Fentanyls and the safety of first responders: Science and recommendations

Opioids have many beneficial uses in medicine, but, taken inappropriately, they can cause life‐threatening health effects. The increasing use of physician‐prescribed and illicit opioids, including highly potent fentanyl and its analogs, have contributed to a significant increase in opioid‐related drug overdoses in the United States, leading to a public health emergency. There have been a number of reports describing adverse health effects experienced by police officers, fire‐fighter emergency medical services providers, and private sector ambulance personnel when responding to drug overdose incidents. Several sets of exposure prevention recommendations for first responders are available from government and the private sector. Understanding the scientific basis for these recommendations, increasing awareness by responders of the potential risks associated with opioid exposure during a response, and educating responders about safe work practices when exposure to opioids is suspected or confirmed are all critical prevention measures that can keep first responders safe.

     

Acute pesticide-related illness among emergency responders, 1993-2002

BACKGROUND: Emergency responders are among the first to arrive at a pesticide-related release event. Magnitude, severity, and risk factor information on acute pesticide poisoning among those workers is needed. METHODS: Survey data collected from the SENSOR-Pesticides, CDPR and HSEES programs between 1993 and 2002 from 21 states were reviewed. Acute occupational pesticide-related illness incidence rates for each category of emergency responder were calculated, as were incidence rate ratios (IRR) among emergency responders compared to all other workers employed in non-agricultural industries. RESULTS: A total of 291 cases were identified. Firefighters accounted for 111 cases (38%), law enforcement officers for 104 cases (36%), emergency medical technicians for 34 cases (12%), and 42 cases (14%) were unspecified emergency responders. Among the 200 cases with information on activity responsible for exposure, most were exposed while performing activities related to a pesticide release event (84%) and not involving patient care, while the remainder involved exposure to pesticide-contaminated patients. A majority of cases were exposed to insecticides (51%). Most had low severity illnesses (90%). The incidence rate was highest for firefighters (39.1/million) and law enforcement officers (26.6/million). The IRRs were also elevated for these professions (firefighters, IRR = 2.67; law enforcement officers, IRR = 1.69). CONCLUSIONS: The findings suggest the need for greater efforts to prevent acute occupational pesticide-related illness among emergency responders.     

A report of occupational deaths attributed to fluorocarbon-113

This study reports two occupational deaths resulting from exposure to fluorocarbon-113 (1,1,2-trichloro-1,2,2-trifluoroethane; FC-113) in enclosed and confined spaces. One incident involved a worker who was exposed to FC-113 after entering a small degreasing tank to clean it. The second case involved a significant spill of FC-113 onboard a marine vessel. The incidents are compared to other fatal exposures.     

A Report of Occupational Deaths Attributed to Fluorocarbon-113

This study reports two occupational deaths resulting from exposure to fluorocarbon-113 (1,1,2-trichloro-1,2,2-trifluoroethane; FC-113) in enclosed and confined spaces. One incident involved a worker who was exposed to FC-113 after entering a small degreasing tank to clean it. The second case involved a significant spill of FC-113 onboard a marine vessel. The incidents are compared to other fatal exposures.     

Chemical suicides in automobiles--six states, 2006-2010

During a 3-month period in 2008 in Japan, 208 persons committed suicide by mixing household chemicals and, while in a confined space, breathing in the resultant poisonous gas. The large number of similar suicides is believed to have resulted from the posting of directions for generating poisonous gas on the Internet. In addition to claiming the suicide victim, lethal gas generated by intentionally mixing household chemicals can leak from confined spaces, triggering evacuations, and exposing bystanders and first responders to injury. Chemical suicides similar to those in Japan in 2008 have been reported increasingly in the United States, with the majority occurring inside automobiles. To characterize such incidents in the United States, the Agency for Toxic Substances and Disease Registry (ATSDR) analyzed reports of chemical suicides and attempted suicides that occurred in automobiles, using 2006--2009 data from states participating in the Hazardous Substances Emergency Events Surveillance (HSEES) system and 2010 data from states participating in the new National Toxic Substance Incidents Program (NTSIP). This report summarizes the results of that analysis, which found that, during 2006--2010, a total of 10 chemical suicide incidents were reported from six states, resulting in the deaths of nine suicide victims and injuries to four law enforcement officers. When responding to suspected chemical suicide incidents, emergency responders must take precautions to ensure both their safety and the safety of any bystanders in the immediate vicinity.     

Critical incident stress: the role of hospital-based social work in developing a statewide intervention system for first-responders delivering emergency services.

Emotional, cognitive and behavioral stress can negatively affect the performance of fire, rescue and law enforcement personnel responding to emergency situations. Impaired professional performance in these crises not only endangers the incident victims, all involved responders and their families, but potentially the lives and property of entire communities. This article describes the major administrative and clinical leadership of a hospital-based Social Work department in implementing one of the few statewide critical incident stress debriefing teams for emergency service personnel in the United States. It represents a model for program development by other organizations.     

Acute drug-related mortality of people recently released from prisons

The rate of acute drug-related mortality, or overdose deaths, among prisoners in the immediate post-release period is unacceptably high. Such incidents result from many factors, including decreased tolerance after a period of relative abstinence during imprisonment and the concurrent use of multiple drugs which, with every additional illicit drug consumed in combination with opioids, nearly doubles the risk of death from opioids. Other important factors are the lack of pre-release counselling, post-release follow-up and failure to identify those at risk. Substance dependence is a chronic disorder with high relapse rates and often requires long-term continuous treatment. The deaths are preventable and a number of interventions including opioid substitution treatment reduces the risk of overdose among opioid users after release.     

Expanded Access to Naloxone Among Firefighters,Police Officers,and Emergency Medical Technicians in Massachusetts

Naloxone is a medication that reverses respiratory depression from opioid overdose if given in time. Paramedics routinely administer naloxone to opioid overdose victims in the prehospital setting, and many states are moving to increase access to the medication. Several jurisdictions have expanded naloxone administration authority to nonparamedic first responders, and others are considering that step. We report here on policy change in Massachusetts, where several communities have equipped emergency medical technicians, law enforcement officers, and firefighters with naloxone.Fatal poisonings, more than 90% of which are drug overdoses, have increased by nearly 600% in the past 3 decades to become the leading cause of injury death in the United States.1This rise has been driven largely by opioid analgesic medications, which now account for more overdose deaths than heroin and cocaine combined.2 Although first responders are not always contacted in time to reverse overdose, emergency department encounters associated with opioids and other sedatives have increased markedly over the past decade.3To address this epidemic, many states are moving to increase community access to the opioid antagonist naloxone, which can reverse opioid overdose if administered in time.4,5 Nearly 200 community-based overdose prevention programs dispensed naloxone as of 2010, and participants reported reversing more than 10 000 overdoses.6 In Massachusetts, communities participating in a community naloxone access program had lower opioid overdose death rates than those that did not, strongly suggesting that increased access to naloxone can reduce fatal opioid overdose.7Naloxone is the standard medication for reversing opioid overdose, and is routinely administered by paramedics for that purpose. Although paramedics typically administer naloxone intramuscularly (IM) or intraveneously (IV), it can also be administered intranasally (IN) via a needleless atomizer. IN administration of naloxone has been shown to be similarly effective as IV administration in the prehospital setting,8–10 and in one study, IN naloxone administration was faster, better accepted, and perceived to be safer than IV administration.11In many areas, the first emergency personnel to respond to overdose calls are not paramedics but law enforcement officers, firefighters, and emergency medical technicians (EMTs; medical first responders who have a lower level of training than paramedics). The National Drug Control Strategy has called for equipping first responders to recognize and manage overdoses since 2010, and the Office of National Drug Control Policy has stated that naloxone “should be in the patrol cars of every law enforcement professional across the nation.”12 Although these first responders in most states are not authorized to administer naloxone, this is rapidly changing; in 2013, 5 states changed law or policy to permit EMTs to administer naloxone, bringing the total up to 13 states.13 Access to emergency prehospital care, including the provision of naloxone, may be an important piece in the overdose prevention puzzle. Nationwide, EMTs outnumber paramedics by approximately 3-to-1, and law enforcement officers are even more numerous.14 In rural areas, EMTs may be the only medical first responders, and hospital transport times can be long.15 A study in one large county demonstrated that EMT nasal naloxone administration could reduce time to naloxone delivery by between 5.7 and 10.2 minutes.16 In tiered EMS departments with high overdose call volume, efficiencies may be created by dispatching EMTs instead of paramedics to overdose calls, reducing response time, and making paramedics available to respond to emergencies that require a higher level of skill and training.16,17We provide an overview of policy change in 3 communities in Massachusetts that expanded naloxone access to firefighters, EMTs, and police officers, and offer some brief thoughts on what this change might mean for other jurisdictions.     

Bioterrorism and mass casualty preparedness in hospitals: United States, 2003

OBJECTIVES: This study examined the content of hospital terrorism preparedness emergency response plans; whether those plans had been updated since September 11, 2001; collaboration of hospitals with outside organizations; clinician training in the management of biological, chemical, explosive, and nuclear exposures; drills on the response plans; and equipment and bed capacity. METHODS: The National Hospital Ambulatory Medical Care Survey (NHAMCS) is an annual survey of a probability sample of approximately 500 non-Federal general and short-stay hospitals in the United States. A Bioterrorism and Mass Casualty Supplement was included in the 2003 survey and provided the data for this analysis. RESULTS: Almost all hospitals have plans for responding to natural disasters (97.3 percent). Most have plans for responding to chemical (85.5 percent), biological (84.8 percent), nuclear or radiological (77.2 percent), and explosive incidents (76.9 percent). About three-quarters of hospitals were integrated into community-wide disaster plans (76.4 percent), and 75.9 percent specifically reported a cooperative planning process with other local health care facilities. Despite these plans, only 46.1 percent reported written memoranda of understanding with these facilities to accept inpatients during a declared disaster. Hospitals varied widely in their plans for re-arranging schedules and space in the event of a disaster. Training for hospital incident command and smallpox, anthrax, chemical, and radiological exposures was ahead of training for other infectious diseases. The percentage of hospitals training their staff in any exposure varied from 92.1 percent for nurses to 49.2 percent for medical residents. Drills for natural disasters occurred more often than those for chemical, biological, explosive, nuclear, and epidemic incidents. More hospitals staged drills for biological attacks than for severe epidemics. Despite explosions being the most common form of terrorism, drills for these were staged by only one-fifth of hospitals. Hospitals collaborated on drills most often with emergency medical services, fire departments, and law enforcement agencies.     

Macroeconomic conditions and opioid abuse

We examine how deaths and emergency department (ED) visits related to use of opioid analgesics (opioids) and other drugs vary with macroeconomic conditions. As the county unemployment rate increases by one percentage point, the opioid death rate per 100,000 rises by 0.19 (3.6%) and the opioid overdose ED visit rate per 100,000 increases by 0.95 (7.0%). Macroeconomic shocks also increase the overall drug death rate, but this increase is driven by rising opioid deaths. Our findings hold when performing a state-level analysis, rather than county-level; are primarily driven by adverse events among whites; and are stable across time periods.     

Human immunodeficiency virus postexposure prophylaxis for occupational exposure in a medical school hospital in Thailand

This is a retrospective review of occupational exposure to human immunodeficiency virus (HIV) and subsequent postexposure prophylaxis (PEP) among healthcare workers (HCWs) in King Chulalongkorn Memorial Hospital (KCMH), Bangkok, Thailand. From January 2002 to December 2004, data were collected from incident reports, the hospital's infectious diseases unit and the emergency department. There were 315 reported episodes of occupational exposure among 306 HCWs. Nurses (34.0%) were the HCWs most frequently exposed and percutaneous injury (91.4%) was the most common type of exposure. One-third of the source patients tested were infected with HIV. PEP was initiated following 200 (63.5%) of the 315 exposures and was started within 24h in >95% of cases. The most commonly prescribed PEP regimen was zidovudine, lamivudine and nelfinavir. Fifty-six percent of HCWs given PEP completed a four-week course but the remainder discontinued PEP prematurely due to side-effects, or after negative results from the source, or following informed risk reassessment or from their own accord. No exposed HCW acquired HIV during the study period. Appropriate counselling and careful risk assessment are important in achieving effective HIV PEP among HCWs.     

Potential work-related exposures to bloodborne pathogens by industry and occupation in the United States Part II: A telephone interview study

BACKGROUND: The companion surveillance portion of this study [Chen and Jenkins, 2007] reported the frequency and rate of potential work-related exposures to bloodborne pathogens (BBP) treated in emergency departments (EDs) by industry and occupation, but it lacks details on the circumstances of the exposure and other relevant issues such as BBP safety training, use of personal protective equipment (PPE) or safety needles, or reasons for seeking treatment in a hospital ED. METHODS: Telephone interviews were conducted with workers who had been treated in EDs for potential work-related exposures to BBP in 2000-2002. Respondents were drawn from the National Electronic Injury Surveillance System. RESULTS: Of the 593 interviews, 382 were from hospitals, 51 were from emergency medical service/firefighting (EMS/FF), 86 were from non-hospital healthcare settings (e.g., nursing homes, doctors' offices, home healthcare providers, etc.), 22 were from law enforcement (including police and correctional facilities), and 52 were from other non-healthcare settings (i.e., schools, hotels, and restaurants). Needlestick/sharps injuries were the primary source of exposure in hospitals and non-hospital healthcare settings. Skin and mucous membrane was the primary route of exposure in EMS/FF. Human bites accounted for a significant portion of the exposures in law enforcement and other non-healthcare settings. In general, workers from non-hospital settings were less likely to use PPE, to have BBP safety training, to be aware of the BBP standards and exposure treatment procedures, and to report or seek treatment for a work-related exposure compared to hospital workers. CONCLUSIONS: This study suggests that each industry group has unique needs that should be addressed.     

Occupational exposures to bloodborne pathogens among healthcare workers in Rio de Janeiro, Brazil

Healthcare workers (HCWs) frequently face the risk of occupational infection from bloodborne pathogens following exposure to blood and body fluids. This study describes the results of a surveillance system of occupational exposure to bloodborne pathogens among HCWs in Rio de Janeiro, Brazil, during an eight-year period. A total of 15 035 exposures reported from 537 health units were reviewed. Six circumstances comprised nearly 70% of the reported exposures: recapping needles (14%), performing surgical procedures or handling surgical equipment (14%), handling trash (13%), during disposal into sharps containers (13%), performing percutaneous venepuncture (10%) and during blood drawing (5%). Easily preventable exposures, such as incidents related to recapping needles, handling trash, and sharps left in an inappropriate place, represented 30% of the exposures reported. Post-exposure prophylaxis (PEP) for human immunodeficiency virus (HIV) was initiated for 46% of exposed HCWs. Although Brazilian guidelines indicate that PEP is usually not recommended for exposures with insignificant or very low risk of HIV infection, PEP was prescribed to a large proportion of exposed HCWs under these circumstances. The prevention of occupational exposure to bloodborne pathogens among HCWs and their safety must be considered as a public health issue. Although infection-preventative measures such as antiretroviral drugs and rapid tests are available, this study shows that there are still a high number of easily preventable exposures. The implementation of more effective prevention strategies is urgently required in this country.     

深圳市龙岗区职业卫生执法能力现况调查

目的调查深圳市龙岗区职业卫生执法能力现况,进行分析并提出改进建议。方法对该区职业卫生执法队伍现状、职业病危害特点、职业病发病情况、监督工作开展情况进行描述和比较分析。结果现有职业卫生监督人员78名,其中临聘人员占51．3％,非医学专业人员占26．9％,中级职称占14．1％。2008--2012年有毒有害企业个数分别为4614、4893、3289、3576和3364个,相当一部分企业未落实职业病防治主体责任。这5年间共发生职业病100起,病例总数为111例。结论建议分设预防保健所和卫生监督分所两个机构,建立区、街道、社区三级工作网络,增强职业卫生监督人员技术力量,进一步加强监督管理力度。     

Hepatitis B exposure incidents in community hospitals

To determine the frequency and distribution of potential hepatitis B exposure incidents among employees of community hospitals, a two-year retrospective study and a one-year prospective study were undertaken in Arizona hospitals. The annual rate of exposure incidents was, respectively, 7.9 and 7.7 per 100 employees; 78 per cent of the incidents were needle punctures. The rate of incidents increased significantly with the size of the hospital and decreased in older employees. While the highest risks of incidents were in phlebotomists, surgical technicians, and laboratory technicians, 14 per cent of all exposures occurred in housekeepers and central supply workers. Only 45 per cent of incidents were reported from employees who would normally expect to be targeted to receive hepatitis B vaccine. The post-exposure use of immune globulins (IG and HBIG) increased from 9 per cent of exposures in the retrospective study to 16 per cent during the prospective study. Exposure incidents occurred at the same rates and in the same occupational groups in community hospitals as previously reported from teaching hospitals and medical centers.     

Relationship between cardiovascular disease morbidity,risk factors,and stress in a law enforcement cohort

It is unclear to what extent law enforcement officers (LEOs) experience increased prevalence of cardiovascular disease (CVD; defined as coronary heart disease, myocardial infarction, angina, or stroke) and, if so, whether perceived stress affects this relationship. First, self-reported CVD risk factors among currently employed male LEOs from 9 states (n = 2818) were compared to CVD risk factors among similarly-aged males with similar incomes in the same states (n = 8046). Second, CVD prevalence was compared among LEOs (n = 1791) and similarly-aged males with similar incomes (n = 2575) from four of these states. Finally, among the LEOs only, the possible effect of perceived stress on the relationship between CVD prevalence and CVD risk factors was assessed. LEOs reported higher prevalence of hypertension, hypercholesterolemia, tobacco use, and elevated body mass index. CVD prevalence did not differ significantly between the LEO group and the general population (2.3% +/- 15% versus 3.1% +/- 17%; P = 0.095). In the LEO-only group, the best predictors of CVD were: time in the profession (OR = 1.07; 95% CI = 1.03-1.11), perceived stress (OR = 1.05; 95% CI = 1.00-1.10), and hypertension (OR = 0.33; 95% CI = 0.18-0.62). In the LEO-only group, perceived stress was associated with CVD (P = 0.008), and three CVD risk factors were significantly affected by perceived stress: cholesterol, hypertension, and physical activity. Perceived stress was affected by duration of time in the profession (P = 0.004), independent of an age effect (P = 0.353). Among susceptible officers, perceived stress may contribute to CVD directly and through potentiating several CVD risk factors.