Revista Mexicana de Bioseguridad 2016

La Asociación Mexicana de Bioseguridad presentó la nueva Revista MExicana de Bioseguridad 2016, que contiene como artículo principal los Lineamientos para la Gestión de Riesgo Biológico, un gran esfuerzo de profesionales de Bioseguridad en México, con base en el CWA15793: Laboratory Biorisk Management 2018. La revista contiene además, el archivo fotográfico y resúmenes de trabajos libres del 8º Simposio de Bioseguridad y Biocustodia desarrollado en 2016. Pueden descargar la revista y sus ediciones anteriores desde la página: http://amexbio.wildapricot.org/Revista

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Establishing protocols for tick containment at Biosafety Level 4.

Tick-borne diseases continue to emerge and have a great impact on public health and agriculture. In addition, many of the agents of tick-borne diseases, which are classified as Biosafety Level 4 (BSL-4) viruses, have the potential to be used as biothreat agents. In spite of the known importance of these pathogens, there is an acute shortage of facilities and trained personnel to study the pathogenesis of tick-borne diseases and to assess vaccine as well as other therapeutic interventions against tick-borne diseases as they are transmitted in nature. We, at the Galveston National Laboratory, have developed facilities and protocols to safely work with BSL4 virus-infected ticks. This capability adds tremendous value to the Nation's training and research endeavors. In this report we describe the procedures and protocols to establish tick work in a BSL4 laboratory.

REFERENCE:
Thangamani S, Bente D. Establishing protocols for tick containment at Biosafety Level 4. Pathog Dis. 2014 Jul;71(2):282-5.
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Preparation of viral samples within biocontainment for ultrastructural analysis

Transmission electron microscopy can be used to observe the ultrastructure of viruses and other microbial pathogens with nanometer resolution. In a transmission electron microscope (TEM), the image is created by passing an electron beam through a specimen with contrast generated by electron scattering from dense elements in the specimen. Viruses do not normally contain dense elements, so a negative stain that places dense heavy metal salts around the sample is added to create a dark border. To prepare a virus sample for a negative stain transmission electron microscopy, a virus suspension is applied to a TEM grid specimen support, which is a 3mm diameter fragile specimen screen coated with a few nanometers of plastic film. Then, deionized (dI) water rinses and a negative stain solution are applied to the grid. All infectious viruses must be handled in a biosafety cabinet (BSC) and many require a biocontainment laboratory environment. Staining viruses in biosafety levels (BSL) 3 and 4 is especially challenging because the support grids are small, fragile, and easily moved by air currents. In this study we evaluated a new device for negative staining viruses called mPrep/g capsule. It is a capsule that holds up to two TEM grids during all processing steps and for storage after staining is complete. This study reports that the mPrep/g capsule method is valid and effective to negative stain virus specimens, especially in high containment laboratory environments.

REFERENCE:
Monninger MK, et al. Preparation of viral samples within biocontainment for ultrastructural analysis: Utilization of an innovative processing capsule for negative staining. J Virol Methods. 2016 Dec;238:70-76. doi: 10.1016/j.jviromet.2016.10.005. PubMed PMID: 27751950.
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#VIDEO: Safety Precautions and Operating Procedures in an (A)BSL-4 Laboratory

Biosafety level 4 (BSL-4) suit laboratories are specifically designed to study high-consequence pathogens for which neither infection prophylaxes nor treatment options exist. The hallmarks of these laboratories are: custom-designed airtight doors, dedicated supply and exhaust airflow systems, a negative-pressure environment, and mandatory use of positive-pressure (“space”) suits. The risk for laboratory specialists working with highly pathogenic agents is minimized through rigorous training and adherence to stringent safety protocols and standard operating procedures. Researchers perform the majority of their work in BSL-2 laboratories and switch to BSL-4 suit laboratories when work with a high-consequence pathogen is required. Collaborators and scientists considering BSL-4 projects should be aware of the challenges associated with BSL-4 research both in terms of experimental technical limitations in BSL-4 laboratory space and the increased duration of such experiments. Tasks such as entering and exiting the BSL-4 suit laboratories are considerably more complex and time-consuming compared to BSL-2 and BSL-3 laboratories. The focus of this particular article is to address basic biosafety concerns and describe the entrance and exit procedures for the BSL-4 laboratory at the NIH/NIAID Integrated Research Facility at Fort Detrick. Such procedures include checking external systems that support the BSL-4 laboratory, and inspecting and donning positive-pressure suits, entering the laboratory, moving through air pressure-resistant doors, and connecting to air-supply hoses. We will also discuss moving within and exiting the BSL-4 suit laboratories, including using the chemical shower and removing and storing positive-pressure suits.

REFERENCE:
Janosko, Krisztina et al. “Safety Precautions and Operating Procedures in an (A)BSL-4 Laboratory: 1. Biosafety Level 4 Suit Laboratory Suite Entry and Exit Procedures.” Journal of Visualized Experiments : JoVE 116 (2016): 52317. PMC. Web. 17 Nov. 2016.
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Containment of Arthropod Disease Vectors

Arthropods

Effective containment of arthropod vectors of infectious diseases is necessary to prevent transmission of pathogens by released, infected vectors and to prevent vectors that escape from establishing populations that subsequently contribute to increased disease. Although rare, past releases illustrate what can go wrong and justify the need for guidelines that minimize risks. An overview of recommendations for insectary facilities, practices, and equipment is provided, and features of four recently published and increasingly rigorous arthropod containment levels (ACLs 1-4) are summarized. ACL-1 is appropriate for research that constitutes the lowest risk level, including uninfected arthropods or vectors that are infected with micro-organisms that do not cause disease in humans, domestic animals, or wildlife. ACL-2 is appropriate for indigenous and exotic arthropods that represent a moderate risk, including vectors infected or suspected of being infected with biosafety level (BSL)-2 infectious agents and arthropods that have been genetically modified in ways that do not significantly affect their fecundity, survival, host preference, or vector competence. ACL-3 is recommended for arthropods that are or may be infected with BSL-3 infectious agents. ACL-3 places greater emphasis on pathogen containment and more restricted access to the insectary than ACL-2. ACL-4 is intended for arthropods that are infected with the most dangerous BSL-4 infectious agents, which can cause life-threatening illness by aerosol or arthropod bite. Adherence to these guidelines will result in laboratory-based arthropod vector research that minimizes risks and results in important new contributions to applied and basic science.

REFERENCE:
Scott TW. Containment of arthropod disease vectors. ILAR J. 2005;46(1):53-61. Review.

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Communicable Diseases and Outbreak Control

Infectious disease during an emergency condition can raise the death rate 60 times in comparison to other causes including trauma. An epidemic, or outbreak, can occur when several aspects of the agent (pathogen), population (hosts), and the environment create an ideal situation for spread. Overcrowding, poor regional design and hygiene due to poverty, dirty drinking water, rapid climate changes, and natural disasters, can lead to conditions that allow easier transmission of disease. Once it has been established that an emergency condition exists, there must be a prompt and thorough response for communicable disease control. A camp should be created, and the disease managed rapidly. The overall goals are rapid assessment, prevention, surveillance, outbreak control, and disease management.

REFERENCE:

AMELI, Jonathan. “Communicable Diseases and Outbreak Control.” Turkish Journal of Emergency Medicine 15.Suppl 1 (2015): 20–26. PMC.

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Informe Mundial sobre el Paludismo 2015

El Informe Mundial sobre el Paludismo 2015 resume la información recibida de los países en los que esta enfermedad es endémica, así como de otras fuentes. En él se evalúan las tendencias mundiales y regionales del paludismo, se destacan los progresos realizados hacia la consecución de las metas mundiales, y se describen las oportunidades y los desafíos en el control y eliminación de la enfermedad.
El informe muestra una disminución dramática en la carga global del paludismo desde el 2000. Cincuenta y siete países redujeron sus casos de paludismo en un 75%, en línea con las metas de la Asamblea Mundial de la Salud para el 2015.
A pesar de este enorme progreso, todavía queda mucho por hacer para reducir aún más la carga del paludismo. La Estrategia Técnica Mundial contra la Malaria 2016-2030, aprobada por la Asamblea Mundial de la Salud en mayo de 2015, establece objetivos ambiciosos pero alcanzables para el año 2030, incluyendo una reducción de por lo menos el 90% en la incidencia y mortalidad por paludismo a nivel mundial.

REFERENCE:
Informe Mundial sobre el Paludismo 2015
Número de páginas: 32
Fecha de publicación: 2016
Idiomas: Español, francés e inglés
Número de referencia OMS: WHO/HTM/GMP.2016.2 (resumen)
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Recent Advances in Antimicrobial Polymers: A Mini-Review

Human safety and well-being is threatened by microbes causing numerous infectious diseases resulting in a large number of deaths every year. Despite substantial progress in antimicrobial drugs, many infectious diseases remain difficult to treat. Antimicrobial polymers offer a promising antimicrobial strategy for fighting pathogens and have received considerable attention in both academic and industrial research. This mini-review presents the advances made in antimicrobial polymers since 2013. Antimicrobial mechanisms exhibiting either passive or active action and polymer material types containing bound or leaching antimicrobials are introduced. This article also addresses the applications of these antimicrobial polymers in the medical, food, and textile industries.

REFERENCE:
Huang, Keng-Shiang et al. “Recent Advances in Antimicrobial Polymers: A Mini-Review.” Ed. Antonella Piozzi and Iolanda Francolini. International Journal of Molecular Sciences 17.9 (2016): 1578.
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VIDEO: Safety procedures for handling sharps

This VIDEO discusses proper safety procedures for handling sharps in the lab:

>>  https://vimeo.com/185731520  <<

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The Weekly Epidemiological Record (WER)

The Weekly Epidemiological Record (WER) serves as an essential instrument for the rapid and accurate dissemination of epidemiological information on cases and outbreaks of diseases under the International Health Regulations and on other communicable diseases of public health importance, including emerging or re-emerging infections.

REFERENCE:
Weekly Epidemiological Record (WER)

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Niveles de bioseguridad

A partir de la publicación del nuevo manual de bioseguridad en el laboratorio de la OMS en Dic/2020, desaparecen los niveles de bioseguridad, y se establecen las medidas de bioseguridad basadas en riesgos. 

REFERENCIA:
Página 15. Manual de bioseguridad en el laboratorio. Tercera edición, Organización Mundial de la Salud. 2005. ISBN 9243546503
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#WEBINAR: The Necrobiome - Microbial Life After Death

What happens to us after we die? A decomposing corpse becomes its own mini-ecosystem, hosting insects, scavengers and multitudes of microbes. Microbes from the environment, the corpse, as well as the insects and scavengers are blended together and work to recycle tissues back to their constituents. Dr. Jennifer DeBruyn will discuss the fascinating process of human decomposition, and how scientists are using that information to inform forensic science, livestock mortality management and fossilization. The talk will start promptly at 6:30 p.m. ET (CDMX: 5:30 p.m.), an you can watch onlineat the ASM Youtube Channel:  https://youtu.be/iqVpL0y5ofM

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OCTUBRE 15: Día mundial del lavado de manos "Siempre lave sus manos"

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HIGH-CONTAINMENT LABS: Improved Oversight of Dangerous Pathogens Needed to Mitigate Risk

The total number of incidents involving incomplete inactivation—a process to destroy the hazardous effects of pathogens while retaining characteristics for future use—that occurred from 2003 through 2015 is unknown for several reasons. One key reason is that the Select Agent Program—operated by the Departments of Health and Human Services (HHS) and Agriculture (USDA) to oversee certain dangerous pathogens, known as select agents—does not require laboratories to identify such incidents on reporting forms. According to the program, 10 incidents occurred from 2003 through 2015. However, GAO identified an additional 11 incidents that the program did not initially identify. Because the program cannot easily identify incidents involving incomplete inactivation, it does not know the frequency or reason they occur, making it difficult to develop guidance to help mitigate future incidents. The 21 identified incidents involved a variety of pathogens and laboratories, as shown below.

REFERENCE:
HIGH-CONTAINMENT LABORATORIES: Improved Oversight of Dangerous Pathogens Needed to Mitigate Risk. GAO-16-642: Published: Aug 30, 2016. Publicly Released: Sep 21, 2016.
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Measuring Pathogen Decay in Bioaerosols

This work aimed to develop an in vivo approach for measuring the duration of human bioaerosol infectivity. To achieve this, techniques designed to target short-term and long-term bioaerosol aging, were combined in a tandem system and optimized for the collection of human respiratory bioaerosols, without contamination. To demonstrate the technique, cough aerosols were sampled from two persons with cystic fibrosis and chronic Pseudomonas aeruginosa infection. Measurements and cultures from aerosol ages of 10, 20, 40, 900 and 2700 seconds were used to determine the optimum droplet nucleus size for pathogen transport and the airborne bacterial biological decay. The droplet nuclei containing the greatest number of colony forming bacteria per unit volume of airborne sputum were between 1.5 and 2.6 μm. Larger nuclei of 3.9 μm, were more likely to produce a colony when impacted onto growth media, because the greater volume of sputum comprising the larger droplet nuclei, compensated for lower concentrations of bacteria within the sputum of larger nuclei. Although more likely to produce a colony, the larger droplet nuclei were small in number, and the greatest numbers of colonies were instead produced by nuclei from 1.5 to 5.7 μm. Very few colonies were produced by smaller droplet nuclei, despite their very large numbers. The concentration of viable bacteria within the dried sputum comprising the droplet nuclei exhibited an orderly dual decay over time with two distinct half-lives. Nuclei exhibiting a rapid biological decay process with a 10 second half-life were quickly exhausted, leaving only a subset characterized by a half-life of greater than 10 minutes. This finding implied that a subset of bacteria present in the aerosol was resistant to rapid biological decay and remained viable in room air long enough to represent an airborne infection risk.

REFERENCE:
Johnson, Graham R. et al. “A Novel Method and Its Application to Measuring Pathogen Decay in Bioaerosols from Patients with Respiratory Disease.” Ed. Nicole M. Bouvier. PLoS ONE 11.7 (2016): e0158763.
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Concentrations and Sources of Airborne Particles in a Neonatal Intensive Care Unit

Premature infants in neonatal intensive care units (NICUs) have underdeveloped immune systems, making them susceptible to adverse health consequences from air pollutant exposure. Little is known about the sources of indoor airborne particles that contribute to the exposure of premature infants in the NICU environment. In this study, we monitored the spatial and temporal variations of airborne particulate matter concentrations along with other indoor environmental parameters and human occupancy. The experiments were conducted over one year in a private-style NICU. The NICU was served by a central heating, ventilation and air-conditioning (HVAC) system equipped with an economizer and a high-efficiency particle filtration system. The following parameters were measured continuously during weekdays with 1-min resolution: particles larger than 0.3 μm resolved into 6 size groups, CO2 level, dry-bulb temperature and relative humidity, and presence or absence of occupants. Altogether, over sixteen periods of a few weeks each, measurements were conducted in rooms occupied with premature infants. In parallel, a second monitoring station was operated in a nearby hallway or at the local nurses’ station. The monitoring data suggest a strong link between indoor particle concentrations and human occupancy. Detected particle peaks from occupancy were clearly discernible among larger particles and imperceptible for submicron (0.3–1 μm) particles. The mean indoor particle mass concentrations averaged across the size range 0.3–10 μm during occupied periods was 1.9 μg/m3, approximately 2.5 times the concentration during unoccupied periods (0.8 μg/m3). Contributions of within-room emissions to total PM10 mass in the baby rooms averaged 37–81%. Near-room indoor emissions and outdoor sources contributed 18–59% and 1–5%, respectively. Airborne particle levels in the size range 1–10 μm showed strong dependence on human activities, indicating the importance of indoor-generated particles for infant’s exposure to airborne particulate matter in the NICU.

REFERENCE:
Licina, Dusan et al. “Concentrations and Sources of Airborne Particles in a Neonatal Intensive Care Unit.” Ed. Jeffrey Shaman. PLoS ONE 11.5 (2016): e0154991.

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Recent advances in synthetic biosafety

Synthetically engineered organisms hold promise for a broad range of medical, environmental, and industrial applications. Organisms can potentially be designed, for example, for the inexpensive and environmentally benign synthesis of pharmaceuticals and industrial chemicals, for the cleanup of environmental pollutants, and potentially even for biomedical applications such as the targeting of specific diseases or tissues. However, the use of synthetically engineered organisms comes with several reasonable safety concerns, one of which is that the organisms or their genes could escape their intended habitats and cause environmental disruption. Here we review key recent developments in this emerging field of synthetic biocontainment and discuss further developments that might be necessary for the widespread use of synthetic organisms. Specifically, we discuss the history and modern development of three strategies for the containment of synthetic microbes: addiction to an exogenously supplied ligand; self-killing outside of a designated environment; and self-destroying encoded DNA circuitry outside of a designated environment.

REFERENCE:
Simon, Anna J., and Andrew D. Ellington. “Recent Advances in Synthetic Biosafety.” F1000 Research 5 (2016): F1000 Faculty Rev–2118. PMC. Web. 19 Sept. 2016.
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Microneedles: A New Frontier in Nanomedicine Delivery

This review aims to concisely chart the development of two individual research fields, namely nanomedicines, with specific emphasis on nanoparticles (NP) and microparticles (MP), and microneedle (MN) technologies, which have, in the recent past, been exploited in combinatorial approaches for the efficient delivery of a variety of medicinal agents across the skin. This is an emerging and exciting area of pharmaceutical sciences research within the remit of transdermal drug delivery and as such will undoubtedly continue to grow with the emergence of new formulation and fabrication methodologies for particles and MN. Firstly, the fundamental aspects of skin architecture and structure are outlined, with particular reference to their influence on NP and MP penetration. Following on from this, a variety of different particles are described, as are the diverse range of MN modalities currently under development. The review concludes by highlighting some of the novel delivery systems which have been described in the literature exploiting these two approaches and directs the reader towards emerging uses for nanomedicines in combination with MN.

REFERENCE:
Larrañeta, Eneko et al. “Microneedles: A New Frontier in Nanomedicine Delivery.” Pharmaceutical Research 33 (2016): 1055–1073. PMC.
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Use of Ultraviolet (UV) Lights in Biological Safety Cabinets

The purpose of this paper is to review information available on the use, risks and benefits of using Ultraviolet (UV) lights in Biological Safety Cabinets (BSC) and set forth a position based on the risk and benefits.

REFERENCE:
BurgenerJ.  Position Paper on the Use of Ultraviolet Lights in Biological Safety Cabinets. Applied Biosafety (2006), 11(4) pp. 228-230
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Respiratory Health in Waste Collection and Disposal Workers

Waste management, namely, collection, transport, sorting and processing, and disposal, is an issue of social concern owing to its environmental impact and effects on public health. In fact, waste management activities are carried out according to procedures that can have various negative effects on the environment and, potentially, on human health. The aim of our study was to assess the potential effects on respiratory health of this exposure in workers in the waste management and disposal field, as compared with a group of workers with no occupational exposure to outdoor pollutants. The sample consisted of a total of 124 subjects, 63 waste collectors, and 61 office clerks. Informed consent was obtained from all subjects before inclusion in the study. The entire study population underwent pulmonary function assessments with spirometry and completed two validated questionnaires for the diagnosis of rhinitis and chronic bronchitis. Statistical analyses were performed using STATA 13. Spirometry showed a statistically significant reduction in the mean Tiffenau Index values in the exposed workers, as compared with the controls, after adjusting for the confounding factors of age, BMI, and smoking habit. Similarly, the mean FEV1 values were lower in the exposed workers than in the controls, this difference being again statistically significant. The FVC differences measured in the two groups were not found to be statistically significant. We ran a cross-sectional study to investigate the respiratory health of a group of workers in the solid waste collection and disposal field as compared with a group of office workers. In agreement with most of the data in the literature, our findings support the existence of a prevalence of respiratory deficits in waste disposal workers. Our data suggest the importance of adopting preventive measures, such as wearing specific individual protection devices, to protect this particular category of workers from adverse effects on respiratory health.

REFERENCE:
Vimercati, Luigi et al. “Respiratory Health in Waste Collection and Disposal Workers.” Ed. Paul B. Tchounwou. International Journal of Environmental Research and Public Health 13.7 (2016): 631. PMC. Web. 18 Aug. 2016.

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Pregnancy, Labor, Delivery & Ebola: Implications for Infection Control in Obstetrics

UNICEF pregnant woman

Many of the survivors of the 2014–2015 epidemic of Ebola virus disease (EVD) in West Africa were women of childbearing age. Limited clinical and laboratory data exist that describe these women’s pregnancies and outcomes. We report the case of an EVD survivor who became pregnant and delivered her child in the United States, and we discuss implications of this case for infection control practices in obstetric services. Hospitals in the United States must be prepared to care for EVD survivors.

REFERENCE:
Kamali, Amanda et al. “Pregnancy, Labor, and Delivery after Ebola Virus Disease and Implications for Infection Control in Obstetric Services, United States.” Emerging Infectious Diseases 22.7 (2016): 1156–1161. PMC. Web. 18 Aug. 2016.

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#Ebola response in Sierra Leone: The impact on children

The West African Ebola virus disease (EVD) outbreak is the largest ever seen, with over 28,000 cases and 11,300 deaths since early 2014. The magnitude of the outbreak has tested fragile governmental health systems and non-governmental organizations (NGOs) to their limit. Here we discuss the outbreak in the Western Area of Sierra Leone, the shape of the local response and the impact the response had on caring for children suspected of having contracted EVD. Challenges encountered in providing clinical care to children whilst working in the “Red Zone” where risk of EVD is considered to be highest, wearing full personal protective equipment are detailed. Suggestions and recommendations both for further research and for operational improvement in the future are made, with particular reference as to how a response could be more child-focused.

REFERENCE:
Fitzgerald, Felicity et al. “Ebola Response in Sierra Leone: The Impact on Children.” The Journal of Infection 72.Suppl (2016): S6–S12. PMC. Web. 18 Aug. 2016.

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Quantitative Microbial Risk Assessment in Occupational Settings Applied to the Airborne Human Adenovirus Infection

Quantitative Microbial Risk Assessment (QMRA) methodology, which has already been applied to drinking water and food safety, may also be applied to risk assessment and management at the workplace. The present study developed a preliminary QMRA model to assess microbial risk that is associated with inhaling bioaerosols that are contaminated with human adenovirus (HAdV). This model has been applied to air contamination data from different occupational settings, including wastewater systems, solid waste landfills, and toilets in healthcare settings and offices, with different exposure times. Virological monitoring showed the presence of HAdVs in all the evaluated settings, thus confirming that HAdV is widespread, but with different average concentrations of the virus. The QMRA results, based on these concentrations, showed that toilets had the highest probability of viral infection, followed by wastewater treatment plants and municipal solid waste landfills. Our QMRA approach in occupational settings is novel, and certain caveats should be considered. Nonetheless, we believe it is worthy of further discussions and investigations.

REFERENCE:
Carducci, Annalaura et al. “Quantitative Microbial Risk Assessment in Occupational Settings Applied to the Airborne Human Adenovirus Infection.” Ed. Andrew Watterson. International Journal of Environmental Research and Public Health 13.7 (2016): 733. PMC. Web. 18 Aug. 2016.

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Occupational health related concerns among surgeons

The surgeon’s daily workload renders him/her susceptible to a variety of the common work-related illness. They are exposed to a number of occupational hazards in their professional work. These hazards include sharp injuries, blood borne pathogens, latex allergy, laser plumes, hazardous chemicals, anesthetic gases, equipment hazards, static postures, and job related stressors. However, many pay little attention to their health, and neither do they seek the appropriate help when necessary. It is observed that occupational hazards pose a huge risk to the personal well-being of surgeons. As such, the importance of early awareness and education alongside prompt intervention is duly emphasized. Therefore, increased attention to the health, economic, personal, and social implications of these injuries is essential for appropriate management and future prevention. These risks are as great as any other occupational hazards affecting surgeons today. The time has come to recognize and address them.

REFERENCE:
Memon, Anjuman Gul et al. “Occupational Health Related Concerns among Surgeons.” International Journal of Health Sciences 10.2 (2016): 279–291. Print.

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Prevalence of Respiratory Protective Devices in U.S. Health Care Facilities

An online questionnaire was developed to explore respiratory protective device (RPD) prevalence in U.S. health care facilities. The survey was distributed to professional nursing society members in 2014 and again in 2015 receiving 322 and 232 participant responses, respectively. The purpose of this study was to explore if the emergency preparedness climate associated with Ebola virus disease changed the landscape of RPD use and awareness. Comparing response percentages from the two sampling time frames using bivariate analysis, no significant changes were found in types of RPDs used in health care settings. N95 filtering facepiece respirators continue to be the most prevalent RPD used in health care facilities, but powered air-purifying respirators are also popular, with regional use highest in the West and Midwest. Understanding RPD use prevalence could ensure that health care workers receive appropriate device trainings as well as improve supply matching for emergency RPD stockpiling.

REFERENCE:
Wizner, Kerri et al. “Prevalence of Respiratory Protective Devices in U.S. Health Care Facilities: Implications for Emergency Preparedness.” Workplace health & safety 64.8 (2016): 359–368. PMC. Web. 18 Aug. 2016.

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