Industrial hygienists should be on the front lines when it comes to preventing the transmission of highly hazardous communicable diseases. Their expertise is also instrumental in responding to HHCDs. While working in the Nebraska Biocontainment Unit (NBU) in 2014–2015 during the recent Ebola virus disease (EVD) outbreak, we saw firsthand how important IH was both during and after the event, particularly in planning the movement of EVD-confirmed patients. IH is a broad discipline that looks after the safety and security of all other occupations involved in the response to an HHCD event, and we found IH to be crucial in implementing policies and procedures to prevent healthcare workers and others from becoming exposed to EVD.

At the NBU, industrial hygienists provided expertise on selecting personal protective equipment for high-level ensembles and stringent donning and doffing protocols; helped manage solid and liquid waste, including highly infectious Category A waste; and established detailed procedures for transforming that waste into Category B waste on site. (According to CDC, infectious substances included in Category B do not cause life-threatening or fatal disease to humans when exposure occurs.) The NBU’s industrial hygienists also detected the potential for occupational exposures to EVD and recommended administrative controls to prevent them; selected appropriate decontamination chemicals and devices; and ensured that equipment was properly used and reprocessed, when possible. As part of the leadership team at the NBU, the hygienists also oversaw the installation of an on-site lab and helped communicate risks to workers, the media, and the community. Their contributions and expertise didn’t end there; industrial hygienists at the NBU were invaluable members of the multi-disciplinary team.  THE NEED FOR IH An article published in the January 2018 Synergist, “Integrating IH into Healthcare,” illustrates the importance of the industrial hygienist in healthcare settings; however, the hygienist should also play a key role in related areas such as public health and emergency management. Fields like these have already begun recognizing the significance of IH in HHCD response. In 2016, an article in the journal Applied Biosafety addressed the professional development needs of biosafety and infection prevention professionals. Biosafety professionals typically focus on protecting laboratory workers from exposure to infectious biological agents, and infection prevention professionals tend to focus more on patient safety and preventing the spread of disease in healthcare settings. The article states that practitioners in both professions can become more effective by looking beyond their traditional foci and ensuring that they have a basic understanding of infectious diseases. 
We know industrial hygienists are needed to ensure the safety of all response workers, but we continue to see them underrepresented in HHCD response planning. This underrepresentation likely occurs because many response-planning professionals do not fully understand how the contributions of IH can satisfy response needs. On the other hand, some hygienists may not recognize the expertise they can bring to HHCD response planning. For example, many of the skills that industrial hygienists develop around PPE, the prevention of occupational disease, and ergonomics are readily adaptable to HHCD response. Basic IH principles can protect workers within various industrial sectors from diseases ranging from a standard seasonal flu to a potential outbreak of Middle East respiratory syndrome coronavirus (MERS-CoV). Industrial hygienists protect the safety and health of workers and the community. For individuals who are concerned with preventing occupational disease, HHCDs are no exception. HHCDs know no political boundaries and do not stay confined in the walls of a hospital. There is rich potential for the hygienist to become more integrated with existing stakeholders involved in national and local HHCD response.  A CONTINUED THREAT The years since the 2014–2016 Ebola outbreak in West Africa presented the perfect time to continue to build the United States’ national preparedness and infrastructure to respond to similar outbreaks and to treat patients with a suspected or confirmed HHCD. Instead, HHCDs have taken a back seat in national attention and priorities. At the height of the outbreak, the Centers for Disease Control and Prevention designated 55 hospitals across the U.S. as Ebola treatment centers, or ETCs. These hospitals had elevated capabilities and capacities over other admitting hospitals, and were intended to serve as a means of national preparedness to address EVD. Our research group surveyed the 55 ETCs in 2016, right after the height of the Ebola outbreak, to assess the overall total adult bed capacity of these high-level isolation units. The study, published in Emerging Infectious Diseases, found that only up to 84 beds could function simultaneously nationwide in the event  of an outbreak. The logistics of preventing, containing, and treating an HHCD spread by airborne transmission (unlike EVD, which is transmitted via infected bodily fluids) are more complex and would drive down bed capacity. 
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HHCDs may be out of sight and out of mind for the general public, but they remain a threat to human health and safety.
One year later, we followed up with the ETCs and found that several high-level isolation units had not been provided sufficient resources to sustain their capabilities and capacities in the event of an HHCD. Some had reverted to regular units.  Funding to expand training and education initiatives continues to dwindle, and media coverage that would draw public attention and advocacy around the issue has become nearly non-existent. These combined factors leave the U.S. once again in a vulnerable position as much of the infrastructure developed to provide care and response to HHCDs—which was minimal before—has further deteriorated.  HHCDs may be out of sight and out of mind for the general public, but they remain a threat to human health and safety. The ease of international air travel and transport of goods likewise increases the ease of disease transmission. An asymptomatic individual who travels to the other side of the world could easily be your neighbor returning from a business trip or a family member returning from vacation, unaware that they are carrying a highly infectious pathogen like EVD.  Even with epidemiologic data, it is challenging to predict which HHCD will soon emerge as the most troublesome; unfortunately, it’s usually the ones we least anticipate. In summer 2017, another EVD outbreak in the Democratic Republic of the Congo resulted in four deaths and the monitoring of 583 individuals. Soon after, CDC cautioned the public about a rise in the number of cases of Yersinia pestis (plague), which has been endemic to the American southwest for decades; the agency had observed an increase in fleas infecting people and their domesticated pets. Lassa fever, another acute viral hemorrhagic illness like EVD that is endemic to West Africa, continued to kill in 2017 and has been more problematic in Nigeria this year. Even some of the more common communicable diseases (non-HHCD) that do not typically have high mortality rates saw an uptick in the U.S. last year. For example, a sizable hepatitis A outbreak in San Diego, Calif., claimed more than two dozen lives. This year’s influenza outbreak has been deadlier.  Additional factors such as changes in climate have caused the proliferation of many vector populations, creating an increase in infectious diseases with grave outcomes. The world is seeing more cases of Zika virus, which is caused by the bite of an infected Aedes aegytpi or albopictus mosquito and poses the greatest threat to pregnant women and their fetuses; leishmaniasis, a disease caused by the bite of infected sand flies that can result in large skin sores; and Crimean-Congo hemorrhagic fever, which is transmitted by tick bites or infected livestock and can result in death by the second week of infection if left untreated. Furthermore, the ever-expanding threat and subsequent challenges posed by antimicrobial resistance will require action from healthcare professionals as well as those involved in exposure assessment and control. Though many unforeseen factors can contribute to an epidemic, one of the few things we can control is our level of preparedness and prevention efforts. A PROPOSED NETWORK To help prepare the U.S. for potential epidemics, we suggest creating a formal highly infectious disease care network, which is described in detail in the June 2017 issue of the journal Health Security. Such a network would expand the current scope of plans and procedures in place for EVD to be applicable and appropriate for the care of other HHCDs; maintain a formal, updated inventory of the capabilities and capacities of high-level isolation units throughout the country; and provide frontline providers, clinicians, and other first responders with an easily accessible, curated internet application or surveillance system to stay up-to-date on current outbreaks. We also recommend continuing to provide training and education to workers—including those outside of hospital settings—who might have exposures to HHCDs.  JUST-IN-TIME TRAINING It’s easy for some to think that events as serious as evacuating EVD-confirmed patients to the U.S. are rare, and that using valuable time to prepare for slim-chance eventualities is neither cost-effective nor the most efficient use of one’s skill sets. But sometimes unexpected scenarios or disasters force industrial hygienists and related professionals to deliver training quickly. “Just-in-time” training provides a quick skills- and education-based session in these situations. Take Hurricane Harvey as an example: there were not enough professionals available to address all the environmental, structural, and health issues that resulted from the storm, and volunteers needed to receive appropriate PPE training before beginning cleanup and recovery efforts. Industrial hygienists play a vital role in training and educating workers on proper donning and doffing techniques, as well as the appropriate care, usage, and limitations of their PPE. (In our experience, many workers do not fully understand the limitations of PPE, so it’s a subject we stress in our trainings.) Just-in-time PPE training should take a broad, all-hazards approach since donning and doffing techniques can be applied to various respirators that protect individuals from different particles. Safe glove removal (for example, the glove-in-glove technique) has the same underlying principles and techniques; while an HHCD like EVD calls for additional layers of gloves and complexity, an individual would take similar steps to protect themselves from Methicillin-resistant Staphylococcus aureus (MRSA) or Clostridium difficile (C. diff).  The basics of IH and PPE that apply to HHCD response can also help protect workers every day. For example, proper glove removal protects a police officer in a range of situations, from responding to a potential HHCD event to giving aid to a victim of a car accident. The injured individual may have breaks in the skin and could have an infectious disease like hepatitis C. Proper respiratory protection will protect a laboratory researcher from influenza as well as extensively drug-resistant tuberculosis, or XDR-TB.  Unfortunately, many organizations have come to rely on just-in-time training as their sole source of PPE training and do not conduct it on a consistent basis. As a result, just-in-time PPE training is frequently workers’ first time learning how to don and doff an ensemble. For others, it’s a “refresher” training that is far removed from their original training and is not conducive to high-pressure, high-stakes scenarios such as responding to HHCDs. There are many steps involved in safely donning and doffing high-level PPE ensembles, and the potential for cross-contamination is high. Workers often experience psychological and physiological stresses in these scenarios, so the chances of them remembering every detail of the just-in-time PPE training are low. In this way, just-in-time PPE training is like placing a Band-Aid on a gaping wound.  An example that illustrates the importance of effective training occurred in 2014, when two nurses at a Texas hospital became infected with EVD after providing care to an EVD-confirmed patient. The nurses were likely not provided the proper training to doff in a safe, evidence-based, and concerted manner. This is not to place the blame on the nurses—far from it—but rather to highlight how just-in-time PPE training may have been inappropriate in that situation. Had the institution conducted regular drills and monitored basic training on proper PPE donning and doffing techniques as it applied to more commonly encountered scenarios for PPE use, the hospital might have been in a better position to reduce the likelihood of exposure. In turn, the institution could have avoided panic in the surrounding community and the exorbitant costs and damage that stemmed from negative media coverage.  Just-in-time training has a place in our overall tool set, but it should not be the primary source of training to familiarize workers with PPE and appropriate donning and doffing processes. Workers should receive training on PPE early in their careers, and training should be tailored to include a focus on scenarios that they are more likely to encounter. They should then undergo regular refresher trainings. This practice will better support just-in-time trainings when an unusual or rare event comes up.  STEPPING UP As the incidence of HHCDs continues to rise, we must prepare to respond by involving all relevant professionals—including the industrial hygienist, who has a dynamic and broadly applicable range of knowledge and skills—in prevention efforts, training and education for occupations with potential exposure, and in advocacy for increased federal support. In this new and challenging era of HHCD prevention, now is not the time to shy away. Industrial hygienists can make a difference and leverage their skill sets on both the national and global stage.    AURORA LE, MPH, CPH, is an academic specialist at Indiana University School of Public Health in Bloomington, Ind., and project coordinator of the Biosafety and Infectious Disease Training Initiative (BIDTI), a National Institute of Environmental Health Sciences Worker Training Program. She can be reached at (812) 855-4756 or via email SHAWN GIBBS, PHD, MBA, CIH, is executive associate dean for academic affairs, interim associate dean for research, professor of environmental and occupational health, and principal investigator of BIDTI. He served as the director of research for the Nebraska Biocontainment Unit in 2009–2015 and assisted CDC and the Office of the Assistant Secretary for Preparedness and Response in crafting guidelines on Ebola patient transport, decontamination, and handling of highly infectious remains. He can be reached at (812) 855-1090 or via email Send feedback to The Synergist.
IH's Role in Preventing the Transmission of Highly Hazardous Communicable Diseases
BY AURORA LE AND SHAWN GIBBS

No Boundaries
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My apologies for the error.
 
- Ed Rutkowski, Synergist editor
Disadvantages of being unacclimatized:
  • Readily show signs of heat stress when exposed to hot environments.
  • Difficulty replacing all of the water lost in sweat.
  • Failure to replace the water lost will slow or prevent acclimatization.
Benefits of acclimatization:
  • Increased sweating efficiency (earlier onset of sweating, greater sweat production, and reduced electrolyte loss in sweat).
  • Stabilization of the circulation.
  • Work is performed with lower core temperature and heart rate.
  • Increased skin blood flow at a given core temperature.
Acclimatization plan:
  • Gradually increase exposure time in hot environmental conditions over a period of 7 to 14 days.
  • For new workers, the schedule should be no more than 20% of the usual duration of work in the hot environment on day 1 and a no more than 20% increase on each additional day.
  • For workers who have had previous experience with the job, the acclimatization regimen should be no more than 50% of the usual duration of work in the hot environment on day 1, 60% on day 2, 80% on day 3, and 100% on day 4.
  • The time required for non–physically fit individuals to develop acclimatization is about 50% greater than for the physically fit.
Level of acclimatization:
  • Relative to the initial level of physical fitness and the total heat stress experienced by the individual.
Maintaining acclimatization:
  • Can be maintained for a few days of non-heat exposure.
  • Absence from work in the heat for a week or more results in a significant loss in the beneficial adaptations leading to an increase likelihood of acute dehydration, illness, or fatigue.
  • Can be regained in 2 to 3 days upon return to a hot job.
  • Appears to be better maintained by those who are physically fit.
  • Seasonal shifts in temperatures may result in difficulties.
  • Working in hot, humid environments provides adaptive benefits that also apply in hot, desert environments, and vice versa.
  • Air conditioning will not affect acclimatization.
Acclimatization in Workers