Partnerships to Care for Our Patients and Communities During COVID-19.

The Coronavirus disease 2019 (COVID-19) pandemic forced not only rapid changes in how clinical care and educational programs are delivered but also challenged academic medical centers (AMCs) like never before. The pandemic made clear the need to have coordinated action based on shared data and shared resources to meet the needs of patients, learners, and communities. Family medicine departments across the country have been key partners in AMCs' responses. The Duke Department of Family Medicine and Community Health (FMCH) was involved in many aspects of Duke University's and Health System's responses, including leadership contributions in delivering employee health and student health services. The pandemic also surfaced the biological and social interactions that reveal underlying socioeconomic inequalities, for which family medicine has advocated since its inception. Key to success was the department's ability to integrate "horizontally" with the broader community, thereby accelerating the institution's response to the pandemic.

Implementation of a Pooled Surveillance Testing Program for Asymptomatic SARS-CoV-2 Infections on a College Campus - Duke University, Durham, North Carolina, August 2-October 11, 2020.

On university campuses and in similar congregate environments, surveillance testing of asymptomatic persons is a critical strategy (1,2) for preventing transmission of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19). All students at Duke University, a private research university in Durham, North Carolina, signed the Duke Compact (3), agreeing to observe mandatory masking, social distancing, and participation in entry and surveillance testing. The university implemented a five-to-one pooled testing program for SARS-CoV-2 using a quantitative, in-house, laboratory-developed, real-time reverse transcription-polymerase chain reaction (RT-PCR) test (4,5). Pooling of specimens to enable large-scale testing while minimizing use of reagents was pioneered during the human immunodeficiency virus pandemic (6). A similar methodology was adapted for Duke University's asymptomatic testing program. The baseline SARS-CoV-2 testing plan was to distribute tests geospatially and temporally across on- and off-campus student populations. By September 20, 2020, asymptomatic testing was scaled up to testing targets, which include testing for residential undergraduates twice weekly, off-campus undergraduates one to two times per week, and graduate students approximately once weekly. In addition, in response to newly identified positive test results, testing was focused in locations or within cohorts where data suggested an increased risk for transmission. Scale-up over 4 weeks entailed redeploying staff members to prepare 15 campus testing sites for specimen collection, developing information management tools, and repurposing laboratory automation to establish an asymptomatic surveillance system. During August 2-October 11, 68,913 specimens from 10,265 graduate and undergraduate students were tested. Eighty-four specimens were positive for SARS-CoV-2, and 51% were among persons with no symptoms. Testing as a result of contact tracing identified 27.4% of infections. A combination of risk-reduction strategies and frequent surveillance testing likely contributed to a prolonged period of low transmission on campus. These findings highlight the importance of combined testing and contact tracing strategies beyond symptomatic testing, in association with other preventive measures. Pooled testing balances resource availability with supply-chain disruptions, high throughput with high sensitivity, and rapid turnaround with an acceptable workload.

Surgical Team Stability and Risk of Sharps-Related Blood and Body Fluid Exposures During Surgical Procedures.

OBJECTIVE: To explore whether surgical teams with greater stability among their members (ie, members have worked together more in the past) experience lower rates of sharps-related percutaneous blood and body fluid exposures (BBFE) during surgical procedures. DESIGN: A 10-year retrospective cohort study. SETTING: A single large academic teaching hospital. PARTICIPANTS: Surgical teams participating in surgical procedures (n=333,073) performed during 2001-2010 and 2,113 reported percutaneous BBFE were analyzed. METHODS: A social network measure (referred to as the team stability index) was used to quantify the extent to which surgical team members worked together in the previous 6 months. Poisson regression was used to examine the effect of team stability on the risk of BBFE while controlling for procedure characteristics and accounting for procedure duration. Separate regression models were generated for percutaneous BBFE involving suture needles and those involving other surgical devices. RESULTS The team stability index was associated with the risk of percutaneous BBFE (adjusted rate ratio, 0.93 [95% CI, 0.88-0.97]). However, the association was stronger for percutaneous BBFE involving devices other than suture needles (adjusted rate ratio, 0.92 [95% CI, 0.85-0.99]) than for exposures involving suture needles (0.96 [0.88-1.04]). CONCLUSIONS: Greater team stability may reduce the risk of percutaneous BBFE during surgical procedures, particularly for exposures involving devices other than suture needles. Additional research should be conducted on the basis of primary data gathered specifically to measure qualities of relationships among surgical team personnel.

Surgical Procedure Characteristics and Risk of Sharps-Related Blood and Body Fluid Exposure.

OBJECTIVE To use a unique multicomponent administrative data set assembled at a large academic teaching hospital to examine the risk of percutaneous blood and body fluid (BBF) exposures occurring in operating rooms. DESIGN A 10-year retrospective cohort design. SETTING A single large academic teaching hospital. PARTICIPANTS All surgical procedures (n=333,073) performed in 2001-2010 as well as 2,113 reported BBF exposures were analyzed. METHODS Crude exposure rates were calculated; Poisson regression was used to analyze risk factors and account for procedure duration. BBF exposures involving suture needles were examined separately from those involving other device types to examine possible differences in risk factors. RESULTS The overall rate of reported BBF exposures was 6.3 per 1,000 surgical procedures (2.9 per 1,000 surgical hours). BBF exposure rates increased with estimated patient blood loss (17.7 exposures per 1,000 procedures with 501-1,000 cc blood loss and 26.4 exposures per 1,000 procedures with >1,000 cc blood loss), number of personnel working in the surgical field during the procedure (34.4 exposures per 1,000 procedures having ≥15 personnel ever in the field), and procedure duration (14.3 exposures per 1,000 procedures lasting 4 to <6 hours, 27.1 exposures per 1,000 procedures lasting ≥6 hours). Regression results showed associations were generally stronger for suture needle-related exposures. CONCLUSIONS Results largely support other studies found in the literature. However, additional research should investigate differences in risk factors for BBF exposures associated with suture needles and those associated with all other device types. Infect. Control Hosp. Epidemiol. 2015;37(1):80-87.

Impacts of Workplace Health Promotion and Wellness Programs on Health Care Utilization and Costs: Results From an Academic Workplace.

OBJECTIVE: This study evaluated the impacts of a long-standing workplace health promotion (HP) program on health care utilization and costs and estimated return on investment (ROI). METHODS: Analyses used a retrospective, observational cohort design based on 7 years (2005 to 2011) of health claims and HP program participation data for 3829 HP participants and 6617 controls. Inverse propensity score-weighted mixed-model regression methods were used to balance employee demographics and comorbidities by study arm. RESULTS: Mean monthly health care costs were $35 less for HP participants compared with controls, and results were robust based on sensitivity analyses. ROI was estimated to be $2.53 for every dollar spent on the HP program. CONCLUSIONS: Results support a positive impact of HP program participation with regard to reduced health care utilization and costs and a positive ROI.

Latex allergy symptoms among health care workers: results from a university health and safety surveillance system.

We sought to describe risk factors for latex glove allergy symptoms among health care workers by combining data from an active clinical surveillance program and a comprehensive occupational health surveillance system. A total of 4,584 employers completed a latex allergy questionnaire. Six percent (n = 276) of subjects reported symptoms consistent with latex allergy. Years of latex glove use was a significant risk factor for latex allergy symptoms even after controlling for the effects of atopy, gender, age, race, fruit, and other allergies. Nurses, medical or lab technicians, physician's assistants, other clinical professionals, and housekeepers had the highest prevalence of latex glove allergy symptoms. Forty subjects (0.87%) who were confirmed as having latex sensitization. Sensitizsation may have been underestimated due to use of specific IgE antibody, less sensitive than skin-prick testing, and tiered design leading to laboratory assessment on a subset of the cohort. This surveillance program identified risk factors for latex allergy symptoms. Our findings provide a basis for tailoring future prevention strategies.

Risk of sharp device-related blood and body fluid exposure in operating rooms.

OBJECTIVE: The risk of percutaneous blood and body fluid (BBF) exposures in operating rooms was analyzed with regard to various properties of surgical procedures. DESIGN: Retrospective cohort study. SETTING: A single university hospital. METHODS: All surgical procedures performed during the period 2001-2002 (n=60,583) were included in the analysis. Administrative data were linked to allow examination of 389 BBF exposures. Stratified exposure rates were calculated; Poisson regression was used to analyze risk factors. Risk of percutaneous BBF exposure was examined separately for events involving suture needles and events involving other device types. RESULTS: Operating room personnel reported 6.4 BBF exposures per 1,000 surgical procedures (2.6 exposures per 1,000 surgical hours). Exposure rates increased with an increase in estimated blood loss (17.5 exposures per 1,000 procedures with 501-1,000 cc blood loss and 22.5 exposures per 1,000 procedures with >1,000 cc blood loss), increased number of personnel ever working in the surgical field (20.5 exposures per 1,000 procedures with 15 or more personnel ever in the field), and increased surgical procedure duration (13.7 exposures per 1,000 procedures that lasted 4-6 hours, 24.0 exposures per 1,000 procedures that lasted 6 hours or more). Associations were generally stronger for suture needle-related exposures. CONCLUSIONS: Our results support the need for prevention programs that are targeted to mitigate the risks for BBF exposure posed by high blood loss during surgery (eg, use of blunt suture needles and a neutral zone for passing surgical equipment) and prolonged duration of surgery (eg, double gloving to defend against the risk of glove perforation associated with long surgery). Further investigation is needed to understand the risks posed by lengthy surgical procedures.

Upper extremity musculoskeletal symptoms and disorders among a cohort of women employed in poultry processing.

BACKGROUND: We evaluated musculoskeletal problems among women employed in poultry processing in rural northeastern North Carolina. Poultry processing is the largest single employer of women in this economically depressed region with a black majority population. METHODS: Data were collected from a cohort of 291 women through interviews and physical exams conducted at 6-month intervals over 3 years. An index of cumulative exposure, based on departmental rankings and work history, was the primary exposure variable. Other variables of interest included work organization factors, other medical conditions, depressive symptoms, children in the home, and hand intensive home activities. Poisson regression with generalized estimating equations was used to evaluate factors associated with occurrences of upper extremity symptoms and incidence of disorders at follow-up. RESULTS: Symptoms making it difficult to maintain work speed or quality and depressive symptoms at baseline were associated with symptoms at follow-up; age, being overweight, and job insecurity at baseline were associated with incident disorders. After considering these factors, the exposure response pattern was J-shaped with risk decreasing in the second quartile of cumulative exposure and then going steadily up; the effect was stronger for disorders. CONCLUSIONS: The pattern of risk is consistent with onset of early musculoskeletal problems among women new to the industry followed by a later increase with continued exposure. Among this highly exposed population, the effects of depressive symptoms and work organization factors were diminished when cumulative exposure was considered, illustrating the contextual nature of the complex relationships between physical work exposures and psychosocial factors.

Depressive symptoms among working women in rural North Carolina: a comparison of women in poultry processing and other low-wage jobs.

We report on the prevalence of self-reported depressive symptoms and associated factors among women employed in a poultry processing plant and a community comparison group of other employed women in northeastern North Carolina in the southern United States. The rural area is poor and sparsely populated with an African American majority. The largest employer of women in the area is a poultry processing plant. The goals of the analyses were 1) to evaluate whether women employed in poultry processing had a higher prevalence of depressive symptoms than other working women from the same geographic area, and 2) to evaluate factors which might be associated with depression among all of these working women, including specific characteristics of their work environment. Recruitment of participants (n=590) and data collection were by community-based staff who were also African American women. Depressive symptoms were measured using the Center for Epidemiologic Studies Depression Scale (CES-D). Work organization factors were measured with the Job Content Questionnaire (JCQ). Log-binomial regression was used to calculate crude and adjusted prevalence ratios. The prevalence of depressive symptoms, based on a CES-D measure of sixteen or more, was 47.8% among the poultry workers and 19.7% among the other working women (prevalence ratio=2.3). After adjusting for socioeconomic variables, health-related quality of life and coping style, the prevalence of depressive symptoms remained 80% higher among the poultry workers. The prevalence of symptoms was also higher among those who perceived low social support at work, hazardous work conditions, job insecurity, and high levels of isometric load. These factors were all more common among the women employed in the poultry plant. The concentration of this low-wage industry in economically depressed rural areas illuminates how class exploitation and racial discrimination may influence disparities in health among working women.

Exploration of work and health disparities among black women employed in poultry processing in the rural south.

We describe an ongoing collaboration that developed as academic investigators responded to a specific request from community members to document health effects on black women of employment in poultry-processing plants in rural North Carolina. Primary outcomes of interest are upper extremity musculoskeletal disorders and function as well as quality of life. Because of concerns of community women and the history of poor labor relations, we decided to conduct this longitudinal study in a manner that did not require involvement of the employer. To provide more detailed insights into the effects of this type of employment, the epidemiologic analyses are supplemented by ethnographic interviews. The resulting approach requires community collaboration. Community-based staff, as paid members of the research team, manage the local project office, recruit and retain participants, conduct interviews, coordinate physical assessments, and participate in outreach. Other community members assisted in the design of the data collection tools and the recruitment of longitudinal study participants and took part in the ethnographic component of the study. This presentation provides an example of one model through which academic researchers and community members can work together productively under challenging circumstances. Notable accomplishments include the recruitment and retention of a cohort of low-income rural black women, often considered hard to reach in research studies. This community-based project includes a number of elements associated with community-based participatory research.

Blood and body fluid exposure risks among health care workers: results from the Duke Health and Safety Surveillance System.

BACKGROUND: Health care workers (HCWs) are at risk of exposures to human blood and body fluids (BBF). Needlestick injuries and splashes place HCWs at risk for numerous blood-borne infections including human immunodeficiency virus (HIV), hepatitis B (HBV), and hepatitis C (HCV). Utilizing a new comprehensive occupational health surveillance system, the objective of this research was to better define the BBF exposure risk and risk factors among employees of a large tertiary medical center. METHODS: A population of 24,425 HCWs employed in jobs with potential BBF exposures was followed for BBF exposure events from 1998 to 2002. BBF exposure rates were calculated for strata defined by age, race, gender, occupation, work location, and duration of employment. Poisson regression was used for detailed analyses of risk factors for BBF exposure. RESULTS: The study population reported 2,730 BBF exposures during the study period, resulting in an overall annual rate of 5.5 events/100 FTEs and a rate of 3.9 for percutaneous exposures. Higher rates were observed for males, persons employed less than 4 years, Hispanic employees, and persons less than 45 years of age. Much higher rates were observed for house staff, nurse anesthetists, inpatient nurses, phlebotomists, and surgical/operating room technicians. Poisson regression results strengthened and extended results from stratified analyses. Rates of percutaneous exposures from hollow needles were found to decrease over the study period; however, exposure rates from suture needles appear to be increasing. CONCLUSION: While continued training efforts need to be directed toward new HCWs, our data also suggest that employees who have been in their job 1-4 years continue to be at higher risk of BBF exposures. This research also points to the need for better safety devices/products and work practices to reduce suture-related injuries.

An integrated comprehensive occupational surveillance system for health care workers.

BACKGROUND: Workers in the health care industry may be exposed to a variety of work-related stressors including infectious, chemical, and physical agents; ergonomic hazards; psychological hazards; and workplace violence. Many of these hazards lack surveillance systems to evaluate exposures and health outcomes. The development and implementation of a comprehensive surveillance system within the Duke University Health System (DUHS) that tracks occupational exposures and stressors as well as injuries and illnesses among a defined population of health care workers (HCWs) is presented. METHODS: Human resources job and work location data were used to define the DUHS population at risk. Outcomes and exposure data from existing occupational health and safety programs, health promotion programs, and employee health insurance claims, were linked with human resources data and de-identified to create the Duke Health and Safety Surveillance System (DHSSS). RESULTS: The surveillance system is described and four examples are presented demonstrating how the system has successfully been used to study consequences of work-related stress, hearing conservation program evaluation, risk factors for back pain and inflammation, and exposures to blood and body fluids (BBF). CONCLUSIONS: Utilization of existing data, often collected for other purposes, can be successfully integrated and used for occupational health surveillance monitoring of HCWs. Use of the DHSSS for etiologic studies, benchmarking, and intervention program evaluation are discussed.

Nail gun injuries among construction workers.

Pneumatic nail guns greatly increase worker productivity and are extensively used in wood frame building construction, with especially high use in residential construction. One surveillance report of nail gun injuries in Washington State has been published; however, other literature consists largely of case reports and case series in trauma journals. The major objective of the current study was to investigate the occurrence of nail gun-associated injuries among construction workers and to identify preventable work-related factors associated with these injuries. Nail gun-related injuries occurring among a cohort of 13,347 carpenters in Ohio who worked union hours during the time period January 1, 1994, until September 30, 1997, were identified by matching the cohort with workers' compensation claims made to the Ohio Bureau of Workers' Compensation. We also analyzed workers' compensation claims for North Carolina Home Builders Association members for the period July 1996-November 1999 to identify nail gun-related injuries. Analyses included stratified analyses of claims by nature and body part injured, calculation of nail gun injury rates, and analyses of free text descriptions of injuries. Overall, nail gun injuries were responsible for 3.9 percent of workers' compensation claims with 8.3 percent to 25.5 percent of claims involving paid lost work time. The overall rate of nail gun injuries (cases per 200,000 work hours) was 0.33 in North Carolina and 0.26 in Ohio, reflecting the greater concentration of wood frame construction workers in the North Carolina population studied. Higher rates of injury were observed for carpenters in North Carolina and among residential carpenters in Ohio. The predominant body part injured was the hands/fingers, with 80 to 89 percent of injuries being nail punctures. Analyses of free text information for puncture injuries found approximately 70 percent of injuries to occur during the framing/sheathing stage of construction. Our data suggest that approximately 69 percent of puncture injuries may be due to an inadvertent gun discharge or misfire, preventable in large part by the use of sequential triggers. Worker training and education also are important components of nail gun injury prevention.

Clinical findings for residents near a polyurethane foam manufacturing plant.

Clinical findings for 38 community residents who complained of symptoms they attributed to exposure to air emissions from nearby fiber processing and polyurethane foam manufacturing facilities are reported. Common complaints included headache, mucosal irritation, shortness of breath, chest tightness, and wheezing. Airway hyperreactivity, measured by methacholine challenge, was observed in 8 individuals (22% of those tested), who also reported temporal relationships between exposure to visible emissions or odors and symptoms consistent with environmentally induced asthma. Six individuals (18.2%) had antibodies to at least 1 of the 3 common industrial diisocyanates. The number of individuals with antibodies to diisocyanates, coupled with the absence of other diisocyanate exposure, was highly suggestive of environmental exposure. The findings raised concern that some residents may have become sensitized to toluene diisocyanate.