BACKGROUND: U.S. construction workers experience high rates of injury that can lead to chronic pain. This pilot study examined nonpharmacological (without medication prescribed by healthcare provider) and pharmacological (e.g., prescription opioids) pain management approaches used by construction workers. METHODS: A convenience sample of U.S. construction workers was surveyed, in partnership with the U.S. National Institute for Occupational Safety and Health (NIOSH) Construction Sector Program. Differences in familiarity and use of nonpharmacological and pharmacological pain management approaches, by demographics, were assessed using logistic regression models. A boosted regression tree model examined the most influential factors related to pharmacological pain management use, and potential reductions in use were counterfactually modeled. RESULTS: Of 166 (85%) of 195 participants reporting pain/discomfort in the last year, 72% reported using pharmacological pain management approaches, including 19% using opioids. There were significant differences in familiarity with nonpharmacological approaches by gender, education, work experience, and job title. Among 37 factors that predicted using pharmacological and non-pharmacological pain management approaches, training on the risks of opioids, job benefits for unpaid leave and paid disability, and familiarity with music therapy, meditation or mindful breathing, and body scans were among the most important predictors of potentially reducing use of pharmacological approaches. Providing these nonpharmacological approaches to workers could result in an estimated 23% (95% CI: 16%-30%) reduction in pharmacological pain management approaches. CONCLUSION: This pilot study suggests specific factors related to training, job benefits, and worker familiarity with nonpharmacological pain management approaches influence use of these approaches.

We appreciate the comments of Chirico and Szarpak1 and their efforts to elucidate several important issues related to antigen testing in the employment setting. We agree that screening testing is one part of a comprehensive approach to reducing transmission in workplaces, which also includes vaccination, risk assessments, contact tracing, physical distancing, and mask use. | | Chirico and Szarpak reiterated the false negative issue in persons with low viral load but confirmed the utility of antigen testing in those with high viral load and no symptoms. They noted that the cost of antigen testing may be an issue in some countries, and this is true. However, in many countries the costs should be within the range of doing business and not constraining. In addition, it is important to consider the potential cost savings and other benefits associated with preventing workplace transmission of SARS-CoV-2. We agree with the point raised that there is more to the costs than the cost of the actual test and emphasize that there is also the need for contact tracing and trained personnel.

Law enforcement officers (LEOs) often encounter rapidly changing and uncontrolled situations that expose them to various hazards. A law enforcement agency requested an evaluation by the National Institute for Occupational Safety and Health (NIOSH) when multiple LEOs reported illness after executing a search warrant and taking a suspect into custody. NIOSH investigators interviewed LEOs and reviewed medical records, forensic laboratory results for collected evidence, and environmental testing results of samples taken after the operation. Two-thirds (25 of 38) of LEOs who participated in the operation reported 1 symptom. Eleven LEOs met a case definition for influenza-like illness (ILI). Members of one unit were more likely to have ILI than non-members (prevalence ratio (PR), 4.1; 95% confidence interval (CI): 1.3-13.0; p=0.01). Influenza vaccination was associated with a lower prevalence of ILI (PR, 0.2; 95% CI, 0.1-0.9; p =0.02). Preventing employees from working while ill and annual influenza vaccination might prevent similar occurrences.

OBJECTIVES: To propose a framework for considering SARS-CoV-2 antigen testing of unexposed asymptomatic workers in selected workplaces. METHODS: This is a commentary based on established occupational safety and health principles, published articles, and other pertinent literature, including non-peer-reviewed preprints in medrixiv.org prior to April 16, 2021. RESULTS: Not applicable to this commentary/viewpoint article. CONCLUSION: Antigen testing is a rapidly evolving and useful public health tool that can be used to guide measures to reduce spread of SARS-CoV-2 in the community and in selected workplaces. This commentary provides a proposed framework for occupational safety and health practitioners and employers for considering antigen testing as a method to screen asymptomatic workers in selected non-healthcare settings. When applied selectively, antigen testing can be a useful, effective part of a comprehensive workplace program for COVID-19 prevention and control.

Congregate work and residential locations are at increased risk for infectious disease transmission including respiratory illness outbreaks. SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), is primarily spread person to person through respiratory droplets. Nationwide, the meat and poultry processing industry, an essential component of the U.S. food infrastructure, employs approximately 500,000 persons, many of whom work in proximity to other workers (1). Because of reports of initial cases of COVID-19, in some meat processing facilities, states were asked to provide aggregated data concerning the number of meat and poultry processing facilities affected by COVID-19 and the number of workers with COVID-19 in these facilities, including COVID-19-related deaths. Qualitative data gathered by CDC during on-site and remote assessments were analyzed and summarized. During April 9-27, aggregate data on COVID-19 cases among 115 meat or poultry processing facilities in 19 states were reported to CDC. Among these facilities, COVID-19 was diagnosed in 4,913 (approximately 3%) workers, and 20 COVID-19-related deaths were reported. Facility barriers to effective prevention and control of COVID-19 included difficulty distancing workers at least 6 feet (2 meters) from one another (2) and in implementing COVID-19-specific disinfection guidelines.* Among workers, socioeconomic challenges might contribute to working while feeling ill, particularly if there are management practices such as bonuses that incentivize attendance. Methods to decrease transmission within the facility include worker symptom screening programs, policies to discourage working while experiencing symptoms compatible with COVID-19, and social distancing by workers. Source control measures (e.g., the use of cloth face covers) as well as increased disinfection of high-touch surfaces are also important means of preventing SARS-CoV-2 exposure. Mitigation efforts to reduce transmission in the community should also be considered. Many of these measures might also reduce asymptomatic and presymptomatic transmission (3). Implementation of these public health strategies will help protect workers from COVID-19 in this industry and assist in preserving the critical meat and poultry production infrastructure (4).

Recent increases in the rate of drug overdose-related deaths, the emergence of potent opioids such as carfentanil, and media reports of incidents have raised concerns about the potential for work-related exposure to a variety of illicit drugs among law enforcement officers (LEOs), other emergency responders, and other workers in the United States. To characterize the risk associated with unintentional occupational exposure to drugs, we retrospectively investigated two incidents that occurred in 2017 and 2018 where LEOs were exposed to opioid and stimulant drugs and experienced health effects. We interviewed five affected LEOs and others. We reviewed records, including emergency department documentation, incident reports, forensic laboratory results, and when available, body camera footage. Multiple drug types, including opioids and nonopioids, were present at each incident. Potential routes of exposure varied among LEOs and were difficult to characterize with certainty. Health effects were not consistent with severe, life-threatening opioid toxicity, but temporarily precluded affected LEOs from performing their essential job duties. While health risks from occupational exposure to drugs during law enforcement activities cannot currently be fully characterized with certainty, steps to prevent such exposures should be implemented now. The creation and implementation of appropriate controls plus education and training are both important to protecting first responders from these hazardous agents. To more fully characterize potential exposures, timely prospective toxicological evaluation of affected responders is recommended.

Improvements in the function, quality of life, and longevity of patients with Duchenne muscular dystrophy (DMD) have been achieved through a multidisciplinary approach to management across a range of health-care specialties. In part 3 of this update of the DMD care considerations, we focus on primary care, emergency management, psychosocial care, and transitions of care across the lifespan. Many primary care and emergency medicine clinicians are inexperienced at managing the complications of DMD. We provide a guide to the acute and chronic medical conditions that these first-line providers are likely to encounter. With prolonged survival, individuals with DMD face a unique set of challenges related to psychosocial issues and transitions of care. We discuss assessments and interventions that are designed to improve mental health and independence, functionality, and quality of life in critical domains of living, including health care, education, employment, interpersonal relationships, and intimacy.

OBJECTIVE: The aim of this study was to describe the process by which a group of subject matter experts (SMEs) in the area of occupational health and primary care developed a clinical decision support (CDS) tool addressing work-related issues, which are important in the care of patients with diabetes mellitus (DM). The CDS is intended for primary care clinicians caring for employed adults with DM. METHODS: The SME's selected guidelines for the management of DM in working adults, reviewed pertinent literature, and developed specific recommendations for action in the clinical setting. RESULTS: Multiple factors at work may adversely affect DM management. Clinicians can support working patients through education and care strategies to improve control. CONCLUSION: Improved recognition of factors at work that can have an impact on DM care provides opportunities for improved management of DM among working adults.

A novel virus, rainbow trout orthomyxovirus (RbtOV), was isolated in 1997 and again in 2000 from commercially-reared rainbow trout (Oncorhynchus mykiss) in Idaho, USA. The virus grew optimally in the CHSE-214 cell line at 15 degrees C producing a diffuse cytopathic effect; however, juvenile rainbow trout exposed to cell culture-grown virus showed no mortality or gross pathology. Electron microscopy of preparations from infected cell cultures revealed the presence of typical orthomyxovirus particles. The complete genome of RbtOV is comprised of eight linear segments of single-stranded, negative-sense RNA having highly conserved 5' and 3'-terminal nucleotide sequences. Another virus isolated in 2014 from steelhead trout (also O. mykiss) in Wisconsin, USA, and designated SttOV was found to have eight genome segments with high amino acid sequence identities (89-99%) to the corresponding genes of RbtOV, suggesting these new viruses are isolates of the same virus species and may be more widespread than currently realized. The new isolates had the same genome segment order and the closest pairwise amino acid sequence identities of 16-42% with Infectious salmon anemia virus (ISAV), the type species and currently only member of the genus Isavirus in the family Orthomyxoviridae. However, pairwise comparisons of the predicted amino acid sequences of the 10 RbtOV and SttOV proteins with orthologs from representatives of the established orthomyxoviral genera and a phylogenetic analysis using the PB1 protein showed that while RbtOV and SttOV clustered most closely with ISAV, they diverged sufficiently to merit consideration as representatives of a novel genus. A set of PCR primers was designed using conserved regions of the PB1 gene to produce amplicons that may be sequenced for identification of similar fish orthomyxoviruses in the future.

OBJECTIVE: To describe the occurrence of selected neurobehavioral concerns among males with a dystrophinopathy and to explore the associations with corticosteroid or supportive device use. METHODS: Medical record abstraction of neurobehavioral concerns was conducted for 857 affected males from 765 families, born since 1982 and followed through 2011, and enrolled in the population-based Muscular Dystrophy Surveillance, Tracking, and Research Network. Cumulative probabilities for attention-deficit hyperactivity disorder (ADHD), behavior problems, and depressed mood were calculated from Kaplan-Meier estimates for the subsample of oldest affected males (n = 765). Hazard ratios (HRs) and 95% confidence intervals (95% CIs) for corticosteroid and supportive device use were estimated from Cox regression models with time-dependent covariates. RESULTS: Of the 857 affected males, 375 (44%) had at least 1 of the 3 selected neurobehavioral concerns; a similar percentage (45%) was found among the 765 oldest affected males. The estimated cumulative probabilities among these oldest affected males were 23% for ADHD, 43% for behavior problems, and 51% for depressed mood. Corticosteroid (HR = 2.35, 95% CI = 1.75-3.16) and mobility device (HR = 1.53, 95% CI = 1.06-2.21) use were associated with behavior problems. Use of a mobility device (HR = 3.53, 95% CI = 2.13-5.85), but not corticosteroids, was associated with depressed mood. ADHD was not significantly associated with corticosteroid or mobility device use. Respiratory assist device use was not examined due to low numbers of users before onset of neurobehavioral concerns. CONCLUSION: Selected neurobehavioral concerns were common among males with a dystrophinopathy. Reported associations highlight the importance of increased monitoring of neurobehavioral concerns as interventions are implemented and disease progresses.

We characterized a La Crosse virus (LACV) isolate from the brain of a child who died of encephalitis-associated complications in eastern Tennessee, USA, during summer 2012. We compared the isolate with LACV sequences from mosquitoes collected near the child's home just after his postmortem diagnosis. In addition, we conducted phylogenetic analyses of these and other sequences derived from LACV strains representing varied temporal, geographic, and ecologic origins. Consistent with historical findings, results of these analyses indicate that a limited range of LACV lineage I genotypes is associated with severe clinical outcomes.

BACKGROUND: Female sex workers (FSW) in Mali are highly vulnerable to HIV. Their prevalence in 2009 was 9 times higher (24.2%) than that among pregnant women (2.7%). METHODS: Four Integrated HIV/sexually transmitted infection (STI) Surveillance and Behavioral Surveys among FSW in Mali (2000, 2003, 2006, and 2009) tracked demographic characteristics, behavior, and HIV and STI prevalence. Logistic regression using generalized estimating equations to control for the cluster effect identified factors associated with HIV-positive serostatus adjusting for potential confounding. RESULTS: Of 2430 FSW, 40.8% were Nigerian, 36.8% were Malian, and 22.4% were from other neighboring countries. Between 2003 and 2009, HIV prevalence dropped from 44.14% to 28.49% (P < 0.0001) among Malians, from 21.33% to 12.71% (P = 0.0082) among Nigerians, and from 43.42% to 33.67% (P = 0.0442) among "others." Between 2000 and 2009, condom availability increased (89.18%-99.3%; P < 0.0001) as did HIV testing (40%-75%; P < 0.0001). Consistent condom use with clients improved for Malians (72.3%-81.5%; P = 0.0092), but not among Nigerians (92.7%-90.94%; P = 0.8240) and "others" (88.9%-88.48%; P = 0.8452). Consistent condom use with boyfriends was low and improved only for Nigerians (9.8%-28.4%; P = 0.0003). Factors associated with HIV prevalence in the multivariate model were older age, study year (2003 and 2006), nationality, lack of education, mobility, STI symptoms, gonorrhea prevalence, and younger age at first sex. CONCLUSIONS: This study documents progress in the fight against HIV among FSW in Mali. The different vulnerabilities to HIV found for different nationality FSW should be considered in programming and future research.

The family Hepeviridae consists of positive-stranded RNA viruses that infect a wide range of mammalian species, as well as chickens and trout. A subset of these viruses infects humans and can cause a self-limiting acute hepatitis that may become chronic in immunosuppressed individuals. Current published descriptions of the taxonomical divisions within the family Hepeviridae are contradictory in relation to the assignment of species and genotypes. Through analysis of existing sequence information, we propose a taxonomic scheme in which the family is divided into the genera Orthohepevirus (all mammalian and avian hepatitis E virus (HEV) isolates) and Piscihepevirus (cutthroat trout virus). Species within the genus Orthohepevirus are designated Orthohepevirus A (isolates from human, pig, wild boar, deer, mongoose, rabbit and camel), Orthohepevirus B (isolates from chicken), Orthohepevirus C (isolates from rat, greater bandicoot, Asian musk shrew, ferret and mink) and Orthohepevirus D (isolates from bat). Proposals are also made for the designation of genotypes within the human and rat HEVs. This hierarchical system is congruent with hepevirus phylogeny, and the three classification levels (genus, species and genotype) are consistent with, and reflect discontinuities in the ranges of pairwise distances between amino acid sequences. Adoption of this system would include the avoidance of host names in taxonomic identifiers and provide a logical framework for the assignment of novel variants.

The classification of hepatitis E virus (HEV) variants is currently in transition without agreed definitions for genotypes and subtypes or for deeper taxonomic groupings into species and genera that could incorporate more recently characterized viruses assigned to the Hepeviridae family that infect birds, bats, rodents, and fish. These conflicts arise because of differences in the viruses and genomic regions compared and in the methodology used. We have reexamined published sequences and found that synonymous substitutions were saturated in comparisons between and within virus genotypes. Analysis of complete genome sequences or concatenated ORF1/ORF2 amino acid sequences indicated that HEV variants most closely related to those infecting humans can be consistently divided into six genotypes (types 1 to 4 and two additional genotypes from wild boar). Variants isolated from rabbits, closely related to genotype 3, occupy an intermediate position. No consistent criteria could be defined for the assignment of virus subtypes. Analysis of amino acid sequences from these viruses with the more divergent variants from chickens, bats, and rodents in three conserved subgenomic regions (residues 1 to 452 or 974 to 1534 of ORF1 or residues 105 to 458 of ORF2) provided consistent support for a division into 4 groups, corresponding to HEV variants infecting humans and pigs, those infecting rats and ferrets, those from bats, and those from chickens. This approach may form the basis for a future genetic classification of HEV into four species, with the more divergent HEV-like virus from fish (cutthroat trout virus) representing a second genus.

INTRODUCTION: Palliative care services that address physical pain and emotional, psychosocial, and spiritual needs may benefit individuals with Duchenne muscular dystrophy (DMD). METHODS: The objective of this study was to describe the palliative care services that families of males with DMD report they receive. A questionnaire was administered to families of males with DMD born prior to January 1, 1982. Thirty-four families responded. RESULTS: Most families (85%) had never heard the term palliative care. Only attendant care and skilled nursing services showed much usage, with 44% and 50% indicating receipt of these services, respectively. Receipt of other services was reported less frequently: pastoral care (27%); respite care (18%); pain management (12%); and hospice care (6%). Only 8 respondents (25%) reported having any type of directive document in place. CONCLUSION: The data suggest a need for improved awareness of palliative care and related services among families of young men with DMD. Muscle Nerve 44: 93-101, 2011.

OBJECTIVE: This article provides an overview of the issues that arise with medical surveillance, exposure registration, and epidemiologic research involving nanomaterial workers. METHODS: An occupational health perspective is applied to detecting risks in nanomaterial workers individually and as a group. RESULTS: General principles for medical surveillance, exposure registration, and epidemiologic research are identified. A model Nanomaterial Worker Health Study is for consideration. CONCLUSIONS: The Nanomaterial Worker Health Study can be developed as a tangible action in assuring the public that steps are being taken to learn of any adverse effects from exposure to nanomaterials.

This issue presents selected articles from the Nanomaterial Workers' Health Conference held in Keystone, Colorado, July 21 to 23, 2010. The conference addressed three critical and related topics: medical surveillance; formation of exposure registries; and the conduct of epidemiologic research. Each topic was introduced with a plenary session followed by group breakout sessions to obtain input from the approximately 120 attendees. This supplement issue of the Journal of Occupational and Environmental Medicine includes selected peer reviewed articles from the conference and summaries of the breakout sessions. The conference was initiated with a general session, and there are articles that provide an overview of the topics (Schulte and Trout) and describe lessons from air pollution particulate epidemiology (Peters et al) and the state-of-the-art of nanotoxicology (Castranova), both of which contributed to the initial concern about potential hazards of nanomaterials. The opening session also included an overview of medical surveillance in the context in which occupational physicians must regularly work and at a time when uncertainties about hazards and risks make decisions about medical surveillance of workers difficult (Nasterlack).

OBJECTIVE: As potential occupational exposure to nanomaterials becomes more prevalent, it is important that the principles of medical surveillance be considered for workers in the nanotechnology industry. METHODS: The principles of medical surveillance are reviewed to further the discussion of occupational health surveillance for workers exposed to nanomaterials. RESULTS: Because of the rapid evolution of nanotechnology, information may not be available to make a well-informed determination of all factors needed to evaluate risk of health effects from occupational exposure to nanomaterials. CONCLUSION: Every workplace dealing with engineered nanomaterials should conduct hazard and exposure assessments as part of an overall surveillance needs assessment for nanotechnology workers. In workplaces where risk is felt to be present, or at least cannot be ruled out, initiation of medical surveillance is prudent to protect workers' health.

OBJECTIVE: To evaluate the immunosuppressive effects of job stress in female nurses, an 8-month longitudinal study was conducted at a major university hospital. METHODS: Four groups of ten subjects each were constructed to represent high versus low objective stress and high versus low subjective stress based on their responses to a job stress questionnaire and objective stress ratings of the hospital's work units. Number of white blood cells (i.e., T cells, B cells, and natural killer cells), and lymphocytic proliferation to mitogens (concanavalin A, phytohemagglutinin, and pokeweed) and toxoid (tetanus) were measured by flow cytometry and radioimmunoassay. Serum levels of hydrocortisol, IL-1beta, IFN-gamma, and TNF-alpha, and salivary IgA were measured by enzyme-linked immunosorbent assay. The data were analyzed by repeated measures analysis of variance controlling for age and smoking. RESULTS: The level of white blood cells was lower among high objective stress group (median: 7,170/m(3); range: 5,386-10,057) compared with that among low objective stress group (8,063; 5,888-9,875) (P = 0.03), however, no other cellular blood variables were found to be significant. In terms of humoral immuno-biomarkers, the level of TNF-alpha was moderately lower among high objective stress group (1.7 ng/ml; 0.3-2.7) compared with that among low objective stress group (2.2; 0.5-3.5) (P = 0.07), whereas the level of total sIgA was significantly higher among higher objective stress group (72.9 end-point titer/mg/ml/min; 14.4-153.4) compared with that among low objective stress group (44.8; 9.9-123.8) (P = 0.02). CONCLUSION: The results of the study suggest that psychological job stress affects the levels of some immunological biomarkers in female nurses.

While there is a growing body of information about hazards of nanomaterials, little is known about the risks to workers exposed to them. However, workers are the first people in society that are being exposed to the growing inventory of "nano-enabled" products in commerce. The number of workers involved in the investigation, manufacture, production, and disposal of these types of products is growing. Although toxicologic research is still the highest priority, it is time to actively anticipate the health needs of workers. To date, precautionary risk management approaches have been widely advocated. Now there is a need to initiate an evolving process to identify the issues in medical surveillance, utilization of exposure registries, and the conduct of epidemiologic research. Each of these are complex endeavors that build on the toxicologic evidence and extent of exposure. There is a need to assess the scientific basis and research needs for determining early functional changes, organ system and disease responses for use in targeted medical surveillance. There is also need for development of criteria for extrapolating toxicological data in biological systems to predict the risk of adverse outcomes in humans. In the meantime, exposure registries may be pivotal in helping societies act in the face of uncertainty in a precautionary manner, but legal, ethical, and logistical issues need resolution. Epidemiologic research will build on these efforts and may ultimately contribute critical definitive rationale for medical monitoring, risk assessment and management.