Dr. Merntz is a graduate of the Kurtzweil College of Osteopathic Medicine with subsequent training in internal and occupational medicine. He's both ND and DO boarded in occupational medicine. After 16 years in academia, he is now working independently. Current work includes occupational and environmental medical legal consulting, reviewing coal miner x-rays for NIOSH, federal black lung evaluations, and aviation medical evaluations. I'm going to turn this over to Carl. Okay, good afternoon, everybody. This will be almost your last experience here, so we'll try to go through this relatively quickly and hopefully make it painless. We're going to talk a little bit about biologic hazards and including that in the bloodborne pathogens standard and how that impacts occupational health. So we're going to go through the standards here. The goal is to, we'll talk about biologic hazards, some protective measures, the bloodborne pathogen standard, TB, and other communicable disease prevention in the workplace. And then we'll help you talk about crafting a program that might work in a workplace where there are biologic hazards. First thing I need to say is that biologic hazards are everywhere. We're only going to talk about the workplace hazards, but a lot of these can be extended to other settings. So when you really think about it, we start out with health care that everybody thinks about. We go on to public safety folks, fire, EMS, police who may interact with the public who might be ill. And then you continue on to people that do like grounds maintenance, need to deal with your local flora and fauna, and researchers in the academic world or commercially world that I came from a couple years ago. There are, as I said, many different kinds of biologic hazards that kind of work. They're all slightly different but parallel. Most medical people are familiar with viruses, bacteria, and fungi. We sometimes include allergies in here if they're from a biologic source. All the critter-related stuff, bites, venomation, zoonoses, and plants, of course. In the world of biohazards, there's a classification scheme that has been kind of proposed by CDC and the National Institutes for Health, and it just allows you to kind of group things together. And we'll go through the different headings and where you run into some of those things. It's also sometimes called the biologic safety level or BSL system, and there's a parallel system for animals, the ABSL system. It talks about the risk from the agent, although you may have to modify the classification based on what they're going to do with the agent, because if they're going to aerosolize it or introduce it into a live animal, it might be different than if you're just going to have a petri dish full of some agent. Once you have it classified, you can typically find pretty good references on how you need to manage that agent so that it's not hazardous to humans. BSL categorization comes in four levels. BSL 1, where there's really no human health effects, if you think back to the tame microbes that they used when you had your microbiology class in medical school, it's those. Those are the BSL 1 versions of plague or staph aureus or whatever, the specific versions that don't cause any human health effects. BSL 2, there is a risk for human health effects, but it doesn't readily aerosolize is the big deal. So you want to be a little careful, but not super worried. BSL 3, there's more risk. It can readily aerosolize. So if I had a petri dish and took the lid off the petri dish, that would put the people in the room at risk. And BSL 4 is when there's a definite human health risk and no effective treatment. And we'll look at some examples of each of these. So BSL 2 is when it doesn't readily aerosolize. So I could take the lid off the petri dish and we're all okay. That would even include things like HIV, hepatitis B, dengue, salmonella. None of those will hurt us in the room if I take the lid off the petri dish. We want to wear gloves and wear splash hazards, but we'll autoclave things before they leave so that they don't end up in some other setting where they might be aerosolized. BSL 3 are agents that are a bigger risk if they were to have aerosolization. So that's where we are at risk if we take the lid off the petri dish. And things like tuberculosis, anthrax, yellow fever, COVID are BSL 3 agents. You need more protection. You need to wear a respirator. Typically, they have the people in a BSL 3 facility. They'll wear scrubs in the facility. They'll shower out. And some of those agents may have biosecurity concerns as well. BSL 4 is the things that we know are harmful to humans, where there's not effective treatment. Smallpox, Ebola, the other hemorrhagic fevers. There's only a couple facilities in the United States where they can work with BSL 4 agents. Everybody thinks of CDC, but there are a couple of others. And the military has one. And Plum Island used to do those, but they're gone. That's the military ones, is at Fort Detrick. There used to be Plum Island for the animal ones, but that's been decommissioned. And then, obviously, these are also the ones that have significant biosafety concerns or biosecurity concerns. Biosecurity means could it be weaponized? Or is that something we worry about? So I'm going to jump right now to the bloodborne pathogens. This is bread and butter OCMED. You need to be able to, if you're going to be anywhere near a healthcare facility or supporting hospitals, occupational medicine program, or anything like that, you need to be pretty conversant with this, because you will see these patients. This whole thing started in response to HIV in the early 80s, and eventually morphed into just having the whole standard for bloodborne pathogens. It covers all of them. It covers everybody who would be expected to be exposed to human tissues or fluids. So we all think of healthcare workers, emergency responders, and probably lab workers. Janitorial depends on what the issue is, what the plans are for a blood or human fluids exposure at the workplace. At the university where I used to work, they elected to say that all janitorial staff were expected to clean up blood and other similar messes. At some other institutions, they may say we have a team of three people that are our bloodborne hazard response team. They're both okay answers. But whatever they decide to do, whoever those people are, they're part of the program. So like in everything we've talked about so far, we always want to talk about the control matrix, starting with elimination and going all the way down to personal protective equipment. The problem is that with bloodborne pathogens, we haven't yet figured out how to have humans without blood or to substitute the blood completely. So that hazard still remains and is always there. So we're down to engineering controls, administrative, and maybe the use of PPE. So engineering things, you'll see this a lot in hospital systems. Sometimes they use self-capping needles. I used those a lot when I was doing COVID shots last year, or self-retracting needles. The needleless IV systems, some laboratories now, a lot of times they just put the tube in to the lab machine that's going to do a CBC, and it just does, it draws the blood out and does everything itself instead of having to do it all by hand. And all the sharps controls that we see in the clinical settings, the sharps containers, using the surgical neutral field, all that sort of thing, those are all engineering controls to limit sharps injuries. The administrative part, we have risk communication with training. That has to be done on a periodic basis. Hopefully we've got everybody to stop needle recapping, because that's just going to end up jabbing somebody eventually. And then the use of containing the waste, biohazard waste separately, either in the sharps containers or biohazard containers. The blood-borne pathogen standard also includes a vaccination program, post-exposure response, and recordability in the OSHA log with a special version that we'll talk about in just a second. So what do you do, what is the post-exposure response if somebody has a needle stick or similar injury? First thing is you want to irrigate and clean the site, soap and water, get the area clean. We need to assess the riskiness of that exposure. If you're allowed to do source testing in your state, most states now allow this, but not all, then do that. In West Virginia, I'm allowed to test any blood that I already have in the lab, I can run for HIV. So if I have a needle stick, I can do that with any blood that's already in the lab. Is it a hollow needle or a solid needle? Because that changes the risk. And then if you decide that it's a high-risk exposure, either because you don't know the status of the donor patient, or because it was a hollow-risk exposure, then the goal is to start the person on post-exposure prophylaxis immediately. And you call, that number is available to help guide you on what the treatment recommendations are for that particular person. You also want to get testing done so you know their current status for HIV, hep B, both antigen and antibody, that you do right away. And then you may repeat them later. But you always want to get it now. Because if you think about it, if they got exposed to HIV in the needle stick that happened at 2 o'clock, they will not be HIV antibody positive at 3 o'clock. So I want to get that testing done quick, so that I, you know, within the first day or so, so that I can know what their pre-exposure status was. From the perspective of the employer, while they may not be happy to be responsible for somebody's needle stick injury and developing HIV, they'll be exceptionally unhappy if they end up becoming responsible for somebody's pre-existing HIV infection. Vaccination for hepatitis B is offered. It is a three-shot series. The recommendation for healthcare workers, but not the general public, is that you follow it with a titer. If the titer is positive once, you're done. You never need to do it again. And they're immune for life. If it's negative after you do the first series, you repeat the series once. And then there's always the question of do we need to do titers over time? The short answer is no. Once they have a positive titer, it's lifelong protection. The other thing that I, that the more often I get questions about is what do we do with people that had hepatitis B long ago? They're a brand-new, newly-minted nurse. They were vaccinated for hepatitis B when they were a newborn. And what do you do with that person? Because they certainly weren't trying to remove all those six-month-olds. And so what we did was we would titer, check their titer. If it's positive, then we're done. If it's negative, what most places do is give one dose and re-titer. If their titer comes up high enough, then you don't worry about it. If not, then you repeat the series. This changed a couple of years ago because it used to be that titers were expensive and vaccine was cheap. And now a single dose of hepatitis B is like $150, and a titer is about $20, just $20 to $30. So it's still to your benefit to titer more often and give jabs less often. So it's required that if somebody's in the blood-borne pathogen program, they receive live training. The first time around, it must be live and in-person. Within 90 days of their initial assignment, then there's annual retraining. You have to have an exposure control plan. And one of the things, the reason that it has to be done live the first time is they have to have the ability to ask questions, and then you maintain those records for three years. The other reason it's done live is because you need to teach people how to take off gloves that are yucky on the outside. That's the real, that's the other main reason why you have to teach the class live. So you can teach people how to take off the gloves and not splatter the blood everywhere, because they will do that. The way most people take gloves off, if they haven't been taught, they will do that. Now, record keeping, if somebody is exposed, then they have to maintain those records for the duration of employment plus 30 years, and we have to keep it confidential. And we'll get into that in just one little second. The record has to include their name, security number, happy status, medical evaluations, treatment, follow-up, everything that's been done relating to exposure. So there's a sharps injury log that employers that would expect to have these, like a hospital, are expected to maintain. They maintain the confidentiality of the employee and the source, because the log, it does have a date, and you may give it like an incident number, but there's no name on the actual incident log. But there's a second page behind that one per employee that will, that has the details for the human. But the log has the details for the exposure. You know, it was a 14-gauge gelco catheter. I was starting an IV as part of a resuscitation of a trauma patient. You know, so it has the details of the exposure, but not the human. I'm going to use the example of Workplace. This is a lovely critical access hospital in West Virginia that I work at a little bit. And so they have to have a program that's kind of all-encompassing for a variety of likely pathogens. Bloodworm pathogens we just talked about, but also things like you could find an inpatient tuberculosis, chickenpox, measles, meningococcus, and then the outbreak of the day. When I originally wrote this, it was H1N1 we were all worried about, but now we've decided we're going to do COVID instead as our outbreak that everybody knows about. It doesn't matter. Quite honestly, the response to an outbreak is yours. The same doesn't really matter what the outbreak is. So hospitals have a standard system. This is in addition to the universal precautions that we use for everybody for bloodworm pathogens. But so standard, it's just gloves. We can add a mask or a face shield or a gown if we need that. Then there's airborne. Think of tuberculosis stuff where we add an N95 respirator, droplet where you get a respirator and a gown, or contact precautions where you get just a gown but no respirator. So this is, and in the world of nursing, each pathogen and clinical care setting, it's a grid, is assigned to one of these categories. We'll talk for just a second about tuberculosis because that's one of the ones that is still around. Just as a reminder, this picture is actually from a trolley museum. They had this up. This is a picture from, I think, the 40s, back when Christmas Seals was trying to help people be protected from tuberculosis. That was their original disease, the Christmas Seals, was TB, back, way back when. Just a reminder of the symptoms. The problem with TB, as we all know, is many people are asymptomatic. And contract tracing for TB still remains important. But I'm going to talk about it mostly in the healthcare setting. It's, asymptomatic TB is pretty common in people that have a competent immune system. Reactivation is, can occur when you mess with their immune system. Transmission is usually airborne with very rare ingestion or physical contact. The communicability depends on the closest duration of exposure. They've done a number of studies on airplanes, and after they'll do one, they show there were no cases, then the next time there'll be a couple of cases of the people in that row, not anywhere at the other end of the airplane, because the air flows are so different. And then it'll always be the flight back from Australia. If you just, if you suspect or diagnose TB, make sure you let local health, public health people be aware. Keep in mind that healthcare for tuberculosis is free in most communities as far, from the prophylactic perspective. So you don't have to, people with no insurance can still get their TB treated for free through the health department. The other thing I always remind people is positive PPD does tell me that they had tuberculosis or one of its friends, because remember like mycobacterium bovis will cause a positive PPD test, and they may or may not have active disease. So PPD does not tell me that. So let's look at TB as an airborne hazard and how we might control this. So it might, I remember I can't eliminate other than excluding potentially TB patients from the hospital, which I don't think is the right way to go. So for engineering, I can use negative pressure rooms. I can cohort the patients. If the, if I have a group that all has the same version of TB, you can't do this with people with like HIV because they have different TBs, even in the same community. And I can have put place my workers and 95 respirators that also will apply to the family. So if the family comes to visit, they go into the 95. If they visit the person's room, if the patient leaves their room, they go into 95 with no exhaust valve to protect the rest of the patients in the hospital and to protect the hospital staff. So screening of healthcare workers, most hospitals used to do this routinely. It's now less common that we do it on a routine basis unless people become symptomatic. Symptom screening is still useful because if a person starts having, you know, night sweats and weight loss and things like that, they probably need to be screened for TB amongst other conditions. If the screen's positive, you do some sort of an additional test. You do a PPD. You can do an x-ray if the PPD is positive. You can do a quantifier on gold or a T-spot. And the big benefit of the quantifier on gold or T-spot, if they're done correctly, is that they're pretty accurate. The downside is, depending on why you're doing this, if it's another tuberculosis, it may or may not test positive. M. bovis should test positive for all of them, which is the one we get from cows. But if they've got one of the other tuberculosis species, you may miss it because that one is designed to only see. It's MTB and M. bovis because they're the two ones that affect most human. Most human cases are one of those two. And you can do those on a scheduled basis. And also, it gives you information to consider whether you need to treat latent disease. And again, you can do it with your infectious disease people. You can treat them yourself if you're comfortable with that. You can refer to the health department because, as I said, all the health departments will treat TB for free in the whole country. There's a federal program. They're all part of it. Okay, there's apparently a cross-border program out of San Antonio. That makes sense. Okay, so apparently in the adjacent parts of Mexico, we do that as well. Sounds like the STD program in Subic Bay. Same idea. Okay, I got it. Okay, so let's talk about an airborne hazard, varicella or tick and pox. Engineering, we put them in negative pressure rooms. We cohort. We want to exclude workers without immunity. And that's one of the reasons why many hospitals will screen inbound employees to see if they're immune to varicella, so we know if I have to protect that person. We want to exclude pregnant workers because that can be a mess, and people with incompetent immune systems, so like cancer patients, shouldn't be working with the varicella patient. PPE would be droplet masks or N95 respirators. I'd recommend the N95s. Then we have the outbreak du jour, and it's the same thing. Negative pressure rooms, cohort the patients, think about respirators, and maybe we cohort. So I'm going to go here to pandemics. Now, the original version of this was written when we were expecting a flu pandemic. However, I want you to notice that the only words that changed on this screen is I added the word flu to the top, and I made the word flu red. Other than that, these screens are unchanged from 2015, okay? So employers are always responsible for the safe and healthful workplace. That's the general duty clause. If a new influenza emerges with little immunity in the human population, there can be serious illness via person-to-person spread, and I know this is a hypothetical thing that could never actually happen. We just want to talk about it just briefly, but it applies to any communicable disease, and again, these are all the things that this is what we saw, okay? It depends on where you're at, and depends on what week it was, but my point is that this is the influenza numbers from 2015 or 2010, long before anybody even knew what the letters COVID spelled, okay? You could have absenteeism. It might shut down your suppliers or customers, which is still happening, and we're two-plus years into this thing. Change in the patterns of commerce, like people would go to online meetings and online shopping. What a horrible idea, and social distancings. We would have no meetings and not handshake. We did all this for like two years, and we're still doing it, and I said this all predates. This hasn't changed. Yeah, this hasn't changed, and it's exactly what we did, so how can an employer maintain operations during a pandemic? Well, you got to have a plan, and some employers did, and some didn't, and thankfully, Zoom helped people that didn't plan ahead. You need to protect both the employees and the customers. You need HR policies. Do we want people to stay home when they're sick? Liz is shaking her head vigorously, yes. Now we need you, and now we've decided that after five days with no science, we're going to make you go back to civilization, which I hope is accurate because this is day 11. This is day 12 for me from when I had COVID last week, so hopefully the CDC is right because if it's not, you guys are in trouble. We also require a negative nasal swab on or after day five because that at least correlates with limited ability to transmit, but CDC doesn't say that, but I understand what you just said about the nasal swab is not a bad idea, but it's not what CDC currently recommends. Trust me, I've been through this in the last week and a half as I was very carefully counting days to see if I was going to be here or not. No, no, no, but what you said is probably better science. It's just not what CDC is recommending, and so the CDC policy right now, the science is a little fuzzy. Yeah, it's a little fuzzier than it probably ought to be, so we got to think about how do we do all this? Are we going to pay people while they stay home? Well, some employers did. Some employers got PPP loans. Some employers didn't. The people showed back up, much that's a good thing, but that's where some of the employers ended up. What about telecommuting? Are we going to limit travel? There's still a lot of employers doing this, but again, we've lived through all this, and it's our things from way before COVID that we told you to think about are still correct. It hasn't changed much in the two years. How can... Wait a minute. Next step, zoonotic and insect-borne diseases. This tends to be the people who work outdoors. Think line crews at the power company. Think the parks people that cut the grass and do all that kind of stuff. Think farmers. It's people that take care of groundskeepers at whatever setting it is, the country club or whatever. The local fauna varies from place to place, and you have to think about the insects, the mammals, the snakes, all that kind of stuff. You can get zoonotic diseases from a lot of animals. Your local cat in your house is probably carrying toxo. At least there's a good chance of it. The way that the mice give it to them is just fascinating because the mice play with the cat until it gets eaten. Toxo affects the mouse to make it have no fear of cats. It's crazy. I don't know how it evolved that way, but that's the way it evolved. You can get it from farm animals. Think about that. Wild animals was always my big concern when I was at the university, and then research animals, which actually were a lower concern unless somebody intentionally infects them or unless they're using primates. Exactly. These are all the zoonotic diseases that were of concern that I had to deal with at the university where I work. A lot of these were because we have, in addition to having the research animals, we had a lot, we had farms and they did more research. We had sheep, we had goats, and we had a pigeon colony. All the researchers would go out into the field and they needed to open up the research cabins in the woods and aerosolize everything and get hantavirus from that. It was all sorts of exciting. Rabies is one of the big ones I worried about. Education is a huge part of rabies prevention. The key thing you need to know is think of the mid-sized animals and those are the ones you worry about. It's the raccoon, the skunk, the possum, foxes. Bats are different, but yes. All those mid-sized mammals because they live long enough after they get infected to expose humans. Little mammals like mice, they last for maybe an hour or two after they get infected. It's the little ones. The little ones don't last very long, but those mid-sized ones, they're the ones you have to worry about. Plus bats, you're completely correct. The post-exposure response is important. There are people that survive rabies. You get about one or two a decade in the United States that survive. You don't want to take that risk because it's much better to have the post-exposure prophylaxis, which now, unlike when I was a kid and it was I don't know, some horrendous number of shots in your belly that all hurt because they're derived from horse serum or something. Now it's a recombinant vaccine and it is kind and gentle, but you need to get it relatively quickly, within a day or two of getting exposed. We need to have programs. People that you think about vaccinating in advance are people who are intentionally going to be interacting with wild mammals. In your community, who do they call when they have a crazy skunk that the police call out? Who's the animal control officer? Probably ought to be pre-vaccinated. Veterinarians or vet techs, especially if they do that. Farm workers. Usually not lab animal contact, which is a good thing. A little bit about plants. On the right, everybody knows what those are. That is the poison ivy, poison sumac, and poison oak. What's the one on the left? Does everybody know? It is bad. You'll find it in the United States. You're actually probably very close to where we are now in Tampa. No, no, no, no. This is poisonwood. This is the other one that causes dermatitis. That's tropical. It's probably maybe not even this far north in Florida. It's really limited to the middle part of the tropics. But it's just like poison ivy. It's not usual like the poison ivy, poison oak, poison sumac, but it's similar. It causes a contact dermatitis where you touch it. It's called poisonwood. You get it in southern Texas. Yeah, in the warm. It's tropical. So think more like probably around Houston. Places where they have palm trees, you might find it. If your girl's made it this far, you're probably safe. Okay. So there's a couple of things that I throw in here for the contact dermatitis. You'll see this everywhere in the United States. It definitely has the poison oak, poison ivy, or poison sumac. So I add this tech new stuff. For people that work outdoors, and they may have to work around it, like the groundskeeper can't say, well, on the fifth, sixth, and seventh holes of the golf course, there's some poison ivy around, so I'm not going to cut the grass there. That's not an okay answer for the employer. Tech new, when you put it on ahead of time, it blocks the oils so that they don't get on your skin. And there's a couple of other products that work that way. It's basically a barrier cream. Correct. The next page, however, is the treatment that I recommend. Xanthel is good. It's expensive. It's about $30 for a tube. And you have to follow the instructions that are actually on the tube. You don't just apply it to your skin. You have to put it in your palm and work into a paste and then put for, and massage it on your palm with a couple of drops of water for the right number of seconds, then put it on the skin. It's amazingly effective. But you have to actually follow the instructions. What's Xanthel? Xanthel is a What's Xanthel? I don't know. It's magic. It's over the counter, but it's expensive. Now it's probably $40. I don't know. It's a pretty good size too. That's a multi-child's worth supply of Xanthel. The tubes are big, the $30 for that. I mean, they're probably, I don't know, 20 grams, 30 grams. Oh, no, it does. I'm saying it's a very good treatment. And when you think linear and blistering in kids that don't know what it is, use Xanthel. Antihistamines are fine. And then consider steroids if it's really bad or if it involves the face. So this is the other one. This is Tree of Heaven. So Tree of Heaven is an interesting, it's the only plant that I know of that is directly trying to kill us. It's very invasive. It spreads quickly. It's hard to get rid of. It has these chemicals called quassinoids in the sap. And so the tree surgeon tries to go and cut it out and it starts bleeding when you cut it. And you get that on your skin. And now it's trying to cause cardiomyopathy. This has been reported in tree surgeons in a couple of areas who were, especially if they were going to do an, you know, we're going to go take this 100 acres of woods and eradicate all the Tree of Heaven. No, contacts on your skin is enough. It goes through the skin, these quassinoids, through the skin into your blood and affects your heart. Yes, if you just, if you get one drop on your skin, you're not going to, it's not going to kill you. But if you're doing this as, if that's your job is to go and cut these trees out, that you can get. No, no, they're everywhere. They're in my backyard. Well, my old backyard. Yeah. This is, this is a very common thing, at least through the middle zones of the United States. Yeah. Chipping is, chipping those trees is also where they get exposed because now you've aerosolized it too. Next biologic hazard I want to talk about is travel by workers. This is, this comes in a couple of different variations on the theme. So it includes getting an exotic disease while you're traveling. You're going and getting dengue or, or, you know, Chagas disease when you're in Argentina. Personal disease is getting worse while you're traveling where there's limited medical care. You have to think about that. And also exotic diseases after you get back. And each of these is something you need to think about if you're going to do occupational medicine and you've got a workforce that travels. So you want to make sure that, you know, if, well, we'll go through them, I think, all separately. So different places have different disease prevalence. There's not any Chagas disease in the United States. You can't get it here. We don't have the bugs. There's, I don't know, I'm not sure, I've read the literature. I'm not sure I believe them. When it's only two and it doesn't happen again, I don't know what that's all about. And because what you need is you need a population that has a disease, the Radovid bug, and then you have to go and camp where they're going to bite you. And it's, you got to, it's a lot of steps. You're saying it came in from someplace else. Well, that's one of the possibilities. The other thing is, you know how every summer around DC, well, not every summer, every couple of years, there's a couple of cases of malaria from people that were never travelers. I think it's kind of like that, the ones in Texas. Not that they didn't get it. I'm not saying that at all. They got it. They got it there. I'm not questioning that. What I'm saying is I think it's like, like, yeah, well, that's also true. But the, like, in DC, every summer, every couple of summers, there's a couple of cases of malaria from people that never went anywhere. And what it is, is all the people that work at the embassies, there's no health screening. If you're from the embassy from some country in Africa, you have it. You come here. We have the, we have the vectors in the United States. We have vectors that'll, that'll, that'll transmit it. And so we all went to the 4th of July thing on the mall, and you just happened to be, your, your, your blanket was next to the guy who's, you know, the junior ambassador from Chad or something. And so, you know, the mosquito makes it that far, and you get a couple of cases, and then, then that kind of quiets out. But it does happen. And, and so I think the Chagas disease is the same thing. Yeah. And remember, if you give blood here, that's one of the questions they answer, ask you, which is my joy is always listening to them try to pronounce Chagas disease and babesiosis, because they have to ask about them. And they can never say them. Do you have Chagas? Okay. Anyway. Huh? Yeah. Okay. I like that. I like that. Yeah, no, she's right. So also remember that when you travel, there's vaccine-preventable diseases that are far more common. Measles is pretty uncommon in the United States, except at Disney and Austin, right. But, but some of those diseases that we don't have here very much are still very common in other parts of the world. There's less focus on public health, or less success in public health. You can't drink the water everywhere. You got to talk to people about that. Air quality may be hard. I've never been to one of these cities, but I understand if you go to like Mumbai or to Beijing, it's, the air condition, the air stuff is horrible. And that might. Now, and that's, now, is that going to be a problem for everybody? No. But the person that's got really bad asthma or COPD, that might tip them over the edge. Vaccination, again, may, you may want to make sure they get their vaccine for the things that they might encounter down there, even if they're not common in the United States. You get their Japanese. Well, yellow fever would be one. I was thinking Japanese encephalitis is another one, because they may not be able to get that vaccine where they are. Well, in Marin County, California, I wouldn't need it either, but. Yeah, Amazon, you need that. Yeah. So, so we're talking about getting yellow fever because you weren't vaccinated first, which is bad. I mean, always remember, oh, yeah, it's a very good vaccine if you can get it. It's hard to get right now. But the thing with yellow, remember, yellow fever is a hemorrhagic fever. It's bad. You know, it's Ebola, just we have a vaccine for it. So if you're going to be involved in this, there's two ways to get information on where people are going. There's other commercial ways, right? So I'm going to start about the two freebie ways is there's a CDC yellow book, and there's an app version of that called Travel Well, and you can look up stuff on that app as far as wherever they're going. There are also commercial services that will provide that information plus more better information, like handouts for people that are going to Chile or to Botswana or wherever, because you may not be, you know, it has both the medical part, which is what is in the yellow book, but it also has some of the cultural stuff. You know, don't ever touch children on the head because it's a curse, you know, kind of a thing, you need to know so that you don't offend the local citizenry. You know, the boil it, peel it, or leave it, you have to talk to people about that for food safety in most places. Do they need vaccinations? Do we need malaria prophylaxis? Again, the CDC yellow book will tell you that. And the yellow book typically has a map, because not even in countries where there's malaria available, it's usually not everywhere. It's usually not in the city. Well, she said not in the cities. Yeah, but my point is that the yellow book has a map. So you look, or they'll say, if you're in these four provinces, you don't need vaccination, you don't need malaria prophylaxis. If you go to these four provinces, you do, and if you're these two, you got to think about it. And that's okay, it gives you information about what's going on locally. And it often suggests what kind of malaria is there so you can pick the right vaccination. We're at prophylaxis, sorry. Vaccination's coming later. No, I'm serious. I think we're going to have HIV and malaria vaccines probably in the next five years, and they'll all be mRNA, because it worked. Yeah. So, yeah, so do they need antibodies for likely pathogens? I would argue that if you're going to go to one of the countries where the water's not safe, you probably ought to have an antibiotic you can take when you, if you encounter the food. It's not safe, if you, so Cipro is what we used to recommend. There are some other choices now, different choices for kids, but think about it, look at what they need for that part of the world. Do they need antibiotic prophylaxis for just things that are around? And the answer generally is no, but I wanted to have the antibiotic with them. I cannot tell you how hard it was when I was in Guatemala trying to find, because my daughter got, who was at that point three, got a little bit of diarrhea, and I'm trying to get some Bactrim for her, because that's the correct, that was the recommended thing for kids at that time. The liquid, because the liquid version. I had a really hard time getting it, because they didn't, and then you get into the, in some, in third world countries, you're buying medicines based on the reputation of the manufacturer, like, you know, and because it's not just Bactrim, Bactrim Merck, and then you hope it's the real thing, not just somebody that puts something in a bottle that's kind of the right color. I mean, it's crazy, because there's, they don't have an FDA. The other thing is thinking about local disease outbreaks. Do you need to send them with an N95 respirator? Are they going to be in an area where TB becomes, is common or endemic? You know, if you're in South Africa, 95% of the population has had TB, so their approach to TB and our approach to TB are really, really different. I want to talk a little bit about laboratory worker health. That's another kind of different segment. So, the biosafety level of the agents you're working with should drive your decision making. The United States, the National Institute of Health has this thing called the BMBL, the Biomedical Biosafety for Laboratory book. It's okay, but there's this thing that Canada has, the Health Canada has, it's their PSDS. It's really good. It's one-pagers for almost all the agents, and you can look stuff up quickly to say, oh, they work with this thing. I go to this Canadian resource. I have information in five minutes. The BMBL is divided into sections, and so you can't look up one agent. You have to look up that same agent in all five sections, and it's not indexed well. It's all there, but it's not indexed. It's really hard to find stuff. The Canadian use is much more friendly for the provider, not the research director, but the provider. And also, you have to think about how they're going to use it. Is there any risk for aerosolization? Are you going to be working with infecting animals who will then aerosolize it to everybody else? So, you have to think about that stuff as well. Hospital labs, every hospital that has a micro lab is a BSL-3 laboratory. They design it to control meningococcus because it will eventually show up in their population. So, that's what they design their laboratory to be safe for. So, they have lots of hazards for culturing stuff. There's varying degrees of automation. A lot of the culture stuff now is no contact once they've inoculated the stuff. And that's what they design for. So, TB, equine encephalitis, they're fine with. If you've got a BSL-4 agent you're worried about, your hospital lab may tell you no. So, if you're worried somebody's got circopithecine virus, we used to call that B virus, the monkey virus, or Ebola, or one of those things, your hospital lab is not prepared for that. So, if ever that patient passes through your hospital, and remember, you may not figure it out until you've exposed people, you need to make sure you remember the lab people. No, but remember the people in the lab that may have been exposed to the specimens that you need to watch to protect them as best you can also. Research laboratories, they spend a lot of time culturing things, growing them out, lots of exposures potentially there. They deal with both human and animal pathogens. And then the ones that drive me nuts is unknown clinical specimens. We kept having this problem where the ortho people wanted to go and go find somebody that had an infection that we could not cure with antibiotics of their prosthetic body part, culture it in their lab, and then use it for research. Well, okay, we couldn't kill it in the person. How's that going to go in the lab? So, they wouldn't do it on a BSL-2, like, no, this is a BSL-3 activity. And you've got to up your game. And they're like, well, but we can't afford that. Well, then you can't do that. Or you can work with a clinical lab and have them do it for you. But you can't be just bringing specimens back and having grad students with no protective equipment culture this stuff out in the lab for things we could, for pathogens we could not kill in vivo. So, the other thing to talk about is viral vectors and transfecting cells. So, a lot of times we use all sorts of virus things. Lentiviral is the most common one used, which is, think of HIV that is not replication competent. And we add all sorts of things to mammalian cells using that technology. The problem is, as long as I put it where it's supposed to go, they're pretty safe. But if I take, if I have, let's just say that I've put, oh, I don't know, an oncogene into a lentiviral vector system. Well, it's incredibly effective at getting that inside mammalian cells. So, if I give it to my mouse, it's got a risk of getting cancer, right? If I give that to my, one of my workers by a needle stick injury, now what happens? And you need to have a response plan that will deal with that, like treat it as if it was an HIV infection and prophylax it like that. Because I don't want that person, I want antiretrovirals in there. I want the antirecombinant DNA stuff. Integrase would be one of the ones you might want to use. It's expensive. But in that circumstance, I think it's warranted. If they've got a needle stick with a, like something that's important as part of the DNA that you inserted. Research animals, thankfully, are mostly small rodents. They're not usually a big problem on their own until we mess with them and make them not necessarily a regular animal. There's a lot of now what we call humanized lines of mice where they've got to, they're trying to make, recreate a human liver in the mouse. And so, we mess with their DNA to make that happen. We don't know what else we gave them when we humanized them. We have another virus just to make life more exciting. A couple slides here that I added on. This is the COVID-19 supplement. And just to kind of walk through this, some of this is obvious and just I won't spend much time on them. So, this is kind of what happens, you know, the number of cases over time. We do no interventions. And this is what we were trying to do with interventions like the vaccine, medications, workplace practices, distancing, stuff like that. Just make the peak less. And if you were in the hospital through or peripheral to the peaks for Delta last year or the peaks for Omicron earlier this year, you got to see why that's important. I don't know how it was where you were, but I did work at that little 24-bed community hospital. It has a three-bed ICU. That's all there are. And they had five patients on vents. And they were transferring patients from big hospitals to this little hospital on vents because they had no place else to put them. So, that's what we wanted to do. We wanted to flatten that thing out so that we don't have that problem. Last slide I'm going to throw in here. And this one, it's a super busy slide. But I think it's actually useful for people to kind of understand how all the timing works. I left it in there, in here, not so much that we're going to talk about it now. But if you're trying to figure out like when does seroconversion antibody tests, IgM and IgG and all that stuff, this is actually, I think, still accurate, a really good timeline as a reference. Does anybody have any questions about any of the stuff we talked about? I know there was a one hour, that was an entire microbiology fellowship in an hour. But does anybody have any questions? The lab stuff that you're talking about for the, you know, integrating genomes and stuff, that's extremely highly specialized. Isn't, is that, is there no other entity other than, does that really fall on the OCMED doc to do that? Isn't there like a higher lab standard for that? Well, we're, so the OCMED doc, I mean, when I was in academic medicine, I was, one of my assignments was I was the OCMED doc for the university's research activities. And what you have to know is the, working with lentiviral vector systems, because it's BSL2, you'll find that at community colleges. I mean, it's not super specialized. The lentiviral vector systems are easy to work with. You could order a kit and do it in your kitchen table right now. I don't recommend that. Just like you can order a CRISPR kit and do that on your kitchen table. For some reason, I don't recommend that either. But these are actually very easy to do kits now that are designed for undergraduate students to be able to actually do experiments. Now, hopefully when they're doing it with students, they're not inserting like real oncogenes. They'll insert something that makes it glow in the dark or something. But that's still, that is, you can find that pretty widely dispersed. Thank you. Let's see. That's Jeff and Bridget. So, okay. So, the question was asked for, I assume this is blood-borne pathogens, whether the annual retraining needs to be live also. The answer to that question for blood-borne pathogens is no. Initial training must be live to include the skills part. And the, after that, it can be done remotely. So, in a lot of places, they'll just, they'll have like a, you know, a 10-minute video that you'll watch as your annual reminder, mostly of when you have to deal with it. And they may demonstrate like taking gloves on and off, but it doesn't have to be live after the first year. You do have to have the ability to ask questions, but that can be done remote, you know, asynchronously. Are there any other questions? Or anything anybody wants to ask about or share? Well, thank you guys very much. And I'll let Jeff do his thing next.

biological hazards

bloodborne pathogens

occupational safety

BSL classification

protective measures

post-exposure protocols

pandemic safety

vaccination

safety training