Safety Management Division

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Medical Industry Trends

• Stephen A. Dawkins, MD, MPH, BSHS, FACOEM
• Caduceus Occupational Medicine
• April 25, 2008

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Agenda

• Introduction
• Anaphylaxis
• Infectious Diseases
• Stress-Related GI Problems
• Repeat Shoulder Surgery
• Conclusion

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Anaphylaxis

• Mediated through the immune system
• Progressively increasing reaction
• May be induced after a single exposure

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Infectious Diseases

• Skin Infections
• MRSA
• URIs (colds, flu, bronchitis, etc.)
• Hepatitis
• HIV

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Skin Infections
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How Infections Happen

• The skin integrity is broken.
• A portal is opened to allow bacteria to enter.
• The bacteria multiply and grow.
• That growth may overwhelm the bodys ability to
  fight the bacteria.
• The bacterial overgrowth leads to a local
  infection.
• That infection is worse if the patient is
  immunocompromised or has other chronic diseases.

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MRSA

• Antibiotic resistant form of infection
• Methicillin resistant staph aureus
• Now possible to distinguish community acquired
  from hospital acquired
• May be controlled if aggressively managed
• Skin eruptions frequently recur
• Occupational risk is due to skin eruptions and
  potential contagion
• Return To Work opinions still do not conform

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Viral Hepatitis - Historical Perspective
Enterically transmitted
Infectious
A
E
Viral hepatitis
NANB
Parenterally transmitted
B
D
C
Serum
F, G, ? other
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Viral Hepatitis - Overview

Type of Hepatitis
A
B
C
D
E
Source of
feces
blood/
blood/
blood/
feces
virus
blood-derived
blood-derived
blood-derived
body fluids
body fluids
body fluids
Route of
fecal-oral
percutaneous
percutaneous
percutaneous
fecal-oral
transmission
permucosal
permucosal
permucosal
Chronic
no
yes
yes
yes
no
infection
Prevention
pre/post-
pre/post-
blood donor
pre/post-
ensure safe
exposure
exposure
screening
exposure
drinking
immunization
immunization
risk behavior
immunization
water
modification
risk behavior
modification
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Acute Viral Hepatitis by Type, United States,
1982-1993
34
47
16
Hepatitis A
Hepatitis B
Hepatitis C
3
Hepatitis Non-ABC
Source CDC Sentinel Counties Study on Viral
Hepatitis
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HEPATITIS A VIRUS
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• HEPATITIS A - CLINICAL FEATURES

• Jaundice by lt6 yrs lt10
  age group 6-14 yrs
  40-50
  gt14 yrs 70-80
• Rare complications Fulminant hepatitis
  Cholestatic hepatitis
  
  Relapsing hepatitis
• Incubation period Average 30 days
  Range 15-50
  days
• Chronic sequelae None

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RISK FACTORS ASSOCIATED WITH REPORTED HEPATITIS
A, 1990-2000, UNITED STATES
Source NNDSS/VHSP
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Hepatitis B Virus
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Hepatitis B - Clinical Features

• Incubation period Average 60-90 days
• Range 45-180 days
• Clinical illness (jaundice) lt5 yrs,
  lt10 ³5 yrs, 30-50
• Acute case-fatality rate 0.5-1
• Chronic infection lt5 yrs, 30-90 ³5
  yrs, 2-10
• Premature mortality fromchronic liver
  disease 15-25

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Geographic Distribution of Chronic HBV Infection
HBsAg Prevalence
³8 - High
2-7 - Intermediate
lt2 - Low
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Concentration of Hepatitis B Virus in Various
Body Fluids

Low/Not
High
Moderate
Detectable
blood
semen
urine
serum
vaginal fluid
feces
wound exudates
saliva
sweat
tears
breastmilk
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Hepatitis B Virus Modes of Transmission

• Sexual
• Parenteral
• Perinatal

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Risk Factors for Acute Hepatitis B United States,
1992-1993
Heterosexual (41)
Injecting Drug Use (15)
Homosexual Activity (9)
Household Contact (2)
Health Care Employment (1)
Unknown (31)
Other (1)
Includes sexual contact with acute cases,
carriers, and multiple partners. Source CDC
Sentinel Counties Study of Viral Hepatitis
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What is hepatitis B?
Hepatitis B is a germ (virus) that gets into your
body and attacks your liver.
Hepatitis B Virus
Your liver helps your body digest the food you
eat and store energy. It also helps your body
get rid of poisons.
Liver
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Hepatitis B can be prevented!
If you have never had hepatitis B,you can get 3
shots . . .
. . . and get long lasting protection.
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Hepatitis C
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Features of Hepatitis C Virus Infection

Incubation period Average 6-7 weeks Range 2-26
weeks Acute illness (jaundice) Mild (lt20) Case
fatality rate Low Chronic infection 60-85 Chroni
c hepatitis 10-70 (most asx) Cirrhosis lt5-20 M
ortality from CLD 1-5
Age- related
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Chronic Hepatitis C Factors Promoting
Progression or Severity

• Increased alcohol intake
• Age gt 40 years at time of infection
• HIV co-infection
• Other
• Male gender
• Chronic HBV co-infection

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Sources of Infection forPersons With Hepatitis C
Injecting drug use 60
Sexual 15
Transfusion 10 (before screening)
Occupational 4
Other 1
Unknown 10
Nosocomial iatrogenic perinatal
Source Centers for Disease Control and Prevention
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Hepatitis D (Delta) Virus
d antigen
HBsAg
RNA
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Hepatitis D - Clinical Features

• Coinfection
• severe acute disease
• low risk of chronic infection
• Superinfection
• usually develop chronic HDV infection
• high risk of severe chronic liver disease

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Hepatitis D Virus Modes of Transmission

• Percutanous exposures
• injecting drug use
• Permucosal exposures
• sex contact

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Hepatitis E Virus
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Hepatitis E - Clinical Features

• Incubation period Average 40 days
• Range 15-60 days
• Case-fatality rate Overall, 1-3 Pregnant
  women, 15-25
• Illness severity Increased with age
• Chronic sequelae None identified

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Occupational HIV Exposures
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Exposures Resulting in Occupational HIV
Transmission June 2001
http//www.cdc.gov/hiv/pubs/facts.htmTransmissi
on
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Sharp Objects Associated with 51 Percutaneous
Injuries Resulting in HIVSeroconversion in 50
Healthcare PersonnelJune 2001
http//www.cdc.gov/hiv/pubs/facts.htmTransmissi
on
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Average Risk of HIV Infection to Healthcare
Personnel by Exposure Route

• Percutaneous 0.3
• Mucous membrane 0.09
• Non-intact skin lt0.1

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GI Reactions to Acute Stress

• Fight or Flight Response
• Increased heart rate, ventilation, blood
  pressure, muscle perfusion and skin tightening
• Typically leads to decreased GI function

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GI reactions to Chronic Stress

• Nausea
• Vomiting
• Diarrhea
• Ulcers
• Irritable bowel disease
• Gastric erosions
• Abdominal cramping

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Joint Anatomy
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Osteoarthritis
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Repeat Shoulder Surgery

• Wrong diagnosis
• Multiple injuries
• Post-surgical injury
• Post-surgical complication
• Bad outcome

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Questions Answers