[Vaccinations for health care workers exposed to biohazard. Evidences and good medical practices]. / Il Medico Competente e le vaccinazioni nel settore della sanità. Evidenze scientifiche e buone prassi.

Biohazard in healthcare settings is an issue for Occupational Physician (OP), owing to the potential relevant adverse effects for health care workers (HCW) and for the non complete effectiveness of primary prevention. Vaccination represents an effective tool to minimize risk of occupational and nosocomial transmission for many relevant communicable diseases. Implementation of vaccination campaigns may however present some critical aspects. The present study evaluates available scientific evidences and reports an Italian multicenter study (9 Hospitals, 3200 HCW), suggesting good medical practices in vaccination, while highlighting the role of the OP in a multidisciplinary context.

[Focus on risk assessment in health environments: results and perspectives of a multicenter working group]. / Focus sulla valutazione del rischio negli ambienti sanitari: risultati e prospettive di un gruppo di lavoro multicentrico.

The hospital risk assessment (VdR) is certainly a relevant issue concerning the activities of prevention for the health of healthcare workers in relation to biological risk. The aim of this paper is to provide an up-date of the issue, based on the suggestions of recent literature about the rules ratified by the new legislative decree and data supplied by the Group of 10 Hospitals participated in this multicenter study. From the analysis of data on healthcare settings (HCS) participating in the project the following considerations can be formulated: i) All HCS considered VdR from biological agents. The method recommended in the Guidelines SIMLII 2005 is the most followed ii) To grading the risk, the use of invasive procedures for carrying out the analysis results is a necessary element iii) the operators classified as exposed to biological risk, and therefore subject to health surveillance, represent almost all of workforce in 7 out of 10 HCS. The subgroup believes that VdR must be conducted in close collaboration with the occupational physician and should represent a worthwhile investment with spin-off character on prevention, decision making, empowering. The presence of environmental requirements and organizational procedures should be considered, so that HCS is enabled for an effective risk management, without which risk assessments cannot be performed. The method of VdR mentioned in the guidelines MLIS 2005, besides being the most widely used by the company participating in the study, still has practical reasons and opportunities to justify its use. The HCS group felt the need to propose an implementation of the definition of invasive procedures and EPP, together with individual assessment. Flexibility was suggested in identifying different levels of risk with the involvement of occupational physicians, especially in the presence of EPP, also in order to plan content and frequency of health surveillance.

[Tuberculosis. Focus on risk assessment and health surveillance in health workers: results and perspectives of a multicenter working group]. / La tubercolosi. Focus sulla valutazione del rischio e la sorveglianza sanitaria dei lavoratori della sanità: risultati e prospettive di un gruppo di lavoro multicentrico.

INTRODUCTION: Tuberculosis (TB) is still a threat for healthcare workers (HCW), due to the non decreasing incidence, the spread of drug-resistance, the introduction of new tests for the screening, the relevant costs of surveillance of exposed subjects. These issues implicate a revision of activities to prevent TB in health-care settings. METHODS: A multidisciplinary working group, led by occupational physicians, examined the activities to prevent TB performed in 9 Italian hospitals and reviewed the literature, with the aim to formulate evidence-based procedures. RESULTS: In the considered hospitals, 23.000 HCW are classified as exposed to TB, out of 32.000 HCW exposed to biological risks; yearly, about 6000 subjects are screened for preventive, periodical or post-exposure surveillance and 110-130 chemoprophylaxis are prescribed. A high proportion of HCW (54-75%) refused or interrupt to assume the drugs. In the period 2004-2008, 14 occupational TB were diagnosed (9/100.000 HCW exposed to biological risks). DISCUSSION: Critical issues are the availability of a specific, written TB control plan, including risk assessment, protocols for identifying, evaluating, managing infectious TB patients, health surveillance, education programs, specifically addressed to increase Standard Precaution adoption and compliance to the screening and to adequate risk perception. Risk assessment identify HCW to be included in TB testing (characterized by low positive predictive value), unrecognized TB and environmental control needed; TB risk classification should include no more than 3 or 4 classes and performed by assessing the issues suggested in the Italian guideline. Tubercolin skin test should be used for HCW screening, adding in vitro test in specific circumstances (for example, skin test positivity in BCG vaccinated HCW); the frequency of the screening should not exceed 2 years. Periodical revision of preventive activities should follow up to date scientific literature and need appropriate data computing.

[Focus on coverage and promotion of anti influenza vaccine in health workers: results and perspectives of a multicenter working group]. / Focus so copertura e promozione della vaccinazione antinfluenzale nei lavoratori della sanità: risultati e prospettive di un gruppo di lavoro multicentrico.

INTRODUCTION: The influenza illness is a concern for health care workers (HCW) due to the potential nosocomial transmission and sickness absenteeism. Immunization and Isolation Precautions might be effective preventive measures. AIMS: To formulate recommendations on vaccination in healthcare settings. METHODS: A multidisciplinary working group, led by occupational physicians (OP), examined the information on seasonal influenza immunisation campaign in 9 Italian hospitals in the period 2005-2009 and reviewed scientific evidence. RESULTS: Many health organizations recommend vaccination of HCW. The literature shows that seasonal influenza vaccination of healthy adult have a modest effect in reducing work day lost; there is no evidence that it affects transmission or it prevents the disease in elderly residents. These observations might be conditioned by methodological limitations. Further studies are required to avoid the risk of bias and in pediatric settings. The rate of flu vaccination among HCW is widely variable and it depends on individual risk perception and information about efficacy and side effects. In the considered hospitals, in the five-years period the vaccination rate ranged between 0 and 29%: the median value was 16-17% in 2005, 2008 and 2009 (only against H1N1 influence), 11% and 13% in 2007 and 2006 respectively. OP participation in the vaccination campaign seems to increase the immunization rate. DISCUSSION: Seasonal influenza immunization of HCW might be effective. We recommend to formalize written procedures in health care settings, to perform data computing and to periodically revise immunization activities and promotion and scientific literature, with the aim to appropriately address resources.

[Focus on health surveillance of health workers exposed to blood-transmissible biological agents: results and perspectives of a multicenter working group]. / Focus sulla sorveglianza sanitaria dei lavoratori della sanità esposti ad agenti biologici trasmissibili per via ematogena: risultati e prospettive di un gruppo di lavoro multicentrico.

The biological risk from exposure to bloodborne pathogens in health care environments represents a frequent and widespread risk, involving a large number of exposed workers. On the basis of the available scientific innovations, the recent legislation regarding health and safety of workers and the experiences of SIMLII guidelines on health surveillance (HS) workers exposed to biological risk, a multicenter study was carried out, involving nine relevant hospitals and about 32 000 healthcare workers (HCW). A review of the literature was performed, with particular reference to the last 10 years. For each hospital, protocols of HS have been examined according to tasks and biological risk from bloodborne viruses (HBV, HDV, HCV, HIV) as well as management of HCW infected with this pathogens. Differences of risk management in the hospitals, in relationship also with recommendations of the literature have been evaluated. The literature supplies important indications for HS management of HCW exposed to bloodborne pathogens, with relevant information also for patient safety. Preventive examinations are in line with the recommendations of literature and similar across the hospitals for HCV and HIV, while they are different for HBV. Periodic surveillance was different for the frequency, among the hospitals and also as compared to national SIMLII guidelines. As for management, no differentiation among the hospitals was detected as referred to different risk of exposure, while differences were observed around definitions of restrictions. Finally, good medical practices to support occupational physicians in the prevention and management of HCWs' exposed to biological risks are suggested.

[Exanthemic diseases (measles, chickenpox, rubella and parotitis). Focus on screening and health surveillance of health workers: results and perspectives of a multicenter working group]. / Le malattie esantematiche (Morbillo, Varicella, Rosolia e Parotite). Focus su screening e sorveglianza sanitaria dei lavoratori della sanità: risultati e prospettive di un gruppo di lavoro multicentrico.

BACKGROUND: Nosocomial transmission of varicella-zoster virus, certain paramixovirus and rubivirus might pose a risk of morbidity for varicella (V), rubella (R), mumps (Mu) and measles (Me) in health care workers (HCW), patients and coworkers. International literature and European legislation recommend preventive interventions to minimize the risk. METHODS: A literature review and a seroprevalence study were carried out in 9 hospitals located in north and central Italy, in order to evaluate risk assessment, health surveillance and fitness for work of HCW exposed to V, R, Mu and Me. Antibodies (Ab) against V, R, Mu and Me were determined. For a subgroup of 4 hospitals; sociodemographic, occupational data and sera were collected and analyzed. RESULTS: About 36000 tests on about 9000 HCW were analyzed. Differences in seroprevalence ratios (V 85.7-95.1%, R 47-96.8%, Me 71.4-97.8%, Mu 52.5-87.6%) were detected. In a subgroup, a relevant number of non immune HCW was also found among women infertile age and areas at higher risk. Statistically significant differences were detected only for selected variables and viruses. DISCUSSION AND CONCLUSIONS: Data of multicenter study confirm literature evidences and allow to define good medical practices for manage and minimize the risk of nosocomial transmission of V, R, Me and Mu. Recommendation are issued about serologic screening on HCW exposed to all 4 viruses thorough the modern analytical techniques, in order to assess risk on individual a group basis and to select priorities for intervention. Vaccination should be prescribed for those HCW non immune, selecting areas and HCW according to priorities.

[Updating in occupational health for health care workers]. / Aggiornamenti in tema di tutela della salute occupazionale dei lavoratori della sanità.

The board of the Thematic Section on Preventive Medicine for Health Care Workers of the Italian Society of Occupational Medicine and Industrial Hygiene (SIMLII) programmed a national conference on occupational risks of health care workers to be held in late 2009. Main topics will be: a) biohazards; b) biomechanical risk; c) psychosocial factors. Three different working groups were established to tackle critical aspects and suggest practical recommendations to occupational health professionals. Preliminary issues are presented while final results will be presented at the conference on September 2009.

Necrotizing fasciitis of the maxillofacial region caused by dental infection. A case report and review.

Necrotizing fasciitis (NF) is a destructive and potentially fatal soft tissue infection characterized by extensive necrosis and gas formation in subcutaneous tissues and fascia, with serious involvement of muscles, vessels, nerves, and fat. In the maxillofacial region, NF is less common. The process can represent the evolution of a dental infection supported by aerobic and anaerobic bacteria that are resistant to antibiotic therapy (multidrug resistance) in immunocompromised patients or the natural evolution of untreated infection. Because of the rarity of the disease, diagnosis and treatment are often delayed, which may result in a fatal outcome due to respiratory problems or systemic complications. The success of the treatment is surgical debridement and high doses of antibiotic therapy. The AA described a case of NF in a female, 59 years old, who developed NF in the maxillofacial and neck region following dental infection and after consulting our Institute for remarkable swelling of the right cheek, palpebral and parotid regions, submaxillary region, and neck; this swelling is associated with hyperpyrexia, trismus, poor systemic conditions, and serious respiratory difficulty. Through prompt clinical diagnosis, early surgical treatment, appropriate antibiotic therapy (culture analysis revealed sensitivity to Imipenem and Levofloxacina), and local control of the lesion through surgical medications twice daily, we were able to not only avoid serious and fatal evolution of the process, but also to limit tissue involvement, preventing further extension of the necrosis to other anatomical structures of the region. A satisfactory clinical result was thus obtained.

[Tuberculin skin test (TST) survey among healthcare workers (HCWs) in hospital: a systematic review of the literature]. / Sorveglianza sanitaria dell'esposizione a Mycobacterium tuberculosis in ospedale mediante intradermoreazione secondo Mantoux: revisione sistematica della letteratura.

OBJECTIVES: To summarize the evidence on the Tuberculin Skin Test (TST) survey among healthcare workers (HCWs) in hospital, in the last decade. METHODS: A systematic search was conducted in PubMed and in the Proceedings of the congresses of the Italian Society of Occupational Health and Industrial Hygiene (SIMLII); researches conducted in areas with medium-high incidence of Tuberculosis were excluded. FINDINGS: 25 publications were identified. The compliance of HCWs to TST surveys ranged from 80 to 100%, the incidence of TST-conversion from 0.07 to 3.7% and the prevalence of positive TST from 5,7 to 57%. TST-conversion and positive TST were significantly associated to BCG vaccination and foreign-born. Most studies found an association between TST-conversion and occupational exposure in certain location (emergency facilities, internal medicine, infectious diseases, intensive care units, pathology, microbiology) and occupational categories (nurses, laboratory technicians). In some studies, period of hospital employment do not increased TST conversion rate. DISCUSSION: Positive TST and TST conversion rate seem to be associated with occupational exposure to Mycobacterium Tuberculosis in hospital, considering non-occupational factors. Evidence from literature seemed to support the use of TST in the tuberculosis screening programme of HCWs in hospital.

[Susceptibility to varicella-zoster, measles, rosacea and mumps among health care workers in a Northern Italy hospital]. / Suscettibilità per varicella, morbillo, rosolia e parotite negli operatori sanitari di un ospedale del Nord Italia.

BACKGROUND: Nosocomial transmission of varicella (V), rubella (R), mumps (Mu) and measles (Me) may be a significant cause of morbidity in health care workers (HCW). Susceptible HCW might be a relevant part of the workforce. METHODS: A seroprevalence study was performed in a public hospital. Antibodies (Ab) against V, R, Mu and Me were determined by ELISA. Sociodemographic, clinical, occupational data and sera were obtained during health surveillance. RESULTS: 2934 tests on 1106 HCW were performed. Seropositivity was 91% for V, 89% for R, 80% for Mu, 92% for Me. No significant differencies were found for the variables tested, except for age (< 36 years) and certain job tasks (e.g. residents). 22% of HCW tested were seronegative for at least 1 virus. More seronegatives were detected as compared with the majority of literature data. DISCUSSION: This study showed a relevant number of susceptible to V, R, Mu and Me. Seroprevalence data are useful for risk assessment, HCW health surveillance, to evaluate fitness for work and to promote vaccination programmes, according to scientific guidelines. OP should include serological screening for Me, Mu, V and R to protect HCW and third parties.

[Effectiveness studies in the Italian literature on occupational health (1990-2006)]. / Studi di efficacia di interventi preventivi in Medicina del Lavoro nelle riviste italiane.

INTRODUCTION: Evidence-based prevention (EBP) is gaining the growing interest of the scientific community in Occupational Health (OH). To highlight the Italian contribution to EBP, a systematic review was performed, on the main OH-journals publishing in Italian language. METHODS: Studies that have evaluated interventions carried out to improve workers' health were found out from the articles published in the period 1990-2006, by means of hand-searching. The selected articles were classified on occupational health topics as health intervention, study design, risk factor, authors affiliation. RESULTS: 16 publications were selected, which represent less than 0.5% of all papers published on the 8 Italian journals examined. The most frequent study-design is the pre-post intervention evaluation; 2 out of 16 (25%) studies are randomized trial. The interventions are directed mainly to control the effects of noise and biomechanical overload; textile, health-care and energy production are the most frequent industrial settings. We did not found researches aimed to evaluate the effectiveness of interventions performed in the metalware industry or addressed to injuries prevention. DISCUSSION: The systematic approach of EBP can be applied to most of the occupational health interventions and effectiveness evaluation should represent a challenge for the occupational health field. The results of the hand searching among publication in Italian could raise interesting debate about methodology and outcomes in the scientific community.

Brain magnetic resonance imaging and manganese exposure.

Due to its paramagnetic properties, manganese (Mn) can be effectively visualized by MRI. Mn accumulates selectively in the globus pallidus of basal ganglia, where it can produce high signals at brain magnetic resonance. These hyperintensities are bilateral, symmetrical, and visible in T1-weighted magnetic resonance imaging of different manganese overload conditions. A review of the literature shows identical findings in manganese exposed workers, hepatopatic patients, and patients undergoing total parenteral nutrition with excessive amount of manganese. Two indicators of exposure and hyperintensity were considered, represented respectively by the concentration of Mn in total blood (MnB), and the pallidal index (PI). These two indicators show a positive association, which indicates a possible continuum from normality to clinical stages both in workers occupationally exposed to Mn and in patients suffering from chronic liver disease. Since both MnB and PI show a high degree of variability, further research should be focused on the identification of more accurate indicators.

Assessment of neurobehavioral performance as a function of current and cumulative occupational lead exposure.

A cross sectional field study was planned to assess neurotoxic effects caused by low-level occupational lead exposure. Two groups of 66 workers and 86 controls were examined with a battery including a questionnaire on neurotoxic symptoms, the measure of performance at neurobehavioral testing, the detection of visual contrast sensitivity, and the dosage of serum prolactin. Both current and cumulative exposure to lead were defined. The average PbB was 27.50 +/- 28 microg/dl (median 28, range 6-61) in the exposed and 8.11 +/- 4.47 microg/dl (median 7, range 2-21). The test results were controlled for possible confounders including age, schooling, alcohol and coffee intake. Significant differences were observed between exposed and controls regarding neurotoxic symptoms reporting, the exposed reporting more frequently mood changes and abnormal fatigue. The exposed subjects showed a decreased visual contrast sensitivity, and a marked increase of prolactin secretion. No changes emerged regarding neurobehavioral testing. The alterations observed resulted associated to the current lead exposure and not to the cumulative indices. A safe exposure level was calculated on the basis of dose-response relationship with prolactin alteration, yielding a PbB value of 10 microg/dl.

Long-term exposure to "low levels" of manganese oxides and neurofunctional changes in ferroalloy workers.

Occupational exposure to manganese can cause early neurobehavioral effects in low- or a-symptomatic workers. A battery of neuropsychological tests was administered to a group of 61 ferroalloy male workers and 87 controls. The average (geometric mean) manganese concentrations in total dust at the plant have changed from 1981 to 1997 respectively from 1597.03 micrograms/m3 to 239 micrograms/m3 at the furnace area; from 151.53 to 255.76 micrograms/m3 at the casting area; from 167 to 54.7 micrograms/m3 at the maintenance (welding operations), yielding a current overall value of 54.25 micrograms/m3. A cumulative exposure index was calculated for each alloy worker and the average value (geometric mean) resulted to be 1204.87 micrograms/m3 x years, which divided by the average length of exposure (15.17 years), showed the concentration of 70.83 micrograms/m3 of manganese in total dust. Blood and urinary manganese geometric means resulted significantly higher in the exposed workers (9.18 micrograms/l and 1.53 micrograms/g creatinine, respectively) than in controls (5.74 micrograms/l and 0.40 microgram/g creatinine, respectively). A positive correlation was observed between the airborne manganese concentrations in total dust and blood manganese (n = 55; R = 0.36; R2 = 0.13; p = 0.0068), whereas no association resulted between cumulative exposure index and both blood manganese and urinary manganese. Higher prevalence of symptoms reporting was observed in the alloy workers concerning irritability, loss of equilibrium and rigidity. Tremor parameters including the central frequency and its dispersion, resulted to be statistically different in the exposed workers compared to the controls. Motor functions exploring the coordination of rapid and alternating movements and memory functions resulted to be impaired in the manganese workers. Dose-effect relationships were observed between the cumulative exposure index and some of the test results, whereas no relationship was found with the airborne manganese concentrations and the biological indicators of exposure. These findings are consistent with the existing knowledge of a cumulative mechanism of action of manganese, which must be carefully considered when setting safe exposure levels. In order to be protective for the entire working life, the average annual exposure level should be lower than 100 micrograms/m3.

Mechanism of neurobehavioral alteration.

Behavioral toxicology is an emerging field which is becoming increasingly important in risk assessment of exposure to neurotoxic substances, due to the high sensitivity of behavior towards neurotoxic action and the integration in behavioral functions of several underlying processes and neurofunctions, such as motor, sensory, attention, motivational. Whenever it is difficult to isolate the relative contribution of sensory, motor, arousal, or cognitive factors that contribute to an observed behavioral change, possible mechanism of behavioral alteration may rely on the involvement of neurotransmitters, such as the dopaminergic system and catecholamines metabolism. Examples are given of different behavioral types of changes induced in humans by organic solvents (styrene), metals (manganese) and anaesthetic gases, based on a possible common underlying mechanism of toxicity.

The potencial role of rare earths in the pathogenesis of interstitial lung disease: a case report of movie projectionist as investigated by neutron activation analysis.

A 60-year-old male subject who worked as a movie projectionist and who was exposed for 12 years to rare earths (RE) containing dusts from cored arc light carbon electrodes was investigated. Chest X-ray films and pulmonary function tests showed an interstitial lung disease, emphysema and a severe obstructive impairment with marked decrease of carbon monoxide diffusion capacity. The histological examination of a transbronchial biopsy confirmed the diffuse interstitial lung fibrosis. Neutron activation analysis (NAA) of the biopsy showed concentrations of cerium (Ce), lanthanum (La), neodimium (Nd), samarium (Sm), terbium (Tb) and ytterbium (Yb) which were high compared to the corresponding elements in the transbronchial biopsies of 5 unexposed subjects as a control group. Thorium (Th) (which is generally present as an impurity of the RE compounds) was also determined in order to estimate the radiation dose in the lung of the worker. On the basis of the clinical observations, of the analytical results by neutron activation analysis of RE and of the presence of Th in the transbronchial biopsy, as well as of the differential diagnosis, which tended to exclude other occupational or non-occupational lung diseases, a relation between the observed interstitial lung fibrosis and occupational exposure to RE is highly probable.

[Exposure to latex in the health setting: practical experience]. / Esposizione a latice nelle aziende sanitarie: esperienze pratiche.

Latex allergy is progressively increasing due to the widespread use of individual protective disposals, especially latex gloves among health care workers. A multidisciplinary Working Group of the Association of Health Care Workers' Preventive Medicine published, in 1995, the Guidelines for the prevention of allergic reactions both in workers and patients. The Group identified a diagnostic protocol, including the assessment of predisposition, cross-reactions, level of exposure and symptoms; etiological diagnosis needs specific, allergologic and provocative tests. Primary prevention, pre-employment education and work restrictions for sensitised workers were particularly taken into account. A short questionnaire was prepared to identify latex sensitisation in patients undergoing invasive procedures; tests are performed only in selected subjects. Preventive measures require the use of nonlatex gloves and the identification and substitution of all latex products in health care settings; such measures are necessary when emergency procedures are performed.

[Risk assessment in health care facilities]. / Il documento di valutazione dei rischi nelle aziende sanitarie.

Risk assessment in health care facilities. The risk assessment is an important procedure in occupational medicine, also due to the international and domestic regulations and recommendations. In hospitals and other health care facilities too, the risk assessment could enable the identification of hazards, the characterization of risk and thus the programme of adequate preventive measures. In this paper some theoretical and methodological aspects of risk assessment practice and related documentation in health care facilities are focussed and the strict relation between preventive activities, quality system and accreditation standards for hospitals and other health services is finally discussed.

[Bladder cancer and occupational activity]. / Cancro della vescica ed attività lavorativa.

Bladder cancer is important in Occupational Medicine and in Occupational Epidemiology. Multicentric studies and pooled analysis have contributed in the last few years to the identification and characterization of several risk factors for bladder cancer, both occupational and non-occupational. Currently, it is a research priority the study of genetic susceptibility and its interaction with environmental and occupational exposure to the various bladder cancer risk factors. Bladder cancer management entails a few aspects that directly involved the Occupational Phisycian in different activities such as biological monitoring of chemicals, known or suspected bladder carcinogens, health surveillance, fitness for work, the return to work of the bladder cancer patients and finally epidemiological surveillance and health promotion.

[Injuries with biological risk in a major hospital: analysis of a caseload]. / Infortuni a rischio biologico in una grande azienda ospedaliera: analisi di una casistica.

This article report preliminary data on injuries involving risks from biological agents occurred in healthcare workers of a major hospital over a 5-years period ('96-'00). The role of Occupational Competent Physician is underlined. Injuries' database, archives of occupational diseases, discharge diagnosis and notification of transmissible infectious diseases were consulted. 200 injuries (3/4 percutaneous) were on average registered yearly, with a decreasing trend. Subjects had a mean age of 34 years and 7 years of length of employment at the hospital. 60% of exposures occurred in nurses and 43% workers belonged to surgical areas. Serological data of the "source patients" were available for 1/3 of the cases and 35% of them were bloodborne viruses infected; 1 seroconversion for HCV was registered. On the whole, our results are similar to data from national and international literature. However a few factors limited the data collection and interpretation, mainly the lack of computer formats and different ways of coding and filing the information. The periodical analysis of injuries is useful to the Occupational Physician, particularly for educational intervention and sanitary surveillance of workers. Moreover, the Occupational Physician plays an important role in injuries prevention, especially in spreading the information on Standard Precautions, evaluating the human factor, reducing the "under-reporting" of accidents, counselling, evaluating prognosis and resuming work.