (NFHS–I and NFHS–II) datasets to compare the malaria mortality and morbidity in the state between 1992-93 and 1998-99. Results revealed no effect of the intervention and indicated an increase of 2.18 times in malaria mortality between 1992-1999 and an increase of 1.53 times in malaria morbidity between 1992-93 and 1998-99 in the state. The difference in the age-adjusted malaria morbidity in the state between the time periods of 1992-93 and 1998-99 proved to be highly significant (t = 4.29 df=16, p<. 0005) whereas the difference between the increase of age-adjusted malaria morbidity during 1992-93 and 1998-99 between Orissa (with intervention) and Bihar (no intervention) proved to be non significant (t=.0471 df=16, p<.50). Factors such as underutilization of World Bank funds for the malaria control program, inadequate health care infrastructure, structural adjustment problems, poor management, poor financial management, parasite resistance to anti-malarial drugs, inadequate supply of drugs and staff shortages may have contributed to the failure of the program in the state.^

The prevalence, health risks, and consequences of asthma among adult residents in Texas

Based on asthma prevalence data collected from the 2000 BRFSS survey, approximately 14.7 million U.S. adults had current asthma, accounting for 7.2% of the total U.S. population. In Texas alone, state data extrapolated from the 1999-2003 Texas BRFSS suggested that approximately 1 million Texas adults were reporting current asthma and approximately 11% of the adult population has been diagnosed with the illness during their lifetime. From a public health perspective, the disease is manageable. Comprehensive state-specific asthma surveillance data are necessary to identify disparities in asthma prevalence and asthma-control characteristics among subpopulations and to develop targeted public health interventions. The purpose of this study was to determine the relative importance of various risk factors of asthma and to examine the impact of asthma on health-related quality of life among adult residents of Texas. ^ The study employed a cross-sectional study of respondents in Texas. The study extracted all the variables related to asthma along with their associated demographic, socioeconomic, and quality of life variables from the 2007 BRFSS data for 17,248 adult residents of Texas aged 18 and older. Chi-square test and logistic regression using SPSS were used in various data analyses on weighted data, adjusting for the complex sample design of the BRFSS data. All chi-square analyses were carried out using SPSS's CSTABULATE command. In addition, logistic regression models were fitted using SPSS's CSLOGISTIC command. ^ Risks factors significantly associated with reporting current asthma included BMI, race/ethnicity, gender, and income. Holding all other variables constant, obese adults were almost twice as likely to report current asthma as those adults who were normal weight (odds ratio [OR], 1.78; 95% confidence interval [CI], 1.25 to 2.53). Other non-Hispanic adults were significantly more likely to report current asthma than non-Hispanic Whites (OR, 2.43; 95% CI, 1.38 to 4.25), while Hispanics were significantly less likely to report current asthma than non-Hispanic Whites (OR, 0.38; 95% CI, 0.25 to 0.60), after controlling for all other variables. After adjusting for all other variables, adult females were almost twice as likely to report current asthma as males (OR, 1.97; 95% CI, 1.49 to 2.60). Adults with household income of less than $15,000 were almost twice as likely to report current asthma as those persons with an annual household income of $50,000 or more (OR, 1.98; 95% CI, 1.33 to 2.94). In regards to the association between asthma and health-related quality of life, after adjusting for age, race/ethnicity, gender, tobacco use, body mass index (BMI), exercise, education, and income, adults with current asthma compared to those without asthma were more likely to report having more than 15 days of unhealthy physical health (OR, 1.84; 95% CI, 1.29 to 2.60). ^ Overall, the findings of this study provide insight and valuable information into the populations in Texas most adversely affected by asthma and health-related consequences of the disease condition. Further research could build on the findings of this study by replicating this study as closely as possible in other asthma settings, and look at the relationship for hospitalization rates, asthma severity, and mortality.^

Health disparities between the United States mainland and Puerto Rico, Guam, and the United States Virgin Islands (United States territories)

Health disparities have been documented for the United States mainland. No literature was found comparing the mainland population to that of Puerto Rico, Guam, and the United States Virgin Islands (United States territories). Using Healthy Lifestyle Characteristics of non-smoking, maintaining a healthy weight, consuming fruits/vegetables daily, and exercising regularly, the health of the mainland was compared to United States territories. The research questions were: (1) Among the characteristics, what are similarities/differences between citizens of the mainland United States and territories?, (2) Among the characteristics, what are similarities/differences in how the territories compare to each other?, (3) Does the mainland and the territories meet Healthy People 2010 goals for these characteristics?, (4) Are perceptions of health concordant or discordant with the characteristics for mainlanders and Puerto Ricans? ^ Using 2007 data from Behavioral Risk Factor Surveillance System (BRFSS), frequency distributions were compared for the Healthy Lifestyle Characteristics for the mainland territories. Research found smoking rates on Guam were statistically greater than the mainland, Puerto Rico or the Virgin Islands. Healthy body mass index levels and physical activity rates were better on Guam compared to other locations. Puerto Rico had significantly more overweight and obese persons, lower fruit/vegetable consumption rates, and lower physical activity rates than the mainland, Guam and the Virgin Islands. Research found mainlanders reported statistically greater participation in regular physical activity than did Puerto Ricans and Virgin Islanders; there were significant differences in fruit/vegetable consumption rates compared to both. The research found no locations met all four of Healthy People 2010 goals. Compared to mainlanders, research showed Puerto Ricans perceive their health significantly worse.^ A better understanding is needed for how United States citizens (mainlanders and territory residents) view participation in healthy behaviors and how health is affected by participating or not in healthy behaviors. For the year examined, Healthy People 2010 goals were not achieved. This study demonstrates Puerto Ricans’ health, using the four characteristics, is significantly worse than residents in the other locations. Public health programs targeting Puerto Ricans are warranted. Finally, this study highlights the need for continued research on the relationships among the mainland and territories.^

Adherence to adjuvant chemotherapy and post-treatment surveillance in a large community-based cohort of patients with colon cancer

The objective of this dissertation was to determine the initiation and completion rates of adjuvant chemotherapy, its toxicity and the compliance rates of post-treatment surveillance for elderly patients with colon cancer using the linked Surveillance, Epidemiology, and End Results – Medicare database.^ The first study assessed the initiation and completion rate of 5-fluorouracil-based adjuvant chemotherapy and its relationship with patient characteristics. Of the 12,265 patients diagnosed with stage III colon adenocarcinoma in 1991-2005, 64.4% received adjuvant chemotherapy within 3-months after tumor resection and 40% of them completed the treatment. Age, marital status, and comorbidity score were significant predictors for chemotherapy initiation and completion.^ The second study estimated the incidence rate of toxicity-related endpoints among stage III colon adenocarcinoma patients treated with chemotherapy in 1991-2005. Of the 12,099 patients, 63.9% underwent chemotherapy and had volume depletion disorder (3-month cumulative incidence rate [CIR]=9.1%), agranulocytosis (CIR=3.4%), diarrhea (CIR=2.4%), nausea and vomiting (CIR=2.3%). Cox regression analysis confirmed such association (HR=2.76; 95% CI=2.42-3.15). The risk of ischemic heart diseases was slightly associated with chemotherapy (HR=1.08), but significantly among patients aged <75 with no comorbidity (HR=1.70). ^ The third study determined the adherence rate of follow-up cares among patients diagnosed with stage I-III colon adenocarcinoma in 2000 - June 2002. We identified 7,348 patients with a median follow-up of 59 months. The adherence rate was 83.9% for office visits, 29.4% for CEA tests, and 74.3% for colonoscopy. Overall, 25.2% met the recommended post-treatment care. Younger age at diagnosis, white race, married, advanced stage, fewer comorbidities, and chemotherapy use were significantly associated with guideline adherence.^ In conclusions, not all colon cancer patients received chemotherapy. Receiving chemotherapy was associated with increased risk of developing gastrointestinal, hematological and cardiac toxicities. Patients were more likely to comply with the schedule for office visits and colonoscopy but failed in CEA tests. ^