Brett Bouchard, 17, was working at Violi’s Restaurant in Massena, NY last month. Press reports indicate he was cleaning out a pasta-making machine when the equipment severed his right arm at the elbow. He was rushed to a local hospital which later transferred the young worker to Massachusetts General Hospital.
Nationally, there are thousands of work-related amputations each year. The Bureau of Labor Statistics (BLS) estimates that 5,100 U.S. workers suffered an amputation injury in 2012. But we’ve written here before about the limitations of BLS’ estimates for work-related injuries. Those limitations include that its “Survey of Occupational Injuries and Illnesses” (SOII) relies exclusively on self-reported data by employers and some categories of workers are not covered by the reporting requirement (e.g., individuals working on small farms and some government employees.) These limitations and others result in an undercount by BLS of the true magnitude of work-related amputations (and, for that matter, all other injuries.)
A paper by researchers at Michigan State University, for example, calculated that the BLS system misses about 70 percent of work-related burns in their state. The researchers also looked at amputations and they identified more than twice the number than the BLS’ figure. Other limitations in BLS’s estimate, some of which also relate to the self-reporting component of the survey, are employers falsifying their records, and some not understanding what is supposed to be recorded. In addition, some injuries may not be included on employers’ injury logs because workers are reluctant and/or discouraged from reporting injuries to their bosses. Others who’ve compared BLS’ annual estimates to alternative data sources (e.g., hospital records, workers compensation claims) also find that the government-reported figures substantially understate the number of work-related injury and illness case (e.g., here, here, here, here, here, here, here.)
In recent years, BLS has been more willing to acknowledge the limitations of its estimates of work-related injuries. Attention from Members of Congress compelled BLS to provide grants to several States and university-based researchers to confirm and quantify the undercount. Three papers funded by those grants have been published recently in the American Journal of Industrial Medicine (AJIM). One written by Les Boden, PhD of Boston University School of Public Health, another by Sara Wuellner, MPH and David Bonauto, MD, MPH of the Washington State Department of Labor and Industries, and the third by a collaboration of researchers from the Massachusetts Department of Public Health (MDPH), UCLA, Boston Children’s Hospital, and Boston University School of Public Health. Leticia Davis, ScD, EdM, director of the MDPH’s Occupational Health Surveillance Program is the lead author.
This third paper addresses work-related amputations in Massachusetts. Davis and colleagues set out to calculate the magnitude of the undercount of amputations reported in BLS’s SOII estimate. They linked and compared the number of amputations cases in the BLS system to hospital and workers’ compensation records. For the period 2007-2008, using the self-reported employer data, BLS estimated there were 210 cases of work-related amputations in Massachusetts. Using the multi-source dataset, the authors identified 787 cases for the same time period. Davis and colleagues report that 41 percent of the actual amputation cases in SOII were not classified properly by the employers as amputations. Instead they were reported as “other injuries,” such as cuts, lacerations or crushings. We can speculate on the reasons for those errors, such as employers trying to misrepresent the severity of the employees’ injuries, or needing better instructions on how to classify injuries on their OSHA logs.
The authors classified each of the 787 case as “SOII eligible” (n=406), “SOII ineligible” (n=96), and “unknown SOII eligibility” (n=285.) They calculated the ratio of the multisource “SOII eligible” cases to BLS’s published estimates. They reported a 48 percent minimum estimate of the undercount.
Davis and colleagues reiterate, as other researchers have also done, that a multi-source surveillance system would provide much better data than BLS’s current system. They note, however, the practical challenges in attempting to design and implement such a system nationwide. Each state, for example, has different workers’ compensation laws and data collection systems, and policies regarding release of hospital records.
BLS called on researchers (and provided funding) to confirm the existence of an undercount and quantify its magnitude. Three of those studies are now published in AJIM. BLS is also sponsoring interviews with employers to learn their practices for recording work-related injuries on OSHA logs, and a study of historical trends in the undercount comparing SOII and workers’ compensation data. The results of these assessments will likely appear also in the literature.
In last year’s news release announcing the most current SOII data, BLS wrote:
“Several studies by outside researchers conducted in the mid 2000′s questioned the completeness of BLS injury and illness estimates from the SOII.
And added that the agency:
“established an ongoing research program to explore potential undercounting of workplace injuries and illnesses.”
At some point in the next few years, I hope we’ll see BLS do something else in addition to funding studies. When the agency releases its SOII data, BLS should mention the conclusions of these studies. I’d suggest, for example, something like the following for the paper by Davis and her colleagues:
“a study examining work-related amputations in Massachusetts found that SOII underestimated by at least 48 percent the number of amputation cases.”
That would be a further step to inform the public and policy-makers on the validity of SOII with respect to the true incidence of work-related injuries.
Seventeen year-old Brett Bouchard’s disabling injury is a reminder that thousands of work-related amputations occur in the U.S. every year. With better data on the magnitude of the problem, there might be more interest in preventing them.
Middle East respiratory syndrome (MERS) is a viral respiratory illness characterized by fever, cough, and shortness of breath, and it has been fatal in 30% of the cases identified since the disease was first reported in Saudi Arabia in 2012. It is caused by a coronavirus (MERS-CoV) and has been shown to spread between humans by close contact; new research suggests the virus may also be transmitted to humans from camels. Cases have been identified in multiple countries in the Arabian Peninsula, and a spike in cases in April — more than 200 in Saudi Arabia and the United Arab Emirates that month — has raised concerns. According to the European Centre for Disease Prevention and Control, 495 cases have now been reported worldwide. On May 2, CDC announced the first US case of MERS, in a patient who traveled from Saudi Arabia to Indiana.
The patient, a man in his sixties, lives in Saudi Araba and was working in a hospital in Riyadh where MERS patients were being treated. He flew from Riyadh to London to Chicago on April 24th, and then took a bus to Indianapolis. He experienced flu-like symptoms on April 27th and sought hospital treatment on April 28th. On May 2nd, CDC’s laboratory confirmed that he had MERS. The Chicago Tribune’s Juan Perez Jr. and Andy Grimm report on measures being taken to reduce the risk of the virus spreading:
Medical workers at an Indiana hospital who now have contact with the man are required to wear gloves, masks, gowns and eye protection. He’s being held in a room designed especially for patients with respiratory infections, segregated from the hospital’s air circulation system.
… As the man’s condition appears to improve and nobody else has shown evidence of infection, officials provided the most detailed account to date of the seriousness of care with which public health and Centers for Disease Control and Prevention have taken to investigate and contain the potential spread of MERS in the United States.
Roughly 50 hospital nurses, clerks, aides, dietary experts and other workers who came into contact with the patient before his infection was confirmed are on paid leave — isolated inside their homes as experts watch for signs of symptoms and test for infection during the virus’ known incubation period.
The man no longer needs the oxygen he received during the first part of his hospital stay, and is expected to be able to resume his visit with his family members, who have been asked to remain at home and to wear face masks if they leave. As of May 5th, none of the Indiana hospital workers tested positive for MERS. Because the incubation period can be as long as 14 days, they will be tested again 14 days after their initial contact with the patient.
Maggie Fox of NBC News notes, “The virus has not been known to spread on airplanes or buses. Most cases have been among people caring for sick patients or in very close contact with them.” Nonetheless, CDC is contacting the man’s airplane seat mates.
In order for officials to implement these kinds of control measures promptly, they need to quickly be able to identify a patient who may have MERS (or another serious contagious disease). In a CDC press briefing announcing the identification of this first US MERS case, Anne Schuchat, head of CDC’s National Center for Immunization and Respiratory Diseases, explained, “Because of the patient’s symptoms and travel history, Indiana public health officials tested for MERS-CoV.” Communication between healthcare providers and public-health officials is essential so that providers know what to look out for — in this case, flulike symptoms combined with recent Middle East travel — and can quickly take the necessary measures when a potential case shows up.
In its Healthcare Provider Preparedness Checklist for MERS-CoV, CDC reminds providers to stay up-to-date on the symptoms and case definitions for MERS-CoV, review infection control policies and recommendations (including personal protective equipment for healthcare personnel), be ready to deal with suspected cases in ways that minimize opportunities for the virus to spread, and know how to report potential cases, know how to communicate with state and local public health agencies.
CDC does not currently recommend that people change their travel plans; instead, its website (updated May 2nd) states:
If you are traveling to countries in or near the Arabian Peninsula, CDC recommends that you pay attention to your health during and after your trip. You should see a doctor right away if you develop fever and symptoms of lower respiratory illness, such as cough or shortness of breath, within 14 days after traveling from countries in or near the Arabian Peninsula. Tell the doctor about your recent travel.
A Washington Post editorial notes that millions of pilgrims will visit Saudi Arabia for Ramadan in July and the hajj in October.
More than a decade ago, SARS — severe acute respiratory syndrome, which is also caused by a coronavirus — emerged in China’s Guangdong province and spread to 25 other countries, killing 774 of the 8,000 people who fell ill. Helen Branswell of The Canadian Press noted that many of the confirmed SARS cases were healthcare workers: 20% worldwide, and 43% in Canada.
China faced intense criticism for long delays in informing the public and sharing information with outside doctors after it first identified that the disease was spreading. Following the SARS outbreak, the World Health Organization revised the International Health Regulations to require members states to report disease outbreaks and to strengthen their surveillance and response capabilities. Prompt and complete sharing of information — both domestically and internationally — can help hospitals, public-health officials, and others prepare to respond promptly to potential and confirmed disease cases in order to limit the outbreak’s spread.
The Coalition of Immokalee Workers’ Fair Food Program has garnered praise from the White House to the United Nations for its innovative strategies to improve working conditions among farmworkers in Florida. The program, which began in 2010, works by getting big buyers to agree to only purchase tomatoes from farms that adhere to worker protection rules and ensure that workers are educated on their rights and responsibilities. Businesses that have signed on include Taco Bell, Chipotle and, recently, Wal-Mart, which according to a New York Times article chronicling progress on Florida farms, sells 20 percent of the nation’s fresh tomatoes. In reporting on the work behind the success as well as challenges ahead, the New York Times’ Steven Greenhouse wrote:
So far, the agreements between retailers and growers are limited to Florida’s tomato fields, which in itself is no small feat considering that the state produces 90 percent of the country’s winter tomatoes.
But gaining the heft and reach of Walmart — which sells 20 percent of the nation’s fresh tomatoes year-round — may prove far more influential. To the applause of farmworkers’ advocates, the retailer has agreed to extend the program’s standards and monitoring to its tomato suppliers in Georgia, South Carolina and Virginia and elsewhere on the Eastern Seaboard. Walmart officials say they also hope to apply the standards to apple orchards in Michigan and Washington and strawberry fields in many states.
…But progress is far from complete. Immokalee, 30 miles inland from several wealthy gulf resorts, is a town of taco joints and backyard chicken coops where many farmworkers still live in rotting shacks or dilapidated, rat-infested trailers. A series of prosecutions has highlighted modern-day slavery in the area — one 2008 case involved traffickers convicted of beating workers, stealing their wages and locking them in trucks.
“When I first visited Immokalee, I heard appalling stories of abuse and modern slavery,” said Susan L. Marquis, dean of the Pardee RAND Graduate School, a public policy institution in Santa Monica, Calif. “But now the tomato fields in Immokalee are probably the best working environment in American agriculture. In the past three years, they’ve gone from being the worst to the best.”
In other news:
The Charleston Gazette: In the wake of January’s Elk River chemical spill in West Virginia, federal officials are developing an “inhalation screening level” for MCHM, a coal cleaning chemical that spilled by the thousands of gallons into the river, contaminating drinking water for residents in nine counties. According to the article, the U.S. Environmental Protection Agency is developing a “‘health protective inhalation screening level’ that may be used, along with information on monitored air concentrations of MCHM, during the site cleanup process ‘to advise the public when exposure to MCHM is not anticipated to be harmful.’” However, state officials say EPA’s work may not be done in time to use during the site cleanup or when dismantling the tanks that contained MCHM. (The Gazette also covered a new federal rule to cut occupational coal dust exposure, which Celeste Monforton wrote about here as well.)
San Antonio Express-News: A decades-old refinery in San Antonio, Texas, is back in the news after an official with the San Antonio River Authority said the refinery’s latest owners aren’t living up to safety promises, with two spills in the span of five weeks. The refinery has a history of fires, accidents and pollution — for example in 2010, “a tanker truck explosion and a series of other blasts at the plant left a driver badly burned and sent thick black smoke skyward. It took firefighters nearly six hours to contain the fire.”
Government Accountability Project Blog: The project’s legal director, Tom Devine, testified before Congress in honor of Workers Memorial Day on whether private-sector whistleblower protections are strong enough to support safe workplaces. In his testimony, Devine noted that a founding pillar of occupational health and safety are laws that protect those who speak up about violations. He said that while whistleblower protections contained in the Occupational Safety and Health Act are the nation’s oldest and most used whistleblower protections, they’re also the country’s weakest whistleblower protections. Click here to watch the Senate subcommittee hearing.
Shreveport Times: An article about worker safety in New York dairies starts out with the story of Francisco Ortiz, who was killed after being caught in a machine that had reportedly been failing for some time. The local sheriff’s office deemed it an “accident,” though surely occupational health and safety advocates would say otherwise. Ortiz’s death was among many that helped jumpstart a worker center-led campaign to improve safety on diary farms. Campaign organizers noted that even though OSHA is planning a series of unannounced inspections this summer, rules that limit OSHA authority to farms with 11 or more nonfamily employees means that many workplaces will continue to fly under the radar.
Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for more than a decade.
Getting down and dirty with boots on the ground is one trait of a successful community organizer. It could also describe the work of the most-skilled epidemiologists. ATSDR scientist Frank Bove, ScD’s past experience with the first—an organizer from 1975 to 1982–makes him especially effective at the second.
Last month, Bove was recognized by the Boston University School of Public Health with the 2014 David Ozonoff Unsung Hero Award for his work. Bove has been the lead researcher in the Agency for Toxic Studies and Disease Registry’s (ATSDR) investigation of U.S. Marine Corps base Camp Lejeune. For nearly a decade, ATSDR has been examining the relationship between adverse health effects of former residents of Camp Lejeune and the association with contaminants in their drinking water. Between the 1950′s and late 1980′s the water provided to residents from the base’s water treatment plants were contaminated with high concentrations of TCE, PCE, vinyl chloride and benzene. Our colleague Dick Clapp has written about the Camp Lejeune here and also testified before Congress about it.
David Ozonoff, MD, MPH for whom the award is named, witnessed Bove’s expertise on the Camp Lejeune project as the ATSDR scientist maneuvered as both an epidemiologist and the community organizer. Ozonoff served in 2005 on an expert panel that made recommendations to Bove’s team on the feasibility and usefulness of conducting additional health studies of the Camp Lejeune population. One of the panel’s seven recommendations, in fact, the first one listed was “future studies should be conducted in full partnership with the exposed community.” The panel wrote:
“In contrast with many other places where toxic contamination of the environment has been a concern, the population at Camp Lejeune is relatively transient. Most of the population of potentially exposed individuals from Camp Lejeune is now widely spread throughout the United States and in some instances, around the world. This creates challenges in tracking individuals, in contacting and interviewing them where necessary, in gaining permission for access to their medical records (if necessary), and in communicating study findings to them. …Community members, with a personal involvement and concern about health effects associated with their past exposures, must be fully involved in any future research effort. These individuals can work closely with researchers and serve a liaison function with members of the more broadly exposed population(s) from Camp Lejeune.”
Some researchers would cringe at this directive. They’d say of the residents “they aren’t scientists, they aren’t capable.” Bove disagrees. He told me:
“Community participation always—always—improves the science. It makes the science relevant to the community.”
ATSDR established a community assistance panel which first met in February 2006. Meeting three to four times per year, the CAP has held 29 meetings. Bove has attended each and every one of them. I was hard pressed to identify many other participant, except the key community leaders, with such a stellar record of attendance. (Dick Clapp, DSc, MPH, who served as a technical adviser to the community group, had nearly a perfect record. Clapp’s philosophy of community-based research mirrors Bove’s.)
I can see another, more important practical reason to embrace the participation of engaged and vocal representatives of the effected community. They, better than ATSDR or most other government agencies with hat-in-hand, can convince lawmakers to not only be supportive of the cause, but to demonstrate support in the most concrete way: $$$. The Camp Lejeune study could not be done on the cheap.
The body of literature developed by Bove’s work is impressive. Besides the government reports, Bove and colleagues have published some of their work, most recently: “Evaluation of mortality among marines and navy personnel exposed to contaminated drinking water at USMC base Camp Lejeune: a retrospective cohort study,” (February 2014); “Evaluation of exposure to contaminated drinking water and specific birth defects and childhood cancers at Marine Corps Base Camp Lejeune, North Carolina: a case-control study, ” (December 2013)
In total, more than 750,000 individuals lived at Camp Lejeune during the four-decades of contamination. A slew of specific adverse health conditions, such as leukemia, breast cancer and miscarriage, including from pre-natal exposure, have been associated with exposure to the contaminated water.
The decades long saga of water contamination at the U.S. Marine Corps’ Camp Lejeune has been the subject of national news stories, the film “Semper Fi: Always Faithful,” and a new book “A Trust Betrayed: The Untold Story of Camp Lejeune and the Poisoning of Generations of Marines and Their Families.” Those who’ve followed the story will recognize the names: Jerry Ensminger, Mike Partain, and Tom Townsend. They are the key protagonists are who have made their mission holding the Marine Corps and DOD responsible for poisoning residents of the military base. Their efforts, and clearly the scientific evidence provided by Bove’s team, led Congress to pass “The Honoring America’s Veterans and Caring for Camp Lejeune Families Act of 2012.”
Ensminger and the others are deserving of the credit they’ve received for seeing that the Marine Corps and DOD are held responsible for their misdeeds related to the poisonings at Camp Lejeune. It’s hard to imagine they’d have had the same success without Frank Bove, ScD’s involvement. He may be unsung, but certainly a public health hero.
A few of the recent pieces I’ve liked:
Jennifer Brown and Christopher N. Osher in the Denver Post: Prescription Kids (a six-part investigative series on the extensive prescribing of psychotropic drugs to Colorado foster children; via Reporting on Health)
Lydia DePillis at Washington Post’s Wonkblog: The U.S. still spends way more on teen pregnancy than family planning
David Moberg at In These Times: Meet the ‘Missing’ Workers (“More than 5 million Americans have given up hope of a job. Who are they?”)
William Laurance at Yale Environment 360: Will Increased Food Production Devour Tropical Forest Lands?
Julie Beck in The Atlantic: The Private Lives of Public Bathrooms
Any other recommendations of public-health pieces worth a look?
For the first time, the World Health Organization has examined antimicrobial resistance globally, and the grim findings won’t be surprising to anyone who’s been following this issue. (Last year, the US CDC and UK’s Chief Medical Officer issued reports with similarly alarming warnings.) The WHO authors write in the report summary:
Antimicrobial resistance (AMR) is an increasingly serious threat to global public health. AMR develops when a microorganism (bacteria, fungus, virus or parasite) no longer responds to a drug to which it was originally sensitive. This means that standard treatments no longer work; infections are harder or impossible to control; the risk of the spread of infection to others is increased; illness and hospital stays are prolonged, with added economic and social costs; and the risk of death is greater—in some cases, twice that of patients who have infections caused by non-resistant bacteria.
The problem is so serious that it threatens the achievements of modern medicine. A post-antibiotic era—in which common infections and minor injuries can kill—is a very real possibility for the 21st century.
The report, which analyzes data from 129 member states’ resistance-surveillance programs, identifies very high rates of resistance among bacteria causing pneumonia, urinary-tract infections, and other common infections. Specifically, many countries reported high rates of resistance to third-generation cephalosporins and to fluoroquinolones among Escherichia coli bacteria that cause urinary-tract and bloodstream infections; resistance to third-generation cephalosporins and carbapenems among Klebsiella pneumoniae bacteria causing pneumonia and bloodstream infections; and methicillin resistance among Staphylococcus aureus bacteria responsible for wound and bloodstream infections (the dreaded MRSA).
In addition, the report describes concerns about multi-drug-resisant tuberculosis, particularly in Eastern Europe and Central Asia; artemisinin-resistant malaria (suspected or confirmed in Cambodia, Myanmar, Thailand, and Vietnam); anti-HIV drug resistance in low- and middle-income countries; and adamantanes resistance in some flu viruses.
“Unless we take significant actions to improve efforts to prevent infections and also change how we produce, prescribe and use antibiotics, the world will lose more and more of these global public health goods and the implications will be devastating,” said Dr Keiji Fukuda, WHO’s Assistant Director-General for Health Security, in an accompanying news release. The report stresses the importance of surveillance, and the news release explains that the report “is kick-starting a global effort led by WHO to address drug resistance” that will involve “the development of tools and standards and improved collaboration around the world to track drug resistance, measure its health and economic impacts, and design targeted solutions.”
Surveillance is an important first step toward a global response to this public-health threat, but slowing the evolution of antibiotic resistance will require governments to crack down on problematic uses of antibiotics. In the US, we seem to have an especially hard time stopping the routine use of antibiotics in healthy livestock (that’s where around 70% of US antibiotics go), a practice that allows animals to grow quickly in cramped conditions, but also one that researchers have linked to antibiotic-resistant infections in humans. Cheaper meat is not nearly as important as effective antibiotics. I’d much rather pay more for chicken cutlets in exchange for knowing that the average case of pneumonia, wound infection, or urinary-tract infection is likely to respond to antibiotics. A post-antibiotic future, as the WHO report reminds us, is a grim one.
Climbing the corporate ladder is usually associated with promotions, salary raises and executive offices. But for many workers, the common metaphor is part of a real-life job description with real-life risks.
Last week, the Centers for Disease Control and Prevention released new data on occupational ladder falls, finding that a fifth — or 20 percent — of all fall injuries among workers involve a ladder. Among construction workers, 81 percent of all fall injuries treated in an emergency department involved a ladder (overall, falls are a leading cause of death in construction). In 2011, CDC researchers found that work-related ladder fall injuries resulted in 113 fatalities and nearly 15,500 nonfatal injuries that were reported by employers and that resulted in more than one day away from work. That same year, work-related ladder falls resulted in about 34,000 nonfatal injuries that ended up in emergency rooms.
To gather the data, CDC’s National Institute for Occupational Safety and Health (NIOSH) analyzed data from multiple surveillance systems, such as the Census of Fatal Occupational Injuries and the Survey of Occupational Injuries and Illnesses.
“Ladder fall injuries represent a substantial public health burden of preventable injuries for workers,” stated the study, which was published in CDC’s Morbidity and Mortality Weekly Report.
The study also found that men and Hispanics experienced higher rates of fatal and nonfatal ladder fall injuries compared to women and whites. Fatality rates were significantly higher among self-employed workers than salary and wage workers, and those businesses with the fewest employees tended to have the biggest fatality rates. Construction and extraction industries were home to the worst rates of fatal and nonfatal ladder fall injuries, followed by installation, maintenance and repair.
Study authors wrote that because the hospital admission rate for emergency department-treated ladder fall injuries was almost three times the rate of other occupational injuries, it suggested that ladder fall injuries are more severe. The authors — Christina Socias, Cammie Chaumont Menendez, James Collins and Peter Simeonov — concluded that ladders contribute “substantially” to the public health burden of fall injuries.
Study authors emphasized that such falls are preventable and called on employers to consider some alternatives, such as using aerial lifts and supported scaffolds. Employers should also select thoroughly inspected ladders, provide safety training, and use creative techniques that reduce the need for ladders as much as possible so that most work can be completed on the ground, the study urged.
“The findings from this study reinforce the need for workplace safety research to prevent falls, including developing and disseminating innovative technologies to prevent (ladder fall injuries),” the authors wrote. “Employers, health care providers and safety professionals should collaborate to ensure availability and training of safe ladder practices.”
Falls are a leading cause of injury among the general population as well as workers, especially among construction workers. NIOSH recently released a mobile app called Ladder Safety that provides guidelines, checklists and helps a worker check that the ladder is angled safely.
To read the full study, visit CDC’s MMWR.
Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for more than a decade.
Third in a series of blog posts from the Russian Arctic on Siberia's Wrangel Island. In the third of three blog posts for Yale Environment 360, Berger — a biologist with the Wildlife Conservation Society and the University of Montana — writes about efforts to better understand how rapid climate change might affect muskoxen and other wildlife in the Russian and North American Arctic. As Berger explains, a key focus of Russian-American scientific cooperation is Beringia, the region of northwestern Alaska and extreme northeastern Russia where two countries — and continents — are divided by the Bering Sea.