Psychopathological Burden among Healthcare Workers during the COVID-19 Pandemic Compared to the Pre-Pandemic Period

This retrospective observational study on hospital staff requesting an "application visit" (from 2017 to 2022) at the Occupational Medicine department aimed at comparing a "pre-COVID group" (2017-2019) with a "COVID group" (2020-2022) regarding (a) sociodemographic data (i.e., age, sex, occupation, years of employment at the hospital), (b) rate and type of psychiatric diagnoses in both groups and rate of psychiatric diagnoses per subject, and (c) rate of drug/psychotherapeutic prescriptions. Two hundred and five healthcare workers (F = 73.7%; mean age = 50.7 ± 10.33) were visited. Compared with the pre-COVID group, healthcare workers evaluated during COVID-19 were significantly younger and reported fewer years of employment at the hospital. Although rates of primary psychiatric diagnoses were similar in both samples, an increased number of psychopathologies per subject and associated treatment prescriptions in the COVID group was observed. In the COVID group, 61% had one psychiatric diagnosis, and 28% had 2+ psychiatric diagnoses, compared with 83.8% and 6.7% of pre-COVID. Furthermore, 56.2%/1.9% in pre-COVID and 73%/6% in the COVID group were prescribed drugs/psychotherapy, respectively. The findings of the present study highlighted an increase in both younger workers' requests and psychiatric comorbidities during the pandemic, representing a burden on the Italian healthcare system. It is thus relevant to address the mental health challenges of healthcare workers accordingly.

A 12-month follow-up of the immune response to SARS-CoV-2 primary vaccination: evidence from a real-world study

A real-world population-based longitudinal study, aimed at determining the magnitude and duration of immunity induced by different types of vaccines against COVID-19, started in 2021 by enrolling a cohort of 2,497 individuals at time of their first vaccination. The study cohort included both healthy adults aged ≤65 years and elderly subjects aged >65 years with two or more co-morbidities. Here, patterns of anti-SARS-CoV-2 humoral and cell-mediated specific immune response, assessed on 1,182 remaining subjects, at 6 (T6) and 12 months (T12) after the first vaccine dose, are described. At T12 median anti-Spike IgG antibody levels were increased compared to T6. The determinants of increased anti-Spike IgG were the receipt of a third vaccine dose between T6 and T12 and being positive for anti-Nucleocapside IgG at T12, a marker of recent infection, while age had no significant effect. The capacity of T12 sera to neutralize in vitro the ancestral B strain and the Omicron BA.5 variant was assessed in a subgroup of vaccinated subjects. A correlation between anti-S IgG levels and sera neutralizing capacity was identified and higher neutralizing capacity was evident in healthy adults compared to frail elderly subjects and in those who were positive for anti-Nucleocapside IgG at T12. Remarkably, one third of T12 sera from anti-Nucleocapside IgG negative older individuals were unable to neutralize the BA.5 variant strain. Finally, the evaluation of T-cell mediated immunity showed that most analysed subjects, independently from age and comorbidity, displayed Spike-specific responses with a high degree of polyfunctionality, especially in the CD8 compartment. In conclusion, vaccinated subjects had high levels of circulating antibodies against SARS-CoV-2 Spike protein 12 months after the primary vaccination, which increased as compared to T6. The enhancing effect could be attributable to the administration of a third vaccine dose but also to the occurrence of breakthrough infection. Older individuals, especially those who were anti-Nucleocapside IgG negative, displayed an impaired capacity to neutralize the BA.5 variant strain. Spike specific T-cell responses, able to sustain immunity and maintain the ability to fight the infection, were present in most of older and younger subjects assayed at T12.

Determinants of Anti-S Immune Response at 12 Months after SARS-CoV-2 Vaccination in a Multicentric European Cohort of Healthcare Workers-ORCHESTRA Project

BACKGROUND

The effectiveness of the immunity provided by SARS-CoV-2 vaccines is an important public health issue. We analyzed the determinants of 12-month serology in a multicenter European cohort of vaccinated healthcare workers (HCW).

METHODS

We analyzed the sociodemographic characteristics and levels of anti-SARS-CoV-2 spike antibodies (IgG) in a cohort of 16,101 vaccinated HCW from eleven centers in Germany, Italy, Romania, Slovakia and Spain. Considering the skewness of the distribution, the serological levels were transformed using log or cubic standardization and normalized by dividing them by center-specific standard errors. We fitted center-specific multivariate regression models to estimate the cohort-specific relative risks (RR) of an increase of one standard deviation of log or cubic antibody level and the corresponding 95% confidence interval (CI) for different factors and combined them in random-effects meta-analyses.

RESULTS

We included 16,101 HCW in the analysis. A high antibody level was positively associated with age (RR = 1.04, 95% CI = 1.00-1.08 per 10-year increase), previous infection (RR = 1.78, 95% CI 1.29-2.45) and use of Spikevax [Moderna] with combinations compared to Comirnaty [BioNTech/Pfizer] (RR = 1.07, 95% CI 0.97-1.19) and was negatively associated with the time since last vaccine (RR = 0.94, 95% CI 0.91-0.98 per 30-day increase).

CONCLUSIONS

These results provide insight about vaccine-induced immunity to SARS-CoV-2, an analysis of its determinants and quantification of the antibody decay trend with time since vaccination.

Factors Associated with SARS-CoV-2 Infection before Vaccination among European Health Care Workers

BACKGROUND

Health care workers (HCWs) were on the frontline of the current pandemic. We aimed at identifying determinants of SARS-CoV-2 infection and the effectiveness of personal protection equipment (PPE) worn by HCWs before vaccination.

METHODS

We abstracted data on SARS-CoV-2 infection based on positive PCR results and sociodemographic characteristics of 38,793 HCWs from public hospitals and public health authorities from 10 European centers. We fitted cohort-specific multivariate logistic regression models to identify determinants of infection and combined the results using random-effects meta-analyses.

RESULTS

The overall prevalence of infection before vaccination among HCWs was 9.58%. Infection was associated with the presence of selected symptoms; no association was found between sociodemographic factors and increased risk of infection. The use of PPE and particularly FFP2/FFP3 masks had a different protective effect during the first and second waves of the COVID pandemic.

CONCLUSIONS

The study provides evidence that mask use was the most effective PPE in preventing SARS-CoV-2 infection among HCWs.

Temporal trends of COVID-19 antibodies in vaccinated healthcare workers undergoing repeated serological sampling: An individual-level analysis within 13 months in the ORCHESTRA cohort

Short summary

We investigated changes in serologic measurements after COVID-19 vaccination in 19,422 subjects. An individual-level analysis was performed on standardized measurements. Age, infection, vaccine doses, time between doses and serologies, and vaccine type were associated with changes in serologic levels within 13 months.

Background

Persistence of vaccine immunization is key for COVID-19 prevention.

Methods

We investigated the difference between two serologic measurements of anti-COVID-19 S1 antibodies in an individual-level analysis on 19,422 vaccinated healthcare workers (HCW) from Italy, Spain, Romania, and Slovakia, tested within 13 months from first dose. Differences in serologic levels were divided by the standard error of the cohort-specific distribution, obtaining standardized measurements. We fitted multivariate linear regression models to identify predictors of difference between two measurements.

Results

We observed a progressively decreasing difference in serologic levels from <30 days to 210-240 days. Age was associated with an increased difference in serologic levels. There was a greater difference between the two serologic measurements in infected HCW than in HCW who had never been infected; before the first measurement, infected HCW had a relative risk (RR) of 0.81 for one standard deviation in the difference [95% confidence interval (CI) 0.78-0.85]. The RRs for a 30-day increase in time between first dose and first serology, and between the two serologies, were 1.08 (95% CI 1.07-1.10) and 1.04 (95% CI 1.03-1.05), respectively. The first measurement was a strong predictor of subsequent antibody decrease (RR 1.60; 95% CI 1.56-1.64). Compared with Comirnaty, Spikevax (RR 0.83, 95% CI 0.75-0.92) and mixed vaccines (RR 0.61, 95% CI 0.51-0.74) were smaller decrease in serological level (RR 0.46; 95% CI 0.40-0.54).

Conclusions

Age, COVID-19 infection, number of doses, time between first dose and first serology, time between serologies, and type of vaccine were associated with differences between the two serologic measurements within a 13-month period.

Corrigendum: Temporal trends of COVID-19 antibodies in vaccinated healthcare workers undergoing repeated serological sampling: an individual-level analysis within 13 months in the ORCHESTRA cohort

[This corrects the article DOI: 10.3389/fimmu.2022.1079884.].

Determinants of Anti-S Immune Response at 9 Months after COVID-19 Vaccination in a Multicentric European Cohort of Healthcare Workers-ORCHESTRA Project

Background: The persistence of antibody levels after COVID-19 vaccination has public health relevance. We analyzed the determinants of quantitative serology at 9 months after vaccination in a multicenter cohort. Methods: We analyzed data on anti-SARS-CoV-2 spike antibody levels at 9 months from the first dose of vaccinated HCW from eight centers in Italy, Germany, Spain, Romania and Slovakia. Serological levels were log-transformed to account for the skewness of the distribution and normalized by dividing them by center-specific standard errors. We fitted center-specific multivariate regression models to estimate the cohort-specific relative risks (RR) of an increase of one standard deviation of log antibody level and the corresponding 95% confidence interval (CI), and combined them in random-effects meta-analyses. Finally, we conducted a trend analysis of 1 to 7 months' serology within one cohort. Results: We included 20,216 HCW with up to two vaccine doses and showed that high antibody levels were associated with female sex (p = 0.01), age (RR = 0.87, 95% CI = 0.86-0.88 per 10-year increase), 10-day increase in time since last vaccine (RR = 0.97, 95% CI 0.97-0.98), previous infection (3.03, 95% CI = 2.92-3.13), two vaccine doses (RR = 1.22, 95% CI = 1.09-1.36), use of Spikevax (OR = 1.51, 95% CI = 1.39-1.64), Vaxzevria (OR = 0.57, 95% CI = 0.44-0.73) or heterologous vaccination (OR = 1.33, 95% CI = 1.12-1.57), compared to Comirnaty. The trend in the Bologna cohort, based on 3979 measurements, showed a decrease in mean standardized antibody level from 8.17 to 7.06 (1-7 months, p for trend 0.005). Conclusions: Our findings corroborate current knowledge on the determinants of COVID-19 vaccine-induced immunity and declining trend with time.

Evaluation of humoral and cellular response to four vaccines against COVID-19 in different age groups: A longitudinal study

To date there has been limited head-to-head evaluation of immune responses to different types of COVID-19 vaccines. A real-world population-based longitudinal study was designed with the aim to define the magnitude and duration of immunity induced by each of four different COVID-19 vaccines available in Italy at the time of this study. Overall, 2497 individuals were enrolled at time of their first vaccination (T0). Vaccine-specific antibody responses induced over time by Comirnaty, Spikevax, Vaxzevria, Janssen Ad26.COV2.S and heterologous vaccination were compared up to six months after immunization. On a subset of Comirnaty vaccinees, serology data were correlated with the ability to neutralize a reference SARS-CoV-2 B strain, as well as Delta AY.4 and Omicron BA.1. The frequency of SARS-CoV-2-specific CD4+ T cells, CD8+ T cells, and memory B cells induced by the four different vaccines was assessed six months after the immunization. We found that mRNA vaccines are stronger inducer of anti-Spike IgG and B-memory cell responses. Humoral immune responses are lower in frail elderly subjects. Neutralization of the Delta AY.4 and Omicron BA.1 variants is severely impaired, especially in older individuals. Most vaccinees display a vaccine-specific T-cell memory six months after the vaccination. By describing the immunological response during the first phase of COVID-19 vaccination campaign in different cohorts and considering several aspects of the immunological response, this study allowed to collect key information that could facilitate the implementation of effective prevention and control measures against SARS-CoV-2.

Difference in safety and humoral response to mRNA SARS-CoV-2 vaccines in patients with autoimmune neurological disorders: the ANCOVAX study

BACKGROUND

Assessing the safety of SARS-CoV-2 mRNA vaccines and the effect of immunotherapies on the seroconversion rate in patients with autoimmune neurological conditions (ANC) is relevant to clinical practice. Our aim was to assess the antibody response to and safety of SARS-CoV-2 mRNA vaccines in ANC.

METHODS

This longitudinal study included ANC patients vaccinated with two doses of BNT162b2 or mRNA-1273 between March and August 2021. Side effects were assessed 2-10 days after each dose. Neurological status and anti-spike receptor binding domain antibody levels were evaluated before vaccination and 4 weeks after the second dose. Healthcare-workers served as controls for antibody levels.

RESULTS

We included 300 ANC patients (median age 52, IQR 40-65), and 347 healthcare-workers (median age 45, IQR 34-54). mRNA-1273 vaccine was associated with an increased risk of both local (OR 2.52 95% CI 1.45-4.39, p = 0.001) and systemic reactions (OR 2.51% CI 1.49-4.23, p = 0.001). The incidence of relapse was not different before and after vaccine (Incidence rate ratio 0.72, 95% CI 0.29-1.83). Anti-SARS-CoV-2 IgG were detected in 268 (89.9%) patients and in all controls (p < 0.0001). BNT162b2 vaccine (OR 8.84 95% CI 2.32-33.65, p = 0.001), anti-CD20 mAb (OR 0.004 95% CI 0.0007-0.026, p < 0.0001) and fingolimod (OR 0.036 95% CI 0.002-0.628, p = 0·023) were associated with an increased risk of not developing anti-SARS-CoV-2 IgG.

CONCLUSION

SARS-CoV-2 mRNA vaccines were safe in a large group of ANC patients. Anti-CD20 and fingolimod treatment, as well as vaccination with the BNT162b2 vaccine, led to a reduced humoral response. These findings could inform vaccine policies in ANC patients undergoing immunotherapy.

Mental Illness and Work-Related Limitations in Healthcare Workers: A Preliminary Retrospective Study

This retrospective observational study investigated hospital staff requests for job fitness visits, addressed to occupational medicine. Specific objectives were to analyze: (1) health workers’ requests, sociodemographic characteristics, psychiatric diagnoses, assigned doctor’s fit notes, and (orthopedic, psychiatric) limitations; (2) associations between psychiatric diagnoses, sociodemographic (sex, age), and work-related (job, department) characteristics; (3) associations between the same psychiatric diagnoses/orthopedic limitations, fit notes, and/or psychiatric limitations. Data of St. Orsola-Malpighi Polyclinic health workers (N = 149; F = 73.8%; mean age = 48 ± 9.6 years), visited by both the occupational medicine physician and psychiatrist (January 2016−May 2019), were analyzed. 83.2% of the sample presented with at least one psychiatric diagnosis, including mood (47%), anxiety (13.4%), and anxious-depressive (10.7%) disorders. Significant differences between psychiatric diagnoses according to sex and fit notes (both p < 0.01) have been found, whereas no significant associations based on age and work-related characteristics have been observed. Analysis of frequencies of participants with the same psychiatric diagnosis (orthopedic limitation being equal), according to doctor’s fit notes and psychiatric work limitations, showed a high heterogeneity of assignments. The current occupational medicine procedure for fit notes/job limitations assignments does not allow taking into consideration clinical factors possibly associated with more specific assignments. To standardize the procedure and translate the psychiatrist’s clinical judgment into practice, further studies to test the usefulness of clinimetrics, which might represent a reliable approach in considering different fit notes and job limitations, are needed.

Comparing the Attitude toward the COVID-19 and the 2020/21 and 2019/20 Flu Vaccination Campaigns among Italian Healthcare Workers

BACKGROUND

While the uptake of the COVID-19 vaccine among healthcare workers (HCWs) is suboptimal, vaccine hesitancy has not been characterized in detail in this population.

OBJECTIVE

The aim of this study was to compare the prevalence of health-related conditions reported by HCWs during the COVID-19, 2020/21 flu, and 2019/20 flu vaccination campaigns, so to test the hypothesis that HCWs were more prone to report health conditions during the COVID-19 campaign.

METHODS

We analyzed vaccination questionnaires of 176 hospital-based HCWs who underwent the COVID-19 and the 2020/21 flu vaccinations; 2019/20 flu vaccination questionnaires were available for 130 of them. Outcomes included self-reported allergies, chronic diseases, and use of medications. We tested for prevalence equality, analyzed differences using the kappa statistics and concordance correlation, and explored factors associated with differences in reporting.

RESULTS

There was no difference in the proportion of HCWs reporting allergies in the three questionnaires, while chronic diseases were more frequently reported in the COVID-19 than in both 2020/21 (p = 0.04) and 2019/20 flu questionnaires (p = 0.02). Furthermore, a higher proportion of HCWs reported medications use in the COVID-19 vaccination questionnaire, compared to both the 2020/21 and the 2019/20 flu vaccination questionnaires (p < 0.001 for both). In each vaccine campaign, women reported more conditions than men, and the difference between chronic disease reports was greater for women than for men.

CONCLUSIONS

Our results show more frequent reporting of health conditions during the COVID-19 than the flu vaccination campaigns, providing quantitative evidence of hesitancy of HCWs towards the COVID-19 vaccine.

Recent Advances in the Evaluation of Serological Assays for the Diagnosis of SARS-CoV-2 Infection and COVID-19

Introduction: Few data on the diagnostic performance of serological tests for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection are currently available. We evaluated sensitivity and specificity of five different widely used commercial serological assays for the detection of SARS-CoV-2-specific IgG, IgM, and IgA antibodies using reverse transcriptase-PCR assay in nasopharyngeal swab as reference standard test. Methods: A total of 337 plasma samples collected in the period April-June 2020 from SARS-CoV-2 RT-PCR positive (n = 207) and negative (n = 130) subjects were investigated by one point-of-care lateral flow immunochromatographic assay (LFIA IgG and IgM, Technogenetics) and four fully automated assays: two chemiluminescence immunoassays (CLIA-iFlash IgG and IgM, Shenzhen YHLO Biotech and CLIA-LIAISON^® XL IgG, DiaSorin), one electrochemiluminescence immunoassay (ECLIA-Elecsys^® total predominant IgG, Roche), and one enzyme-linked immunosorbent assay (ELISA IgA, Euroimmune). Results: The overall sensitivity of all IgG serological assays was >80% and the specificity was >97%. The sensitivity of IgG assays was lower within 2 weeks from the onset of symptoms ranging from 70.8 to 80%. The LFIA and CLIA-iFlash IgM showed an overall low sensitivity of 47.6 and 54.6%, while the specificity was 98.5 and 96.2%, respectively. The ELISA IgA yielded a sensitivity of 84.3% and specificity of 81.7%. However, the ELISA IgA result was indeterminate in 11.7% of cases. Conclusions: IgG serological assays seem to be a reliable tool for the retrospective diagnosis of SARS-CoV-2 infection. IgM assays seem to have a low sensitivity and IgA assay is limited by a substantial rate of indeterminate results.

Biological monitoring of occupational exposure to antineoplastic drugs in hospital settings

BACKGROUND

In view of the evidence of cytotoxicity of chemotherapic antineoplastic drugs (AD), current guidelines recommend the evaluation of the health risks of hospital personnel exposed to these compounds. Biological monitoring is the main tool to evaluate all possible drug intake and measure workers' real risk.

OBJECTIVES

The aim of this study was to assess occupational exposure toAD in a large hospital in Northern Italy in order to verify the effectiveness of the structural and procedural improvements carried out over the last decade.

METHODS

Three biological monitoring campaigns were performed using LC-MS/MS analysis of cyclophosphamide (CP) and metotrexate (MTX) as biomarkers of internal dose in the urine of hospital workers. In the first two campaigns, 50 and 81 workers respectively were monitored during AD preparation operations. The last campaign, concerning AD administration activity, was performed after a centralized preparation unit had been set up. Two environmental monitoring campaigns were carried out as well, to complete AD exposure assessment.

RESULTS

During the first monitoring campaign we found positive urinary samples in all the wards studied (total positivity 36%), whereas in the second campaign 11% of the samples were positive and four departments showed negative results in all urine samples. The last campaign showed all urinary CP and MTX levels below the detection limit of the analytical method

CONCLUSION

Exposure of oncology ward nurses considerably decreased due to the centralization of AD preparation operations together with training and education of workers. The last biological monitoring results were reassuring; nevertheless, surface contamination still occurred and safety measures should be further improved in order to achieve the lowest reasonably possible contamination levels.

The micronucleus assay as a biological dosimeter in hospital workers exposed to low doses of ionizing radiation

The health risk associated with low levels of ionizing radiation is still a matter of debate. A number of factors, such as non-target effects, adaptive responses and low-dose hypersensitivity, affect the long-term outcome of low-dose exposures. Cytogenetic bio-dosimetry provides a measure of the absorbed dose, taking into account the individual radiation sensitivity. The aim of the present study is to evaluate the value of the micronucleus (MN) test as a bio-dosimeter in hospital workers exposed to low doses of ionizing radiation. Blood samples were obtained from 30 subjects selected among workers exposed to X- and gamma-radiation, and 30 controls matched for sex, age and smoking from the same hospital. Micronucleus frequencies were analyzed by use of the cytokinesis-block method. The MN frequency was compared among the groups considering the confounding factors and the length of employment. No increase in the number of bi-nucleated cells with MN (BNMN), but a significant increase in the number of mono-nucleated cells with micronuclei (MOMN) was observed in exposed subjects compared with the controls. The relationship between MN frequency and accumulated dose (mSv) was evaluated. The length of employment did not affect the extent of MN frequency, but an increase of BNMN and MOMN cells was observed based on the accumulated radiation dose. Our study shows the sensitivity of the MN test in the detection of cytogenetic effects of cumulative exposure levels, suggesting the potential usefulness of this assay in providing a biological index in medical surveillance programs.

[Tuberculosis. Focus on risk assessment and health surveillance in health workers: results and perspectives of a multicenter working group]

INTRODUCTION

Tuberculosis (TB) is still a threat for healthcare workers (HCW), due to the non decreasing incidence, the spread of drug-resistance, the introduction of new tests for the screening, the relevant costs of surveillance of exposed subjects. These issues implicate a revision of activities to prevent TB in health-care settings.

METHODS

A multidisciplinary working group, led by occupational physicians, examined the activities to prevent TB performed in 9 Italian hospitals and reviewed the literature, with the aim to formulate evidence-based procedures.

RESULTS

In the considered hospitals, 23.000 HCW are classified as exposed to TB, out of 32.000 HCW exposed to biological risks; yearly, about 6000 subjects are screened for preventive, periodical or post-exposure surveillance and 110-130 chemoprophylaxis are prescribed. A high proportion of HCW (54-75%) refused or interrupt to assume the drugs. In the period 2004-2008, 14 occupational TB were diagnosed (9/100.000 HCW exposed to biological risks).

DISCUSSION

Critical issues are the availability of a specific, written TB control plan, including risk assessment, protocols for identifying, evaluating, managing infectious TB patients, health surveillance, education programs, specifically addressed to increase Standard Precaution adoption and compliance to the screening and to adequate risk perception. Risk assessment identify HCW to be included in TB testing (characterized by low positive predictive value), unrecognized TB and environmental control needed; TB risk classification should include no more than 3 or 4 classes and performed by assessing the issues suggested in the Italian guideline. Tubercolin skin test should be used for HCW screening, adding in vitro test in specific circumstances (for example, skin test positivity in BCG vaccinated HCW); the frequency of the screening should not exceed 2 years. Periodical revision of preventive activities should follow up to date scientific literature and need appropriate data computing.

[COMMUNITY: project proposal for a multicenter study on musculoskeletal comorbidity among nursing staff]

BACKGROUND

While a high prevalence of musculoskeletal disorders (MSDs) has been registered among nurses, little is known on the prevalence of musculoskeletal comorbidities and their effect on the natural history of spinal diseases. Here we present a project called COMMUNITY (COMorbidities of MUsculoskeletal disorders among Nurse in ITalY) which is aimed at: 1) studying the prevalence of musculoskeletal comorbidities; 2) investigating the aetiology of MSDs; 3) investigating the aetiology of lumbar or cervical disk herniation; 4) evaluate the natural history of spinal disk herniation and its effect on work ability.

MATERIALS AND METHODS

COMMUNITY will be a multicentric study conducted in participating Italian hospitals and articulated in 3 phases. Phase 0 will be a preliminary cross-sectional study conducted in one hospital and aimed at collecting basic information for further studies. Phase 1 will be a multicentric cross-section study enrolling a sample of nursing population. A self-administered questionnaire will be used to collect data concerning exposures and MSDs. The nurses studied during Phase 1 will be followed up in a cohort study (Phase 2). The follow-up will be based on at least 2 questionnaire administrations (at 2 and 4 years) and the use of data collected during health surveillance.

CONCLUSIONS

COMMUNITY is aimed at increasing knowledge in a field of occupational medicine that is still largely uncovered. Phase 0 will provide the essential information necessary to prepare the protocol for the subsequent phases.

[Focus on risk assessment in health environments: results and perspectives of a multicenter working group]

The hospital risk assessment (VdR) is certainly a relevant issue concerning the activities of prevention for the health of healthcare workers in relation to biological risk. The aim of this paper is to provide an up-date of the issue, based on the suggestions of recent literature about the rules ratified by the new legislative decree and data supplied by the Group of 10 Hospitals participated in this multicenter study. From the analysis of data on healthcare settings (HCS) participating in the project the following considerations can be formulated: i) All HCS considered VdR from biological agents. The method recommended in the Guidelines SIMLII 2005 is the most followed ii) To grading the risk, the use of invasive procedures for carrying out the analysis results is a necessary element iii) the operators classified as exposed to biological risk, and therefore subject to health surveillance, represent almost all of workforce in 7 out of 10 HCS. The subgroup believes that VdR must be conducted in close collaboration with the occupational physician and should represent a worthwhile investment with spin-off character on prevention, decision making, empowering. The presence of environmental requirements and organizational procedures should be considered, so that HCS is enabled for an effective risk management, without which risk assessments cannot be performed. The method of VdR mentioned in the guidelines MLIS 2005, besides being the most widely used by the company participating in the study, still has practical reasons and opportunities to justify its use. The HCS group felt the need to propose an implementation of the definition of invasive procedures and EPP, together with individual assessment. Flexibility was suggested in identifying different levels of risk with the involvement of occupational physicians, especially in the presence of EPP, also in order to plan content and frequency of health surveillance.

[Exanthemic diseases (measles, chickenpox, rubella and parotitis). Focus on screening and health surveillance of health workers: results and perspectives of a multicenter working group]

BACKGROUND

Nosocomial transmission of varicella-zoster virus, certain paramixovirus and rubivirus might pose a risk of morbidity for varicella (V), rubella (R), mumps (Mu) and measles (Me) in health care workers (HCW), patients and coworkers. International literature and European legislation recommend preventive interventions to minimize the risk.

METHODS

A literature review and a seroprevalence study were carried out in 9 hospitals located in north and central Italy, in order to evaluate risk assessment, health surveillance and fitness for work of HCW exposed to V, R, Mu and Me. Antibodies (Ab) against V, R, Mu and Me were determined. For a subgroup of 4 hospitals; sociodemographic, occupational data and sera were collected and analyzed.

RESULTS

About 36000 tests on about 9000 HCW were analyzed. Differences in seroprevalence ratios (V 85.7-95.1%, R 47-96.8%, Me 71.4-97.8%, Mu 52.5-87.6%) were detected. In a subgroup, a relevant number of non immune HCW was also found among women infertile age and areas at higher risk. Statistically significant differences were detected only for selected variables and viruses.

DISCUSSION AND CONCLUSIONS

Data of multicenter study confirm literature evidences and allow to define good medical practices for manage and minimize the risk of nosocomial transmission of V, R, Me and Mu. Recommendation are issued about serologic screening on HCW exposed to all 4 viruses thorough the modern analytical techniques, in order to assess risk on individual a group basis and to select priorities for intervention. Vaccination should be prescribed for those HCW non immune, selecting areas and HCW according to priorities.

[Focus on coverage and promotion of anti influenza vaccine in health workers: results and perspectives of a multicenter working group]

INTRODUCTION

The influenza illness is a concern for health care workers (HCW) due to the potential nosocomial transmission and sickness absenteeism. Immunization and Isolation Precautions might be effective preventive measures.

AIMS

To formulate recommendations on vaccination in healthcare settings.

METHODS

A multidisciplinary working group, led by occupational physicians (OP), examined the information on seasonal influenza immunisation campaign in 9 Italian hospitals in the period 2005-2009 and reviewed scientific evidence.

RESULTS

Many health organizations recommend vaccination of HCW. The literature shows that seasonal influenza vaccination of healthy adult have a modest effect in reducing work day lost; there is no evidence that it affects transmission or it prevents the disease in elderly residents. These observations might be conditioned by methodological limitations. Further studies are required to avoid the risk of bias and in pediatric settings. The rate of flu vaccination among HCW is widely variable and it depends on individual risk perception and information about efficacy and side effects. In the considered hospitals, in the five-years period the vaccination rate ranged between 0 and 29%: the median value was 16-17% in 2005, 2008 and 2009 (only against H1N1 influence), 11% and 13% in 2007 and 2006 respectively. OP participation in the vaccination campaign seems to increase the immunization rate.

DISCUSSION

Seasonal influenza immunization of HCW might be effective. We recommend to formalize written procedures in health care settings, to perform data computing and to periodically revise immunization activities and promotion and scientific literature, with the aim to appropriately address resources.

[Focus on health surveillance of health workers exposed to blood-transmissible biological agents: results and perspectives of a multicenter working group]

The biological risk from exposure to bloodborne pathogens in health care environments represents a frequent and widespread risk, involving a large number of exposed workers. On the basis of the available scientific innovations, the recent legislation regarding health and safety of workers and the experiences of SIMLII guidelines on health surveillance (HS) workers exposed to biological risk, a multicenter study was carried out, involving nine relevant hospitals and about 32 000 healthcare workers (HCW). A review of the literature was performed, with particular reference to the last 10 years. For each hospital, protocols of HS have been examined according to tasks and biological risk from bloodborne viruses (HBV, HDV, HCV, HIV) as well as management of HCW infected with this pathogens. Differences of risk management in the hospitals, in relationship also with recommendations of the literature have been evaluated. The literature supplies important indications for HS management of HCW exposed to bloodborne pathogens, with relevant information also for patient safety. Preventive examinations are in line with the recommendations of literature and similar across the hospitals for HCV and HIV, while they are different for HBV. Periodic surveillance was different for the frequency, among the hospitals and also as compared to national SIMLII guidelines. As for management, no differentiation among the hospitals was detected as referred to different risk of exposure, while differences were observed around definitions of restrictions. Finally, good medical practices to support occupational physicians in the prevention and management of HCWs' exposed to biological risks are suggested.

Gene expression changes in medical workers exposed to radiation

The use of nuclear resources for medical purposes causes considerable concern about occupational exposure. Nevertheless, little information is available regarding the effects of low-dose irradiations protracted over time. We used oligomicroarrays to identify the genes that are transcriptionally regulated by persistent exposure to extremely low doses of ionizing radiation in 28 exposed professionals (mean cumulative effective dose +/- SD, 19 +/- 38 mSv) compared with a matched sample of nonexposed subjects. We identified 256 modulated genes from peripheral blood mononuclear cells profiles, and the main biological processes we found were DNA packaging and mitochondrial electron transport NADH to ubiquinone. Next we investigated whether a different pattern existed when only 22 exposed subjects with accumulated doses >2.5 mSv, a threshold corresponding to the natural background radiation in Italy per year, and mean equal to 25 +/- 41 mSv were used. In addition to DNA packaging and NADH dehydrogenase function, the analysis of the higher-exposed subgroup revealed a significant modulation of ion homeostasis and programmed cell death as well. The changes in gene expression that we found suggest different mechanisms from those involved in high-dose studies that may help to define new biomarkers of radiation exposure for accumulated doses below 25 mSv.

Simultaneous determination of low levels of methotrexate and cyclophosphamide in human urine by micro liquid chromatography/electrospray ionization tandem mass spectrometry

The aim of this study was to develop and validate a novel solid-phase extraction (SPE) liquid chromatography/tandem mass spectrometry (LC/MS/MS) method for the simultaneous determination of two antineoplastic drugs, cyclophosphamide (CP) and methotrexate (MTX), in human urine using trophosphamide as internal standard. The method showed good precision and accuracy (mean RSD 2.8% and 0.9%; bias 2.7% and 2.4% for MTX and CP, respectively). The lower limits of detection obtained, 0.2 microg/L(urine) for MTX and 0.04 microg/L(urine) for CP, were lower than the best previously reported values. The use of a 96-well SPE plate for matrix purification ensures a high throughput (50 samples/day), allowing the routine biological monitoring of CP and MTX as measures of occupational exposure at very low levels.

Micronuclei in humans induced by exposure to low level of ionizing radiation: influence of polymorphisms in DNA repair genes

Understanding the risks deriving from protracted exposure to low doses of ionizing radiation has remarkable societal importance in view of the large number of work settings in which sources of IR are encountered. To address this question, we studied the frequency of micronuclei (MN), which is an indicator of DNA damage, in a population exposed to low levels of ionizing radiation and in matched controls. In both exposed population and controls, the possible influence of single nucleotide polymorphisms in XRCC1, XRCC3 and XPD genes on the frequency of micronuclei was also evaluated. We also considered the effects of confounding factors, like smoking status, age and gender. The results indicated that MN frequency was significantly higher in the exposed workers than in the controls [8.62+/-2.80 versus 6.86+/-2.65; P=0.019]. Radiological workers with variant alleles for XRCC1 or XRCC3 polymorphisms or wild-type alleles for XPD exon 23 or 10 polymorphisms showed a significantly higher MN frequency than controls with the same genotypes. Smoking status did not affect micronuclei frequency either in exposed workers or controls, while age was associated with increased MN frequency in the exposed only. In the combined population, gender but not age exerted an influence on the yield of MN, being higher in females than in males. Even though there is a limitation in this study due to the small number of subjects, these results suggest that even exposures to low level of ionizing radiation could have genotoxic effects and that XRCC3, XRCC1 and XPD polymorphisms might contribute to the increased genetic damage in susceptible individuals occupationally exposed to chronic low levels of ionizing radiation. For a clear conclusion on the induction of DNA damage caused by protracted exposure to low doses of ionizing radiation and the possible influence of genetic polymorphism in DNA repair genes larger studies are needed.

Spectrum of chromosomal aberrations in peripheral lymphocytes of hospital workers occupationally exposed to low doses of ionizing radiation

Chromosome aberrations frequency was estimated in peripheral lymphocytes from hospital workers occupationally exposed to low levels of ionizing radiation and controls. Chromosome aberrations yield was analyzed by considering the effects of dose equivalent of ionizing radiation over time, and of confounding factors, such as age, gender and smoking status. Frequencies of aberrant cells and chromosome breaks were higher in exposed workers than in controls (P = 0.007, and P = 0.001, respectively). Seven dicentric aberrations were detected in the exposed group and only three in controls, but the mean frequencies were not significantly different. The dose equivalent to whole body of ionizing radiation (Hwb) did appear to influence the spectrum of chromosomal aberrations when the exposed workers were subdivided by a cut off at 50 mSv. The frequencies of chromosome breaks in both subgroups of workers were significantly higher than in controls (< or =50 mSv, P = 0.041; >50 mSv, P = 0.018). On the other hand, the frequency of chromatid breaks observed in workers with Hwb >50 mSv was significantly higher than in controls (P = 0.015) or workers with Hwb < or =50 mSv (P = 0.046). Regarding the influence of confounding factors on genetic damage, smoking status and female gender seem to influence the increase in chromosome aberration frequencies in the study population. Overall, these results suggested that chromosome breaks might provide a good marker for assessing genetic damage in populations exposed to low levels of ionizing radiation.

[Current epidemiological evidence regarding the health effects of low-dose ionizing radiation. Implications for radiation protection, public health and forensic medicine]

The health effects of low-dose ionizing radiation have been widely studied, but remain uncertain. Up-to-date knowledge about epidemiologic evidence for potential human health effects of low dose ionizing radiation is important for revising national radiation protection legislation. This review, conducted by a multidisciplinary research team of the Italian Institute of Social Medicine, evaluates epidemiologic studies published since July 2003. After careful selection, a total of 302 studies were reviewed. Greater emphasis was given to papers that analyzed data using standardized incidence and mortality ratios and to studies regarding occupational exposures in all workers, healthcare workers and aircrew members. Nevertheless, studies regarding A-bomb survivors of Hiroshima/Nagasaki, Chernobyl cleanup workers, patients exposed for medical reasons, and workers in nuclear plants were also included. Given the limitations of epidemiological studies and excluding the cosmic rays context, which requires further research, the authors conclude that harmful effects from exposures to ionizing radiation at doses lower than 100 mSv cannot be ruled out. Nevertheless, if any harmful health effects do exist, they are certainly very small. The implications for radiation protection, public health and forensic medicine are discussed.

Lack of association between occupational radiation exposure and thyroid nodules in healthcare personnel

OBJECTIVES

To investigate whether healthcare workers routinely exposed to low-level ionizing radiation have a higher prevalence of thyroid nodularity.

METHODS

Presence of thyroid nodularity, as assessed by 10-MHz neck ultrasonography, was compared with accumulated radiation doses of 579 exposed university hospital workers (M:F 350:229) obliged to wear a personal dosimeter.

RESULTS

Nodules were detected in 141/579 (24.3%) subjects. Mean accumulated dose was not different among subjects with and without nodules (14.19+/-28.00 mSv vs 17.71+/-32.89 mSv; P=0.12). Duration of occupational exposure (<10 years vs 10-19 years vs >or=20 years) did not affect prevalence of nodularity. At multivariate analysis, only female gender and age were significant risk factors.

CONCLUSIONS

Mildly exposed health workers do not appear to incur any excess risk of thyroid nodularity.

Micronuclei frequencies in hospital workers occupationally exposed to low levels of ionizing radiation: influence of smoking status and other factors

In the context of a medical surveillance program aimed at preventing cancer risk from exposure to ionizing radiation, we investigated chromosomal damage in peripheral lymphocytes from 37 hospital workers exposed to low levels of ionizing radiation and 37 controls. The micronuleus (MN) assay was used as a biomarker of genetic damage. The influence of confounding factors like smoking status, age and gender was investigated by multiple regression analysis. The results indicated that, overall, MN frequency was higher in exposed workers than in controls, although the difference was not statistically significant. Interestingly, smoking status significantly raised MN frequency among the exposed workers but not among controls. This suggests that smoking can influence chromosomal damage induced in humans by ionizing radiation. Among both exposed workers and controls, MN frequency was found to increase with age. Female gender influenced the increase in MN frequency in the exposed group. Our results suggest that the effect of cigarette smoking should be carefully factored into genetic monitoring studies assessing the risks associated with low level radiation exposure.

[Bronchial hyperreactivity to methacholine in a group of bakers sensitized to wheat flour]

BACKGROUND

Bakers' allergic diseases are a well known occurrence. Wheat flour is the most important allergen responsible for rhinoconjunctivitis and IgE mediated asthma. The good correlation between atopy, wheat flour sensitization and allergic diseases is also well known. In a previous study we described the results concerning sensitivity to wheat flour in a group of 300 bakers, followed up for 8 years. In this study we showed that the same subjects who were sensitive to wheat flour had no symptoms.

AIM

The aim of this study was to carry out the metacholine test for bronchial hyperreactivity in a group of 14 bakers selected from the group of 300 previously studied.

METHODS

The subjects underwent: pulmonary function test, IgE test, skin prick test with grass pollen, Dermatophagoides farinae, Dermatophagoides pteronissinus, wheat flour, and the metacholine test.

RESULTS

The results of the metacholine test showed only one positive case in a subject with positive skin prick test. This agreed with the assumptions of our previous study that showed a sensitization (10%) to wheat flour but a low prevalence of allergic symptoms.

CONCLUSIONS

Limited to the subjects studied, the results indicate an absence of a relationship between positive prick tests and aspecific bronchial hyperreactivity. Recent research that suggest a probable different genetic control of atopy, bronchial hyperreactivity and asthma is discussed. In our opinion effective primary and secondary prevention could account for this absence of relationship.

Screening of health care workers for hepatitis B virus and hepatitis C virus: criteria for fitness for work

The aim of this study was to propose a protocol for assessment of markers of infection with hepatitis B virus (HBV) and hepatitis C virus (HCV) in exposed health care professionals and to define criteria for evaluation of fitness for the job of the infected personnel. The study comprised 800 persons involved in operative procedures, including 414 surgeons, 275 nurses, and 111 anaesthetists. A graduated protocol was created for monitoring markers of HBV and HCV infection. A well-defined combination of markers of antigen-antibody systems enabled identification of four groups of persons with HBV infection differing in fitness for work: 1) HBsAg-positive, HBeAg-positive, HBV DNA-positive; 2) HBsAg-positive, anti-HBe-positive, HBV DNA-positive; 3) HBsAg-positive, anti-HBe-positive, HBV DNA-negative; and 4) anti-HBs-positive, anti-HBc-positive, anti-HBe-positive group. For HCV infection, two groups with different job fitness were identified: 1) anti-HCV-positive, HCV RNA-negative and 2) anti-HCV-positive, HCV RNA-positive. Screening of hospital personnel at risk to HBV and HCV infection requires a well-defined protocol which may help to evaluate the fitness of the infected personnel for a specific job.

[Use of diverse diagnostic techniques in the study of silicosis]

This study would examine the efficiency of different diagnostic tools, imaging and functional, in the study of pulmonary system of workers exposed to silicotigen dusts. 24 male miners were examined with chest H.R.T.C., spirometry with study of DLCO and of total lung capacity. 13 of 24 miners were submitted to pulmonary ventilatory scintigraphy (99mTcDTPA). All 24 miners were previously yet submitted to two follow-up by means of chest radiography in conformity with ILO guidelines. The chest radiography, even evaluated in conformity with ILO guidelines, is subject to remarkable differences when performed and reported by different operator. Useful data are provided by functional studies. H.R.T.C. is necessary to evaluate the degree of parenchymal involvement and for medicolegal porpoises. Scintigraphy with 99mTc DTPA need of further studies in the evaluation of exposure to silicotigen dusts.

Ocular hypertonia and crystalline lens opacities in healthcare workers exposed to ionising radiation

Some activities performed by healthcare workers may still involve total or partial exposure to ionising radiation exceeding the limit values. In addition to the appearance of crystalline lens opacities which may lead to rays-cataract, recent studies have indicated possible induction of ocular hypertonia in occupationally exposed subjects. The aim of this study was to establish the actual prevalence of ocular hypertonia and crystalline lens opacities in a group of healthcare workers exposed to ionising radiation. The collected data failed to show significant risk of ocular hypertonia and suggested that crystalline lens opacity was not an important indicator of exposure. Notwithstanding, preventive and periodic (every 5 years) ophthalmologic control may prove helpful for medicolegal purposes. Namely, such control would record congenital crystalline lens opacities in many individuals and would thus rule out unjustified claims of occupational disease due to exposure to ionising radiation. Additionally, ophthalmologic control should focus on different and probably more important ocular risks for the radiologists such as the ocular fatigue resulting from a prolonged use of a video display terminal or other diagnostic screens or electrodiaphanoscopes.

Gardening work and heavy metals in urban environment

Urban soil may be a source of occupational exposure to various pollutants in gardening and land cultivation. This paper presents data of a one-year follow-up of lead, cadmium, nickel, chromium, and vanadium in the environment of the city of Bologna. Samples of soil and leaves were collected at three locations; gardens from the inner-city high-traffic area, parks in moderate-traffic area, and parks in suburban, low-traffic area. The top and deeper layers of soil and leaves were mainly polluted by lead at all locations, which corresponded to the traffic density. Personal samplers recorded greater concentrations of airborne metals than did the area samplers but the values kept below the threshold limit established by the American Conference of Governmental Industrial Hygienists for the working environment. Due to cumulative nature and interactive effects of toxic metals with other toxic and essential elements, long-term exposure to metals in the urban environment may be a health risk for occupationally exposed gardeners.

Use of ultrasonography in monitoring work-related carpal tunnel syndrome: a case report

Carpal tunnel syndrome (CTS) is a syndrome whose diagnosis is well established. One cause could be occupational factors, while others have no relation to work or the work environment. We present in this article a case report regarding a worker affected by CTS, which is of interest concerning the sensitivity of ultrasonography and electroneurography, applied as diagnostic methods, related in our protocol to the variations in occupational exposures. The case reports an agricultural worker, whose tasks required repetitive and high frequency movements of the hand-arm. Diagnosis of CTS used ultrasonography and electroneurography techniques. In our opinion, the clinical evolution of CTS encompasses three "work-related" phases (preclinical phase; phase of nerve compression; phase of irreversible damage). Ultrasonography provides greater information about the evolution of CTS, as well as other cumulative trauma disorders, and is able to discern tendinitis of flexors causing a compression on the median nerve in the carpal tunnel.

[Biomechanical pathology of the upper limb: a new epidemic?]

Work-related upper limb disorders are one leading occupational diseases in many industrialized countries. The paper reviews the evidence of work-relatedness of the most common upper limb disorders (namely carpal tunnel syndrome, hand-wrist and shoulder tendinitis, trapezius myalgia, hand hammer syndrome). Attention is drawn to the difference in the number of reported cases in Italy and other countries, assuming, as an underlying cause, underreporting of such conditions in Italy.

[Repetitive movement of the upper limbs: results of a current exposure evaluation and a clinical investigation in workers employed in the preparation of pork meat in the province of Modena]

Exposure assessment tests were undertaken to measure the biomechanical overload factors affecting the upper limbs. The tests were carried out on a group of 86 workers employed on the cutting, boning and trimming line of a pork meat processing plant. Anamnestic screening and clinical tests targeted at correlated disorders were also performed and were followed by instrumental tests. The results are reported with respect to frequency of repetitive technical actions, degree of muscular involvement, postural risk, several complementary factors and distribution of recovery periods. The clinical investigation showed a high prevalence of carpal tunnel syndrome, tendon disorders of the hand and epicondylosis of the elbow, in addition to other disorders. The report confirms the presence of additional risks for the workers, both in the past and under present circumstances, and suitable preventive measures are formulated.

Cumulative trauma disorders of the upper limbs in workers on an agricultural farm

The work associated with repetitive efforts and inadequate resting periods, strong physical exertion, awkward postures or static positioning exposes workers to the risk of cumulative trauma disorders of the upper limbs. These risk factors are present in many agricultural activities. A study was carried out among workers on an agricultural farm. The workers' histories were taken and they were given periodical medical check-ups. The presence of upper limb disorders was shown in a group of workers. A sample of 42 people was selected for the study by means of specific tests: electromyography, ultrasonography and laser-doppler flowmetry. The tests showed a high incidence of carpal tunnel syndrome and microcirculation disorders. The study confirmed that electromyography, ultrasonography and/or laser-doppler flowmetry are highly useful tools for identifying cumulative trauma disorders.

[Entrapment of the ulnar nerve at the elbow caused by repetitive movements: description of a clinical case]

The paper describes a case of ulnar neuropathy in a man who made household fittings and toys using bamboo. Several years after starting the job he showed symptoms and physical signs of ulnar nerve entrapment at the elbow, which were confirmed by electrophysiological findings. Job analysis revealed biomechanical risk factors consisting of a high repetition of forceful flexion and extension of the elbow, wrist and fingers without sufficient rest periods. Chronic musculoskeletal overuse gradually leads to tendon and nerve disorders. The ulnar neuropathy described can be classed under cumulative occupational trauma, which is the most important cause of musculoskeletal disorders among the working population.

[Electromyography of those exposed to vibration]

Electrophysiological findings in the median and ulnar nerves of a group of ten workers who operate hand-held vibrating power tools are described. Motor conduction velocities, motor latencies and amplitude of evoked compound muscle action potentials were measured. We have observed statistically significant changes in the distal latencies and in the amplitude of evoked compound muscle action potentials of median nerves in all the subjects examined, whereas the motor conduction velocities were normal in both median and ulnar nerve. These findings are compatible with functional changes without a clinically manifest neuropathy and they are suggestive of a compression damage such as carpal tunnel syndrome: the possible pathogenic mechanism of these damages are discussed. It's necessary to emphasize the importance of further studies in order to estimate the type and entity of the exposure to vibrations to show a cause-effect relationship.

[Assessment of exposure to perchloroethylene in dry-cleaning shops]

The occupational work-risk by PCE was evaluated in a group of 143 workers in 47 laundries, where perchloroethylene (PCE) was the only solvent used. Airborne measurements of PCE showed mean concentration values below the TLV-TWA, and a number of instant concentration values superior to TLV-STEL. Trichloracetic acid (TCA) values in the urine of exposed workers was superior to the limit established by our institute (29% of workers).