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NIOSH Interim Guidance for Postexposure Medical Screening of Workers Leaving Hurricane Disaster Recovery Areas |
October 2005 |
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OverviewWorking in physically demanding, unclean, or unstable work environments, such as hurricane recovery areas, raises the question of whether work exposures will have adverse health consequences. The likelihood of such adverse health outcomes will depend on factors such as work load and work duration, type and severity of work exposures, and work organization, as well as the workers’ prior physical and mental health status, knowledge about and experience with disaster work, and precautions taken while working (e.g., work practices, personal protective equipment). Because of potential health risks inherent in postdisaster work, screening programs should be undertaken to determine the extent, if any, to which individual workers have been adversely affected by their work and to identify as early as possible any affected workers needing preventive measures or medical care. This document is intended for occupational health professionals and other clinicians who are responsible for physical and mental health oversight of workers who have deployed or worked in hurricane disaster response (e.g., response and recovery workers). It provides interim guidance on an appropriate medical screening approach for these workers as they complete their response activities or return home from the affected areas. The document does not address issues related to the period prior to initiating response or recovery work, such as predeployment screening, medical clearance, or training; these are important occupational safety and health considerations that will be addressed in a separate document. This interim document is based on information available as of October 1, 2005, and will be updated or revised, as appropriate, as additional information becomes available. In general, the level of screening appropriate for a given work activity depends on multiple factors. However, because the conditions encountered by response and recovery workers may involve a complex, uncontrolled environment, possibly involving mixed chemical exposures, hazardous substances, microbial agents, heat extremes, long work shifts, or stressful experiences, all such workers as a precaution should receive some assessment. This may range from completion of brief assessment forms to more comprehensive and focused evaluations. High priority worker groups include those most likely to have exposures to hazardous agents or conditions and those reporting outbreaks of similar adverse health outcomes. Public health criteria, such as frequency of adverse health effects; their severity, preventability, or communicability; public interest; and cost effectiveness, are often useful for setting screening priorities. Purpose of screeningThe primary purpose of worker screening programs is to protect worker health by early identification of work-related conditions in individual workers. Through screening, adverse effects in individuals can be recognized in a timely way to provide intervention for the individual, while identifying potential risks to others in the same population of workers or populations with similar exposures. The goal of screening is to identify those who need further medical attention, not necessarily to definitively diagnose or treat based only on information provided through the screening. Therefore, screening programs collect and analyze individual-specific data related to postexposure physical and mental health status, which is used to:
Determining a need for screeningWhen developing a postexposure screening program, it is important to determine who should be screened and the reasons for screening them. For each group of workers, work-related risk factors or characteristics of commonly experienced occupational injuries and illnesses will determine the level or extent of screening appropriate to members of the group. These may include emotional as well as physical health factors. The following factors should be considered:
Deciding who should be screenedGiven the broad range of potential hazards and difficult working conditions encountered in hurricane response work, all workers returning from or completing hurricane response activities should receive some basic screening to capture information about their demographics, preexisting medical conditions, work experience and potential exposures while deployed, and any injuries or illness symptoms experienced while in the field or since leaving the disaster area. As described below, those meeting certain criteria should receive more extensive screening. Determining the type of screening to be doneIn the early phases of response efforts, it was not possible to fully characterize the spectrum of hazardous agents and conditions that might have caused immediate or may cause future adverse health outcomes. As time elapses since the dates of the hurricanes, environmental conditions, response activities, exposures, and possible health outcomes will continue to evolve, and information about some of these factors may remain incomplete. It is not possible to specify here a single defined set of conditions for which workers should be screened. Decisions about screening needs and which health outcomes to monitor should be based on information about known or suspected risk factors (listed in the section “Determining a Need for Screening”), which is elicited through the basic screening recommended for all workers leaving the disaster area. Similarly, acute physical, cognitive, or emotional symptoms experienced during response work may be indicators of a potential future chronic condition, so the presence of symptoms during or after deployment may indicate a need for more extensive screening. Different screening approaches will be appropriate for different groups. For example, rescue and recovery workers with prolonged and repeated exposures to contaminated floodwater, workers at an evacuation center, truck drivers delivering supplies, and workers handling logistics at a staging facility will each require different screening strategies. Without specific information about chemical exposures, biological monitoring (i.e., measuring in body tissues or fluids [such as blood or urine] a chemical, one or more of its metabolites, or a biochemical marker of its effects) will not have great predictive or diagnostic value, nor would it be expected to be cost effective. Such specific exposure information is unlikely to be available for most locations and circumstances. Additionally, biological monitoring would be recommended only if its use as a screening tool for a specific exposure were well established and certain criteria were met, for example, exposure to the specific hazardous agent; ability to retrieve the agent or its metabolites from the body; existence of established reference values for interpreting test results; and relevance and usefulness of results (e.g., important for determining treatment and for predicting health outcome, severity, chronicity, or need for future screening or surveillance). Any other use of biological monitoring would be considered investigative (e.g., toxicology research), with objectives that are different from those of screening programs. In addition to documenting anticipated adverse health outcomes (on the basis of known exposures, activities, and work conditions), screening programs may identify unexpected health outcomes. Should such a potential emerging problem be identified, further investigation using an epidemiologic or “outbreak investigation” model may be necessary to characterize it and assess possible work-relatedness. If this investigation suggests that the unanticipated health outcome was related to response work, the screening program could then be modified to incorporate this new information to detect reappearance of the problem at an early stage. When to screenImmediate data on postexposure health status should be collected at the time of completion of response work or departure from the affected area, or as soon as possible afterward. Depending on what is learned about exposures and on the results of the initial screening, more detailed medical evaluation may be indicated. Long-term data on health status may need to be collected on some individuals after a period away from exposure. Timing will depend on the nature of the exposure or health condition. Minimum screening information needsThe following information should be collected on all individuals undergoing screening upon completion of or return from response or recovery activities: Personal informationIdentifying and Contact Information
Usual work
Special needs
Health status before response work
Response-related information Response work
For known hazardous exposures or conditions
Injuries sustained or symptoms experience during response work
Additional screening information needsWorkers leaving disaster work who report repeated or prolonged exposures or who report injuries or symptoms should receive more comprehensive screening, which should address the specific exposures or adverse health effects encountered. Additional screening may include a more comprehensive medical history and review of systems, a physical examination, or, in some instances, laboratory testing, as indicated by clinical judgment and good occupational medical practice. For reported exposures If potentially significant exposures are reported, additional screening should be directed to detect potential adverse affects commonly associated with these exposures. Thus, for example, if repeated or prolonged exposures to dusty or moldy environments are reported, screening should address possible respiratory or allergic outcomes. For reported symptoms If illnesses or symptoms are reported, information should be obtained regarding corresponding organ systems (e.g., cardiac, respiratory, gastrointestinal, skin, mental health), symptoms, whether illnesses or symptoms represent new onset or exacerbation of preexisting condition, and treatment, if any. For reported injuries If injury is reported, information should be obtained regarding location and operation where injury occurred, nature of injury, part of body affected, severity (e.g., lost work time), and treatment. Minimum information about injury should include information sufficient to meet OSHA requirements for recordable injuries. Injuries caused by acts of violence should be included. How information will be usedFor the reasons listed in the previous section titled “Purpose of Screening,” screening programs may be set up by various organizations, including public health agencies from all levels of government, public sector response programs (including regulatory agencies and contractors), medical staff at private companies, or individual practitioners. To maintain confidentiality of workers’ medical information, medical or public health personnel typically administer screening programs. Other interested parties, such as public health organizations, academicians, media, labor unions, and attorneys, may want access to grouped screening results (with individual identifiers removed) for other reasons. Other considerations
Administrative
Staffing
Logistics
Other
Summary
Page last updated: September 4, 2008
Page last reviewed: September 4, 2008 Content Source: National Institute for Occupational Safety and Health (NIOSH) Education and Information Division |
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