thesynergist | NEWSWATCH
CDC Delays Publication of Infection Control Guidance
In January, CDC requested more information from the Healthcare Infection Control Practices Advisory Committee (HICPAC) on its draft of revised guidelines for isolation precautions in healthcare facilities. HICPAC submitted the draft to CDC for review on Nov. 3, 2023. If CDC had accepted the guidelines, they would have been published in the Federal Register, initiating a comment period.
Instead, the agency has asked HICPAC to consider four sets of questions that “reflect concerns or areas of confusion that continue to be raised by stakeholders,” as stated in a letter to Drs. Sharon Wright and Michael Lin, the co-chairs of HICPAC’s Isolation Precautions Guideline Workgroup. The questions address matters related to the wearing of masks and respirators. The letter also states that the workgroup will be expanded to include additional experts who can help respond to the questions.
HICPAC’s draft guidelines have stimulated significant opposition, including from AIHA, which sent a letter (PDF) to CDC last July that characterized the draft as “grossly deficient.” AIHA was among the cosponsors of a webinar in October during which presenters raised concerns that the draft guidelines were less protective for healthcare workers than current practice. Recordings of the webinar presentations are available from the Rutgers School of Public Health website.
Another organization critical of the draft guidelines, National Nurses United, applauded CDC’s decision to send the draft back to HICPAC. “We are gratified that the CDC is asking HICPAC to resolve some of our core concerns, including the use of N95 respirators versus surgical masks to protect healthcare workers from pathogens that transmit through the air,” said NNU President Jean Ross, RN. NNU is the largest union of registered nurses in the United States.
A post published Jan. 24 on CDC’s Safe Healthcare Blog provides additional context on CDC’s decision. Coauthored by Dr. Daniel Jernigan, director of the National Center for Emerging and Zoonotic Infectious Diseases, and Dr. John Howard, director of NIOSH, the post indicates that clarification is needed around the terms “routine air precautions,” which involve only basic protections, and “special air precautions,” which would require respirators. Jernigan and Howard state that the workgroup should ensure that the draft “cannot be misread to suggest equivalency between facemasks and NIOSH Approved respirators, which is not scientifically correct nor the intent of the draft language.”
The post also explains that CDC will seek to appoint new members with appropriate technical backgrounds to HICPAC’s Isolation Precautions Guideline Workgroup and that the expanded workgroup will discuss CDC’s questions at HICPAC’s next public meeting. The date of the meeting had not been published when this issue of The Synergist went to press.
The draft guidelines (PDF) are the first of two documents intended to replace the existing “Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings” (PDF), which has been in place since 2007. An earlier post on the Safe Healthcare Blog had indicated that the first document was not expected to be finalized before June 2024. As of late January, CDC had not stated whether the timeframe has changed to account for additional deliberation of the draft guidelines by HICPAC.
DOL Announces Increases to OSHA's Civil Penalty Amounts
A final rule published by the Department of Labor adjusts for inflation the civil monetary penalties it assesses or enforces, effective Jan. 15. The adjustments for 2024 apply to OSHA as well as MSHA, the Employee Benefits Security Administration, the Employment and Training Administration, the Office of Workers' Compensation Programs, the Office of the Secretary, and DOL’s Wage and Hour Division. OSHA’s maximum penalty for serious violations is now $16,131, and the maximum penalty for willful or repeated violations is $161,323 per violation. The agency’s maximum penalty for failure to abate violations increased to $16,131 per day beyond the abatement date. A table detailing the updated penalty amounts is available on the agency’s website. More information about the inflation adjustments for this year is available in a Federal Register notice.
NIOSH Recommends Removal of Two Drugs from Hazardous Drugs List
NIOSH is considering removing the drugs liraglutide and pertuzumab from its list of hazardous drugs in healthcare. NIOSH’s reevaluations of liraglutide and pertuzumab are based on the process for requesting drugs’ removal from or placement on the list as described in Procedures for Developing the NIOSH List of Hazardous Drugs in Healthcare Settings. In both cases, the drugs’ manufacturers requested that NIOSH reevaluate their placement on the list.
Liraglutide is in a class of medications called incretin mimetics and is used in the management of type 2 diabetes. Pertuzumab is an antineoplastic agent used in the treatment of HER2-positive metastatic breast cancer.
NIOSH determined through its reevaluations that the intrinsic molecular properties of liraglutide and pertuzumab and the nature of the specific hazards posed by exposure to these drugs mean that they are “not likely to pose [hazards] to workers in healthcare settings.” According to the Federal Register notice that explains NIOSH’s reasoning, the properties of the two drugs either limit or greatly decrease dermal, oral, and inhalation bioavailability, and repeated unintended needlestick injuries would have to occur to reach the levels required to result in adverse health effects from exposure.
As of late January, the 2023 List of Hazardous Drugs in Healthcare Settings had not been published.
For more information about hazardous drug exposures in healthcare, visit the NIOSH website.
Two Final Tox Profiles and Two Drafts Newly Available from ATSDR
Final toxicological profiles for the substances vinyl chloride and nitrobenzene and draft tox profiles for chloroethane and chloroform were published in January by the Agency for Toxic Substances and Disease Registry (ATSDR). Vinyl chloride has made headlines over the past year as one of the hazardous substances on board the Norfolk Southern train that derailed in February 2023 near East Palestine, Ohio. The substance is used by the plastics industry to produce polyvinyl chloride, or PVC, and workers and others who live near plastic manufacturing facilities or hazardous waste sites may be exposed to vinyl chloride through inhalation. Skin absorption is another possible route of exposure for workers. Liver damage and cancer are among the many potential health effects of vinyl chloride exposure. Nitrobenzene is primarily used to produce other chemicals during the manufacture of products including explosives, rubbers, pesticides, herbicides, insecticides, pharmaceuticals, and dyes. It is also used as a solvent in petroleum refineries. Workers in industries that use nitrobenzene are at increased risk of exposure to the chemical through dermal exposure and inhalation of workplace air. New draft tox profiles are available for the gas chloroethane and for chloroform, a colorless liquid. Chloroethane is used as a solvent as well as in the production of cellulose, dyes, medicinal drugs, and formed plastics. Examples of present uses of chloroform include as a solvent and in the manufacture of other chemicals. Workers in industries that use or manufacture chloroform may be at increased risk for exposure, while those working in printing and publishing, chemical manufacturing, oil and gas production, petroleum refining, and pulp and paper may be exposed to higher levels of chloroethane. Comments on the two draft profiles are due April 18. More information on submitting comments is available in the Federal Register. A full list of toxic substances with published profiles is available on the ATSDR website.
NIOSH Rescinds Respirator Approval Issued to A & Z Pharmaceutical
A notice published in January states that NIOSH has honored the request of the company A & Z Pharmaceutical Inc. to voluntarily rescind one of its respirator approvals. As of Dec. 6, 2023, respirators bearing the approval number TC-84A-9307 are no longer approved by NIOSH and may no longer be used, manufactured, assembled, sold, or distributed. The agency directs individuals to contact A & Z Pharmaceutical regarding inquiries about the decision to voluntarily rescind this approval.
NIOSH’s certified equipment list no longer includes the approval number TC-84A-9307. The agency encourages respirator users and others to use this list to confirm testing and certification approval numbers, which are printed on NIOSH-approved respirators. The website of the agency’s National Personal Protective Technology Laboratory provides a list of additional guidance documents intended to inform users of respiratory protective devices.
CSB Determines Faulty “Bubbler” Tube Cause of Fatal Liquid Nitrogen Release
The U.S. Chemical Safety and Hazard Investigation Board (CSB) recently released its final report (PDF) on a deadly liquid nitrogen release that occurred on Jan. 28, 2021, at a poultry processing plant in Gainesville, Georgia. The release caused the deaths of six poultry plant workers and seriously injured three other workers and one firefighter responding to the incident.
The report states that a “bubbler” tube, a device used to measure liquid nitrogen levels inside industrial freezers, was likely damaged on the morning of the incident, during maintenance on a freezer used to prepare chicken product. Unable to measure and control liquid nitrogen levels inside the freezer, the damaged tube allowed liquid nitrogen to overflow into the freezer room. The nitrogen vaporized into a cloud that displaced the room’s oxygen up to five feet above the floor. Two maintenance workers succumbed to asphyxiation. The remaining fatalities and serious injuries among plant employees occurred during their attempts to rescue their coworkers.
The report also states that Messer LLC, the freezer manufacturer and owner, had identified deficient safety practices by Foundation Food Group (FFG), the company that owned the Gainesville plant at the time of the incident, but continued to supply the plant with liquid nitrogen.
FFG had not installed atmospheric monitoring and alarm systems that could have detected the oxygen-deficient atmosphere, automatically shut off the liquid nitrogen supply, and alerted workers to evacuate, CSB found. Employees lacked personal protective equipment that would have allowed them to safely enter the freezer room, and no process safety management system had been implemented by FFG.
More information about the incident and CSB’s findings and recommendations may be found in the board’s press release.
EPA Eyes Vinyl Chloride Among Other Chemicals for Risk Evaluation
EPA announced in December that vinyl chloride is among five chemicals it plans to prioritize for risk evaluation under the Toxic Substances Control Act (TSCA). The agency will begin risk evaluations for vinyl chloride and four other chemicals—acetaldehyde, acrylonitrile, benzenamine, and 4,4’-Methylene bis(2-chloroaniline), or MBOCA—if it designates the chemicals as high-priority substances during the 12-month statutory process required by TSCA. A designation of low priority would mean that the agency believes risk evaluation is not warranted at this time.
EPA selected these five chemicals in part because of how they are used and whether they affect “potentially-exposed susceptible sub-populations,” including workers. In the United States, vinyl chloride is used primarily by the plastics industry to produce polyvinyl chloride, or PVC. Workers and people who live near plastic manufacturing facilities or hazardous waste sites may be exposed to vinyl chloride through inhalation. Workers may also be exposed through skin absorption.
Three other chemicals identified by EPA alongside vinyl chloride for potential risk evaluation are also used to manufacture and process plastics: acrylonitrile, benzenamine, and MBOCA. The fifth chemical, acetaldehyde, is used in the manufacturing and processing of adhesives and petrochemicals.
The publication of this information in the Federal Register in mid-December launched a 90-day comment period that closes March 18.
For further information, see the Federal Register notice, EPA’s news release, and the agency’s webpage on chemical substances undergoing prioritization.
Regional Emphasis Program Focuses on Tree Trimming and Removal
OSHA announced on Jan. 11 that the agency has launched a regional emphasis program (REP) to protect workers in tree trimming, tree removal, and land clearing operations in OSHA Region 2, which includes the states of New York and New Jersey and the territories of Puerto Rico and the U.S. Virgin Islands.
Workers in these industries may experience injuries and fatalities associated with falls, amputations, noise, electrical hazards, and struck-by hazards. The Bureau of Labor Statistics reported that 222 tree and landscape service workers nationwide suffered fatal workplace illnesses and injuries in 2022.
The REP is scheduled to run through fall 2028 and includes an outreach element to raise awareness of hazards connected to tree and landscaping industry operations. The program will also target OSHA safety and health inspections of these operations.
More information may be found in the Department of Labor press release. The new REP may be downloaded as a PDF.
NIOSH Urges Training Regarding Unresponsive Firefighters and PPE
A NIOSH safety and health advisory highlights the importance of training fire service workers to rapidly remove unresponsive firefighters from turnout gear and self-contained breathing apparatus (SCBA). A firefighter’s personal protective equipment can impede rescuers’ ability to assess their airway, breathing, and circulation as well as delay emergency medical care, including effective chest compressions in response to cardiac arrest or arrhythmia. Firefighters wearing PPE can become unresponsive due to medical issues like reduced oxygen supply to the brain, heat stroke, severe dehydration, and neurological problems. Wearing PPE during periods of intense exertion and heat exposure increases firefighters’ risk of experiencing a cardiac medical emergency, which can result in unresponsiveness.
The agency recommends that firefighters, officers, and instructors be trained on when and how to rapidly remove turnout gear and SCBA so that emergency medical care can start quickly. Rapid removal methods include Firefighter Down CPR, a 10-step process involving multiple rescuers working together to remove an unresponsive firefighter from PPE in less than 30 seconds, and cutting off turnout gear using manual shears, scissors, or battery-powered fabric cutters.
The safety advisory is available on the NIOSH website.
Washington State Updates Process Safety Management Rules
Recent updates to Washington state’s process safety management rules are intended to increase safety for workers in petroleum refineries. The updated rules were filed by the Washington State Department of Labor and Industries (L&I) in December 2023 and will take effect on Dec. 27, 2024.
Under the updated rules, employers will be required to regularly review processes that are likely to damage or wear down equipment and to conduct root cause analyses after significant accidents. The rules also call for employers to frequently analyze hazards, controls, mechanical factors, and process changes and to update safety programs accordingly, as well as to address workplace safety culture to prioritize safety rather than production.
The U.S. Chemical Safety and Hazard Investigation Board issued a statement on Jan. 5 in support of the new rules, which it says implement many of the measures recommended by CSB following its investigation into the explosion and fire that killed seven workers at the Tesoro Anacortes Refinery in Washington in 2010.
Further details about Washington’s new rule can be found in L&I’s rulemaking order (PDF), its news release, and on the department's website.
Washington State Adopts Workplace Rules for Wildfire Smoke
New permanent rules requiring employers in Washington state to protect workers from wildfire smoke went into effect on Jan. 15. The rules address exposures to PM2.5, particles of burned material less than 2.5 micrometers in diameter. The rulemaking adds agriculture-specific requirements to the existing Washington Administrative Code (WAC) chapter for safety standards in agriculture and creates a new chapter to address exposures for all other industries.
Under the new rules, covered employers must prepare a written wildfire smoke response plan, monitor PM2.5 conditions and forecasts, establish a two-way system to communicate changing wildfire smoke conditions to employees, and make provisions in advance for employees who display symptoms of wildfire smoke exposure to receive prompt medical attention without reprisal. The wildfire smoke rules call for employers to train workers on wildfire smoke before exposing them to PM2.5 concentrations of 20.5 µg/m3 or more and then to repeat training at least annually.
As PM2.5 levels increase, the rules require additional protections. For example, when PM2.5 measures 35.5–250.4 µg/m3, covered employers must implement exposure controls and make N95 respirators available for voluntary use. At PM2.5 levels ranging from 500.4 to 554.9 µg/m3, employers are required to implement a respiratory protection program that requires the use of particulate respirators and includes fit-testing and medical evaluations. When PM2.5 measures 555 µg/m3 or greater, the rules state that employers must require respirators with an assigned protection factor of 25 or more.
More information about the new rules can be found on the website of the Washington State Department of Labor & Industries: one page focuses on the wildfire smoke rulemaking, and another provides information on wildfire smoke and workplace safety and health.
European Agency Recommends OEL for Bisphenol A
A scientific report (PDF) published in December by the European Chemicals Agency includes ECHA’s recommendations regarding occupational exposure limits for 4,4-isopropylidenediphenol, also known as bisphenol A. The agency was tasked by the European Commission to evaluate exposure to bisphenol A to assess the option of an airborne OEL, other limit values such as biological limit values and biological guidance values, and notations. According to ECHA, bisphenol A has endocrine-disrupting properties. It is also classified as a reprotoxic substance under reproductive toxicant category 1B, which means that it is presumed to have adverse effects on sexual function and fertility in humans based on evidence from animal studies.
Bisphenol A is primarily used in the manufacture of polycarbonate plastics and epoxy resins. It is also used as an additive—for example, as a photo-developer in thermal papers like receipt paper—and to manufacture other chemicals. Routes of exposure include inhalation, dermal, and ingestion, according to OSHA method 1018. ECHA’s report notes that workers in manufacturing are more likely to be exposed via dust inhalation, while workers who handle receipts containing bisphenol A are likelier to encounter dermal exposures.
ECHA recommends an OEL of 0.2 mg/m3 as an eight-hour time-weighted average. The agency also proposes a skin notation for bisphenol A because it is absorbed after dermal exposure, and a skin sensitization notation due to its harmonized classification under the European Union’s regulation on the classification, labelling, and packaging of substances and mixtures.
More information is available on the agency’s website.