Good morning, good afternoon, everybody. Welcome to the post-prandial edition of Medical Center Occupational Health, Effective Management for Daily Success. And for those veteran audience members who've been in our previous sessions, this is the same session as Stump the Chumps that we've had in previous years. So we want you to give us any of your pain points, any of your questions that are really troubling you. And you can try and stump us, and we'll try and help you out with the perfect solution. Before we get started, next slide, it's not advancing. I wanted to introduce our esteemed panel. To my left, my immediate left, is Dr. Melanie Swift. She's the Medical Director of the Physician Health Center and Associate Medical Director of Occupational Health at the Mayo Clinic. To her left is Dr. Mark Russe, who's the Director of Occupational Health Services at Yale New Haven Hospital. Then we have Lori Rolando. She is the Director of Occupational Health at Vanderbilt University Medical Center. And then there's me. I'm the Medical Director of Occupational Medicine Services at Atlantic Health System in New Jersey. And then to Lori's left is Amy Berman, who is the Director of Occupational Medicine at the University of Pennsylvania. And then finally, last but not least, we have Dr. Rebecca Guest, who's the Director of Employee Health and Wellness at Memorial Sloan Kettering Cancer Center. And the disclosures are noted on the slide. So if this will work. It switched backwards. Okay. So here are our learning objectives today. We want to make sure that you have an understanding of some of the controversial occupational health issues that are currently affecting medical centers and clinical research facilities and laboratories. And also help you to be better able to manage complex cases that you may encounter and be able to describe the resources available to address these difficult issues. So that being said, what are your pain points? What are issues that you have to deal with that are really causing you trouble? So we have the handheld mics and we are trying to get some microphones set up, but meanwhile, who would like to bring out their inner Oprah and help us distribute one of these mics to the audience members with questions? Thank you so much. You're my volunteer. Thank you so much. And what is your name? Jolene Mitchell. Jolene Mitchell from Overland Park, Kansas, Everside Health. Thank you so much. We appreciate you. Also, just one real word because we had a little issue when we had a very nice moderator a couple of years ago. I'm going to say it now. This is the Medical Center Occupational Health Session, Stump the Chumps. We want questions about taking care of healthcare workers. This is not the medical review officer panel where you bring all your drug screen questions. So just making that point. Thank you. And one other thing, the medical review officer panel is tomorrow at this same time, but next door. Does anybody have any questions? Yes, you do. All right. Jolene, over here. Okay. Raise your hand one more time because I missed it. I was getting in trouble for being by the speaker. Hi. Thanks for hosting this. At the University of Colorado, we've had a large number of, of course, female healthcare workers that are pregnant, pretty significant back injuries, and lots of very strong opinions on things like imaging and MRIs between the patient, their specialist, their OBGYN. And so we've kind of had a herd of people that we're kind of watching and waiting until delivery. Several are very legit. Some are questionable. But I probably have 10 or 15 at this point. I just inherited this job. So I was kind of thinking... Can you speak up a little bit? It's kind of hard to hear you guys. Hold the microphone. Hi. The question is dealing with the pregnant healthcare worker. I probably had 15 cases right now that I inherited that are kind of complicated. And it seems like I'm probably not the only provider dealing with this because there's a lot of people in the room. And just, I'm sure I'm not the first one to deal with this, so, how about it? Were you inquiring primarily about traumatic injuries or exposures or both? Primarily about mechanical lifting, you know, slip and falls, radiculopathy, weakness. I'll just start off since I have the mic in my hand and say that I don't know that I have anything brilliant to solve this very difficult and very frequent situation, except that I can't think of any times it hasn't been useful to really engage with the obstetrician whenever that's possible. So I think that's kind of my first principle, usually, assuming, of course, that the injured employee agrees to that, and that they usually do. And the second thing I'll say is that physical therapy is almost always a good idea. And the third thing I'll say is that I think early return to work programs are always a good idea to, you know, I'm stating the obvious to this group, but to remove the secondary gain or decrease the fearfulness that may be part of a delayed return to work. And the fourth thing is, in terms of imaging, if it's actually necessary for, you know, to rule out a surgical lesion in, you know, a pregnant woman, then with the agreement of the obstetrician, usually just go ahead. And otherwise, I would get them into physical therapy. I don't know if that's a helpful answer or not, but... I think you said that a three-way. And I'm curious, are these folks where they have presented with ridiculous symptoms, weakness, so they truly do need an MRI, or are some of them... The whole spectrum. I mean, some, you know, have those subtle weakness findings, you know, little bit of urinary spotting, but then, you know, okay, they're eight months pregnant. And then it's also even in the post phase where the MRI is completed and it shows whatever it may. And then they have ongoing pubic symphysis or SI dysfunction, and the adjuster, let's call it what it is, you know, might be a male who says, okay, why aren't they back to full duty? Well, they just gave birth to a 10-pound child, you know, a month ago. So I just wanted input, and it's fine if everybody agrees, yeah, this is tough. Yeah, and where I thought you were going to go with that, actually, and I'll just, in case others are wondering this, is about imaging after... to rule out active tuberculosis in your screening. So a pregnant worker is IGRA or TST positive. And just reminding folks that you can do a single view with the abdomen shielded, and you do need to exclude active TB. And so you shouldn't be, like, putting that off until delivery to do that imaging. If I could just briefly add to that, since it's true, my last active TB case in an employee was, in fact, a pregnant woman who... for whom imaging was delayed by her primary care provider. She, poor thing, must have had 12 COVID tests, but never the X-ray to see if her positive IGRA had actually become active TB. So it clearly would have been, retrospectively, in her best interest to have done it. Hi, everybody. I'd like to get a sense from you all how you partner with other kind of affiliated people dealing with the mission of employee safety. So in our institution, we have, within our employee health initiatives, we've got one for blood-borne pathogen exposures. We've got one for workplace violence. We've got one for, say, patient handling and mobility. We've got one for slips, trips, and falls because... And so I've got this kind of, like, constant interplay with a relatively green, say, patient handling and specialist nurse, a former CV nurse who's now a person. And I was wondering if you could offer us what your own roles have been in terms of working with these folks because, obviously, we see them when injured, and we're trying to champion these people to work with us on the prevention side of things and identify capital investment and program, things like that. Can you share some of your own experiences dealing with, say, patient handling specialist or your corporate safety person, if you've got a real, live, formally credentialed safety person that helps support your mission of providing a safer workplace? Hi. Thanks. Oh, that's loud. It's not? It's okay? So that's a great question. I think over the last half-dozen years, we have really improved where... I'm at Sloan Kettering, our collaboration and regular communication with safety that we have... They put together an executive council of safety in the environment. And essentially, all these different players that you're mentioning, plus a few others, like other safety issues, all get together regularly and go through regular reports, and we communicate. And not to put Dr. Agrawal on the spot, but I am. She's sitting there. She's done a terrific job, actually, using key performance indicators for some of the things that you're talking about, and tracking which departments within our medical center have the highest safety issues, injuries, the things that we see, and showing that at these meetings so that it's really out in center where we should be focusing and agreed upon based on the data. And then when they sort of see, oh, these departments, the usual culprits have the most... Whether it's animal handlers or patient care technicians or the usual groups, when you can see year over year the number of injuries, the lost work days, the workers' compensation costs, et cetera, it becomes a very compelling mission for prevention. So I think that that sort of meeting of minds has been really instrumental, getting everyone together in one room. Yeah, I completely agree with Rebecca. And I will say, at our institution, we have a... In addition to our strong partnerships, sort of one-on-one partnerships with infection prevention or with environmental health and safety or with our ergonomist who is in the nursing safety realm but sort of has a dotted line partnership to us, or risk management, we also have a very strong committee structure, which I'm sure other folks do as well. So we have multiple sort of subcommittees, a blood and body fluid subcommittee, for example, that has a lot of the key stakeholders, including nursing and nursing education and sort of the boots on the ground, or an ergonomics committee that includes the ergonomist, our ergonomist, and the one who's the dotted line is actually our patient handling ergonomist. We have an ergonomist in our department as well to handle non-patient handling issues, along with all of representation from all of our high-risk departments. So as Rebecca was mentioning, sort of trending injuries and being able to look at that data and know where your pain points are and who are having concerns or seeing higher injuries, we're able to reach out to those departments and engage them and their workforce and bring them all together, or we have a meeting and a committee with the Division of Animal Care for our animal care workers, and then all of those report up to the safety committee that has all of the institutional stakeholders, and we report out our data and we report out our trends and we talk about the issues that we're seeing so that we can get that engagement at the institutional level, and those reports go up to the C-suite. C-suite. So when we see issues, that's the perfect place to really be able to engage and, I think, get that institutional buy-in when there are concerns. The one other thing I would add, and the threshold may be higher to get over for this. I mean, we have a similar structure with an individual who runs violence and runs safe handling and runs... Being the medical director for all of that cuts through a lot of... So it may be more difficult to propose that you should be the medical director for all of these safety activities, but you probably should be the medical director for all these safety activities, and then you have the opportunity to interact with those folks on a daily, weekly, however often you want, basis. You become the medical authority who essentially weighs in and to whom they have to report, and it kind of cuts through a lot of the years and years and years of trying to argue for stuff instead of just having a simpler but ultimately more elegant solution to it. I am on all the committees, and so all these people report ultimately up through the quality and patient experience. The PhD nurse is a real, very easy person to work with, but everybody on the committee are basically volunteers. There's no one who any of these committees is, with the exception of, say, patient handling specialists. It's not part of essential job functions. They're basically dragged into this, and so the time commitment to the energy is highly variable. Yeah. So we used to do that, and then we essentially just established an employee safety group, and so we hired seven professionals, and I serve as a medical director for it, and it cuts through a lot of the challenges of volunteerism. At our institution, we have a director of environmental health and safety who has a team of safety officers, including an ergonomist, and they work very closely with occupational medicine services, and we all sit on the same environment of care committees, and we problem solve together. I think it's really interesting just based upon the relative size of these organizations. So I've got 6,000 employees, four hospitals, beautiful suspects out there, and I find it a real challenge to budgetarily get them to loosen the purse strings and have to pay people to do this as opposed to a Yale or a school catering or a pen. You know, in places, it's not always easy to nail a big nail down, so it's hard. Okay. I just wanted to... I'm sorry. Go ahead. I just wanted to mention somebody from the cyber audience said, for your question about the pregnant health care worker, they commented, consider the use of NCSEMG in lieu of imaging for evaluation of radicular pains when appropriate in pregnant women. So I have a question about modified duty programs or early return to work, like you mentioned earlier. I think I'd love to hear any success stories or innovative solutions you found in your organizations to getting people back to work, I think, aside from just relying on their departments or their supervisors to find a modified duty spot, which we all know is difficult sometimes, especially with our nurses who might have, you know, a back strain or something or a knee injury that doesn't totally disable them but prevents them from, you know, lifting patients and doing their normal job. I can answer that one. We have a transitional duty program at our medical centers, and it has its own budget. It comes out of our safety budget or ergonomics budget, and it allows us to send people back to work sooner, and they will work in different areas of the hospital in jobs that they can physically do, even if they can't meet all the essential functions of their job, and then they have 90 days to transition back into their full duty position. So we don't do it for longer than 90 days because we don't want to give the appearance that we can accommodate these people permanently, because if you're in transitional duty too long, that can be the expectation. Yeah. I highly recommend that you ensure you've got senior-level support for truly supporting return to work and stay at work. One little pitfall to be aware of, and one reason why tracking your injuries and having a line of sight in occupational health into where people have been, you know, which departments have had injured workers who've been accommodated with their restriction, is to ensure that you don't have a supervisor that likes Sally but doesn't like Joe, right? And they have the same restriction, and Sally's accommodated because they're friends and they're neighbors and they're nice, and then six months later, Joe's not accommodated because Joe's kind of a pain, right? Or there's some bias. And so having that, I always found that a very powerful talking point with supervisors and we, you know, when having an official return to work policy, the supervisor who says, but I can't accommodate that if you actually have the records that they did in the past. Oh, tell me what's changed since you accommodated Sally six months ago. And so that's one little tip. Keeping people in their same department whenever possible is better on many levels, one of those being accountability and, you know, having continuity of supervision for performance expectations, right? So if you do have someone who's not meeting their job expectations, that new temporary supervisor isn't going to know it as well. That said, certainly there's place for transitional duty and I can brag a little, Mayo has a really robust one and it's because they have really senior level support. They actually will allow folks to work in a transitional duty period longer than the 90 days, which is kind of standard in the industry. That has to do with their philosophy, it has to do with limited recruitment area of potential replacement workers, when you have a medical center in a big corn field, you're limited. You've got to have high level support from the C-suite that it's important to them, they see the value on the dotted line to keeping those folks engaged and productive. We don't lose that intellectual capital of the nurse who's got ICU experience because we say, well, she can't move patients, so we have to lose her to the ICU. I think that's been maybe one silver lining of COVID, is healthcare workers are not throwaways. I think that the healthcare worker shortage, as painful as it is for us on the front lines, has underscored that, that we want to use their capacities in any way we can. I was just going to add quickly that skin in the game for the department is actually good. If somebody has a light duty clearance and the department chooses not to accommodate it, the department actually is still paying for that person the entire time. That they're out or that they're working in another department. They're actually incented to find a way to bring them back into that department. Jill? Sorry. Just two more really quick points, just to add on to what everyone else has already said. One thing that we have that has been very helpful is we have a position who, she's an occupational health nurse and she is our return to work coordinator. She works with managers all the time to be able to brainstorm with them when an individual has restrictions to come up with things that they can do. Because it's understandable when you have a manager who's got an employee who comes back and says, I can't do A, B, and C. Their first thought is, well, how can you do your job or how can we keep you here? But it just takes sometimes a little bit creative thinking. If they can't stay in their department, then we will move them. There's a whole policy to Melanie's point about making sure you have senior level buy-in. This is formalized in a policy, the return to work program. We can find alternate work for them, but again, if we can keep them in the department, that's great. And having somebody who can really make those connections and work with those managers is key. And the one other thing I will say is when you're writing restrictions, please be as specific as possible. Because one of the big challenges is if you just come back and say, no use of the right arm. And they're like, okay. Well, in the context of their job, maybe you can be more specific about what that person can do and can't do, which will then allow the manager to work with them and find things that are amenable to being able to do. That's a great question, by the way. Obviously, we all spend a lot of time thinking about it. My two cents is going to be that in addition to having a case manager embedded with us who helps people find early return to work, that's the name of our program, jobs, ideally in their own department or elsewhere, we now have a designated adjuster with our third party administrator. They have a lot of skin in the game from a financial point of view. And we now have one person who's our single point of contact to help find jobs for those difficult cases, the CNA who isn't ever going to be able to transfer a patient again. And we find that's helpful in terms of getting people into light-duty positions where they can learn new skills and eventually return to the workplace, even if not to their original job. Well, a lot has been said already. I would just say we did make sort of a process change, which is quite helpful, which is when a manager wants to say no light-duty or no, we can't make this accommodation, there's sort of an automatic, well, nothing's automatic, but there's a reflex that it becomes escalated to the HR employee relations advisor who's sort of like an HR business partner. So that it's no longer sort of okay to just say no, we're not accommodating. It's automatically escalated to HR. And I think that that makes managers think a little bit harder before just denying, knowing that they're going to have that next conversation. On this topic, I'm going to ask you guys a question. Raise your hand if your medical center has a transitional duty early return to work program for your employees. You let people come back with some restrictions. Keep your hand up for a second. Keep your hands up. I want to see how many folks have a program. Leave your hand up if people can be in that program for a non-occupational injury. Half the hands went down. Okay. You can put your hands down. How much of your work, lost productivity, disability, do you think is due to occupational injury, and how much of it is due to our employees' rest of their lives, right? So I would challenge you to think about that. Think about the potential lost productivity that we have from, you know, the broken ankle that happened while ice skating, you know, compared to the broken ankle that happens at work. Which do you think is more common, right? And how much of your workforce productivity are you losing if you don't have a way to accommodate the non-occupational injuries? So I'm just putting that out there. And it's difficult to sell that to upper level management. We've been trying to get that going for several years, but that's a great point, Melanie. So are you not sure about that with upper management, that there's a liability issue? They don't want non-work related injuries to come back to work and potentially be vulnerable to that injury becoming exacerbated or now becoming a workplace injury that the employer then owns. Has that been an issue that you've come across? Well, so work restrictions are functional, right? And the work restriction that the person comes back with, limited walking, you know, lift up to 10 pounds occasionally, that's applicable. So that gets back to how do you prescribe a work restriction, right? How do you write a work restriction? You write a work restriction based on the person's capacity, their tolerance, and the risk. And that's the same. That's the same paradigm. I'm looking at Laura Brear in the audience, who's one of the retain proponents for our state, but that's the whole point of the retain project, is that we write functional work restrictions that allow safe return to work. So assessing risk of re-injury, whatever, is part of writing that work restriction, and the principle's the same, whether it's a work related injury or not. So if you're saying that the person has the ability to safely work with this restriction because they had a work related injury, how do you justify they're not safe to come back with the same injury and the same restriction for a non-work related injury? So I just want to put that food for thought there, because I know that the practice in general has been not to accommodate those non-work related injuries, and I just want to challenge you to go back and think about that a little bit more, especially when we have about 30% of RN positions open in this country. I have a question from the chat. What is your level of threshold for infectious disease referral at baseline for an occupationally exposed employee whose source patient was triple or quadruple positive, HIV, hepatitis B, hepatitis C, and possibly syphilis? Rachel, can you repeat that? Yes. What is your threshold for infectious disease referral at baseline for an occupationally exposed employee whose source patient was triple or quadruple positive, meaning infected with HIV, hepatitis B, hepatitis C, and or syphilis? Yes. So, I mean, these days someone who is getting care for HIV is on triple therapy, no doubt. And so anyone who has been on antiretrovirals needs to be a candidate for the non-cookbook approach. And very often you're – I think that is the case that I would have a conversation with infectious disease about. I think when you have an experienced HIV patient, you need to have that conversation. You know, with hepatitis B and hepatitis C, it's sort of – that would not necessarily be a knee-jerk, oh, we need to involve infectious disease for this because the management is still – you're not giving prophylaxis. What you need to do for hepatitis B is clear based on whether the person has a surface antibody that's positive at some point or not. And with hepatitis C, essentially with the relatively new guidance, that's fairly straightforward for the testing that needs to be done on both the source patient, the exposed healthcare worker, the repetition of that testing, a few weeks later, and no recommendations still for any sort of prophylactic use of the effective hep C agents. We would refer were there a seroconversion for hep C, for, you know, choice of direct acting agent for that, and of course, which are extremely effective. But I think the key one with that is an experienced HIV source patient who's been on antiretrovirals, and you want to give some consideration to, you know, to which antiretroviral there might be resistance. And so let's take HIV out of the equation for a second, and you've got someone with multiple blood-borne pathogen infections, so then you potentially have someone at high risk for HIV that's not test positive yet. So that's another, I think, thing to think through carefully. You don't have a serologically positive HIV positive source, but you have someone with risk factors, including other blood-borne pathogen infections. So I think that's, again, worthy of probably a conversation and consideration of HIV PEP. Yeah, and they're really, you know, they're really probably only two times when you're going to consider sort of that next level of testing for such an individual, like the use of a PCR test. You know, I mean, if you had a source patient who had engaged in every risky behavior known to man in recent weeks and is infected with other blood-borne pathogens, you might want to subject that source patient to not just antibody testing, but also PCR testing for HIV. If you're really suspicious that the source patient might be HIV positive. And then, you know, the only other indication that's worth mentioning, it's a totally different circumstance when you might use an HIV PCR test in the setting of a blood-borne pathogen evaluation, is the health care worker who gets exposed to a known positive patient and who three weeks later has a fever of 104, et cetera. And if it's actually HIV, then the PCR will show you a sky-high viral load. And the much more likely scenario that it's another virus can be, you know, if your PCR turns out to be negative, then it's not HIV. Because the PCR with the acute HIV syndrome is really, really high. But, of course, the antibody can still be negative. If I can just add in, structurally, when you have people that are exposed to HIV and the source is on multiple drugs, and so, therefore, they're typically going to have resistance to the isentrous and Truvada treatment that we all use. We set up a process whereby the HIV team at UCLA was on call one doc, 24-7, 365, and a backup two docs, so that when we got those exposures, we would pick up the phone to figure out which drugs we're going to put them on. Because, honestly, it's a cocktail of esoteric drugs that most doctors have never heard of, including most occ health doctors who deal with BVPs. And yet they could coach us to figure out which drug to start the people on and work through the process. And generally, you know, 90% or more of the people that were put on drugs for HIV patients on multiple drugs that we're not familiar with, the HIV docs would just coach us through what to do. We would not have to do an actual referral. We would start them and just make phone calls and it worked very smoothly. Thank you, Warner. If you are in such a complex situation and appropriately consulting your infectious disease team, you don't have to go ahead and give that first dose of Truvada reltegravir that you have in the starter pack at your elbow. You don't have to wait. You'll just be changing it for the next dose. We have the video here. The audio is on here. So we have one person that asked a question with a remote mic. After that, if you could bring the mic up and then we'll start a line here for folks to come up and ask a question. Yeah, I have a question about your medical center. Does your medical center entertain non-work-related injury or illnesses? And if so, or if you don't, how you deal with it? That's my first question. My second question is regarding, do you test all your COVID positive employees simultaneously for the tuberculosis? Do you screen them again with the quantifrons if they are tested being positive, COVID positive? Thank you. Can you clarify your first question? Are you asking if our occupational health clinics see non-work-related injuries and illnesses? We do. We will see individuals and assess them if they come in with, we call it an acute injury or illness. So much in kind of an urgent care context. So we will do that. And we're not testing every COVID positive employee at the time they test positive for TB as well at this point, if that was your question. No to the first question. And I think this is just institution by institution, how you're set up. So it was interesting. I think the first question was, how do you assess the patient's condition? So it was interesting. And Wendy was talking about in her really riveting TV discussion yesterday morning on how COVID has changed TB, that early in the pandemic, it was a very successful strategy in India. We have very high rates of TB, of co-testing COVID-19 and TB in symptomatic individuals. So the presentation of the cough, the symptoms, in a high endemic country, in a high TB burden country, made sense to co-test. Because really the COVID pandemic has set back our TB testing and reporting globally really significantly. And so I think this depends on where you practice. In the United States, we're a very low TB burden country. We know that we're testing our healthcare workers at higher. So if they have TB infection, we would know that at the time of higher. Especially untreated latent TB infection. And they become symptomatic. And that cough persists despite a negative COVID test. I think it's a really good reminder not to forget to also rule them out for active TB. So thank you for bringing that up. But we don't co-test prospectively. And this kind of dovetails with what Melanie just said. But I think it's really important to bear in mind that, you know, this is a 2 to 3 per 100,000 incidence country for TB. I mean, the pretest probability that that's TB is really, really low. But that doesn't mean that you shouldn't, for any such case, size up TB risk factors. Is this someone who's been in prison? Is this someone who has just come in from the Philippines? Is this, right? I mean, it's all the things that we recognize as TB risk factors. And we need to continue to be clinicians, right, and give consideration to those things. And certainly bear in mind that, you know, is this someone who needs a chest x-ray? Do you really think that this is active TB? I mean, if they come in symptomatic. And, you know, I think everyone is familiar with the C change in TB guidance that came out in 2019. One of the main drivers of that is that, you know, the positive predictive value of a tuberculin test in a healthcare worker is about 5%. I mean, we are, by and large, a pretty darn low risk group. That said, if you have an individual with substantial risk factors who comes in with respiratory symptoms, always on the differential. Since I actually have a case that I already mentioned briefly that does illustrate what Mark just said about using clinical judgment. I think that's what this really comes down to. My recent case was not a healthcare worker. So let me say that up front. No patients were exposed. Her diagnosis was delayed for tuberculosis because she was pregnant and the individuals following her did not want to image her. She had a known positive, very, very high positive interferon gamma release assay, had known childhood exposure from Nepal, actually. She was Nepalese. And had been repeatedly seeking help throughout the second half of her pregnancy. She delivered a healthy baby and still coughing, took her infant back to Nepal to visit family, as one does. And several, I mean, I talked to her extensively when she came back. Several of her relatives said, are you sure you don't have tuberculosis? And sure, they got her tested in Nepal. She tested positive. And then was only, of course, able to return once she had cleared her sputum. She's fine. The baby's fine. Again, not a healthcare worker case. But I think illustrates the fact that if your prior probability is extremely high, you should pursue it. Got my, I'm very invested in this case. Okay. I have another question from the chat. About hepatitis B immunity in healthcare systems. This person has a lot of healthcare personnel who have positive hepatitis B titers. But, hold on one second. And verbally report completing the hepatitis B vaccination series, but they don't have documentation of vaccination. And according to CDC guidelines regarding hepatitis B immunity, health care personnel who cannot provide documentation of three doses of hepatitis B vaccine should be considered unvaccinated and should complete the vaccine series. Health care facilities are encouraged to try to locate vaccine records for health care personnel and to enter all vaccine doses in their state immunization information system. The question is, is anyone's policy more relaxed than that? In other words, do you accept a positive hepatitis B titer plus or minus a verbal report of past immunizations as proof of immunity to hepatitis B? I mean, if someone has a positive hepatitis B surface antibody, they are protected from hepatitis B and they have had the hepatitis B vaccine. So we would regard them as protected, particularly in the absence of any other positivity in their, I mean, if it's a lone hepatitis B surface antibody, positive individual, we would regard them as vaccine protected. Particularly if they're coming in and say, yeah, I got it, I just don't have the records. Yeah, we would, I mean, the cutoff we have used is 10 million and we're not going to cut off any international units. Because if they've been vaccinated, you know, they'll do this, right? And if they responded to the vaccine, they'll do that with a single boost. I do understand the question, though, and for compliance purposes, we will accept the surface antibody. We clinically will talk to the person about the fact that we don't have a record, so the CDC would indicate that, you know, long-term immunity has only been confirmed for individuals because they looked at people who had both the documented series and the antibodies. So we will offer them, you know, if they would like to be revaccinated, we will offer them that. We do the same, but we also have a declination form for the individual to sign should they perfectly, reasonably, frankly, decline to be re-immunized. Yes, also, we accept it, but the CYA is the declination form in terms of your policy. You have them decline, offer it and have them decline. It's perfectly reasonable to decline. So I think the following question, and this happens to us in Philadelphia because bad things happen in Philadelphia. Why do you think the CDC made up this? I mean, I came to Philadelphia from New York and encountered exactly this same issue. Do we accept positive antibodies for other vaccine? Why do we think that the CDC has this? Because it was thrown in my face, absolutely, that, you know, this is what the CDC said and this is the way, the truth and the life. And so, anyway, just curious if anybody had any background as to why the CDC came up with such a stringent requirement that we wouldn't even accept a biological evidence of immunity. I think what the reasoning behind it is because they consider that you have to have three doses of hepatitis B to confer long-term immunity. So I think they just want to be assured that somebody has long-term. We may get an antibody and find that it's positive, but if they've only had two doses of hep B and they get a needle stick five years later, they may not really be protected. So I believe that's where that comes from. Yeah, I think it's because when they looked at long-term immunity, it was people who had the documented full series and you could potentially get a transiently high antibody in the middle of a vaccine series. But if they haven't completed the full series, they can't speak to long-term immunity. That was exactly the point that I was going to piggyback on. So we do, at Mayo, we do hepatitis surface antibody to check for immunity at the time of hire. If someone said, yes, I got the full series, I finished it when I was, you know, 20, it's now 40 years later, I can't find the documentation. But where we don't draw the hepatitis surface antibody is if someone says, you know, I've had my first dose but not the other two, we don't want that surface antibody in our system because then it might be misinterpreted as long-term immunity later. So that's a good point. So I'm going to turn around and ask a question to everybody else then on this particular topic. So if you have someone knowing sort of what the CDC says and kind of, you know, how it's being handled, if someone does have a needle stick, they've got a history of a surface antibody positive but no documentation of the vaccine and the source patient is hepatitis B, surface antigen positive, how would you handle that? Would you continue to assume immunity or would you recheck them at the time of the exposure and only assume immunity if their antibody is still positive? I would recheck. Yeah. Though it would be reportable if that person were not protected. Though, I mean, the experience is, I mean, we know that at 10 years out, 50 to 60% of people have surface antibody levels that weigh in down below 10 million or national units and we know that those vaccine responders with a single boost jump right back up. I mean, that's the common challenge, right? And it's, and particularly increasingly as you're hiring young healthcare workers who've gotten their hepatitis B vaccinations when they were 13 and nobody ever checked a surface antibody because that's not the recommendation for the general population in contrast to the recommendation for healthcare workers where we get it, we log it in, and then they're good for the rest. So that's often what we encounter is, you know, and then in that case, you check their surface antibody and if it's negative and you boost once and if they jump right back up, then you would regard them as protected. And that is a case where, you know, where you have documentation of that vaccine in the past. Right. So I want to, I just want to, oh, I'm sorry, Michael. One second. So how many of you in your occupational health programs have access to your state immunization registry? Okay. If you don't, please get it. Problem is we've got 50 state immunization registries, right? But, you know, given that we're getting older and the healthcare workers that are hiring are apparently not getting older, they keep coming in, I think we're hiring 12-year-olds now. They all look really young. But more and more of them now were born in the 90s and even in the 2000s, yes, after the introduction of universal childhood hepatitis B vaccine. And to the extent we had state immunization registries, it started with pediatrics. And so making that effort to get access to their childhood immunization records, it's becoming less challenging as participation in those state registries gets more and more robust. Of course, you're hiring from people in other states, et cetera, and there are relatively few state compacts and it's complex. That's why we need to get a national immunization registry. But make that effort because it does make a difference. If you can document that positive antibody that you had at hire three years ago was after a childhood vaccination three-dose series that they had 20 years ago, then you're golden, right? So I would make the attempt to do that if you can at all. And if you can pull electronically from your state immunization registry, all the better. And so I just want to highlight there's a collaborative between ACOM and some other organizations, the CDC and CMS, to look at ways to do that more robustly for workers' vaccinations beyond COVID and flu. And so this is one reason why such a partnership is really important, that we have linkage between our occupational health record and our state immunization registries. Michael. Thank you. Well, I wanted to comment that we probably have given 18,000 hepatitis B's in our facility, and what we've seen is that for the first series, there's about 6% that are non-responders. If we repeat that series, it goes down to 3%. So just because you received the vaccine, just because you have documentation of the vaccine doesn't mean you're necessarily protected. And if you're asking how CDC makes decisions, they do it by the Delphi approach. I don't know if you're familiar with that. Delphi approach is where you get 65 experts and you ask them that in the absence of any data, what would be your best guess? And the consensus guess is their decision. This applies to hepatitis B because we're in a very low endemic area in the United States. And so they can be more liberal about not requesting titering. Their only caveat, if you look at the regulation, is high-risk people. So you put healthcare workers in that category, you put certain researchers in that category. But if you look at other countries where there's hyper-endemicity and universal vaccination programs like Taiwan, they have already published that they see that their teenagers, when they drop below detectable levels, they get hepatitis B. So when Rikomavax was being developed, they only went to 14 years to get FDA approval. So you can't assume that someone's going to all get 1,000 million international units per ml response to their vaccination. So I think it really comes down to how comfortable you are. And when you look at CDC's table guidelines, it's are they, do they have immunity, do they not have immunity documented, or is it unknown? That's the only criteria they use. So I just wanted to bring that up. How many, show of hands, how many of you are still vaccinating with Engirex B? I got a quasi, I know what that's about. How many of you are using Heplisav? All right, thank you. Yeah, so, yeah, so the cost-benefit analysis of that is going to change as your population changes, right? So we actually looked at this with incoming medical students, all of whom were vaccinated in childhood less than 30 years ago, for the most part, right? And yes, and drew their surface antibodies, and they were, you know, 60% of them were negative, et cetera. And so the question at that point is, do you give that challenge dose with the cheaper Engirex B, knowing that they're pretty much all going to respond, right? And that's the one dose, that's the only dose you've got to give them. Or do you give them the more expensive Heplisav B, knowing that if it's negative, you only got to give them one more dose to complete that series, right? So the cost-benefit of that depends on your population. If you have a population of older workers who are not going to respond as well to Engirex B as they are to Heplisav, and who may not have had a good response when they were initially vaccinated, because they were vaccinated at age 30 originally, and now they're 60, then you want to likely go ahead and give them the Heplisav B as their challenge dose, right? Because you know that if they're over 40, if they're diabetic, et cetera, they're going to respond a lot better to the adjuvanted vaccine. But if you're in a medical school, and your incoming health care workers, so to speak, are young, healthy, vaccinated in infancy, then in our analysis, you actually came out more cost-effective with not only lower cost for the vaccine, but fewer follow-up visits, fewer additional blood draws, et cetera, if you went ahead and gave that challenge dose with the Engirex B, because they all respond. I am a little shy. I do have a question about COVID return to work. So right now, in my hospital, we're doing the contingency protocol for five days return to work, because we are still going through a staffing crunch. And a lot of our providers would like to go to the 10 days, back to the 10, but I was wondering whether you've come across any data to show whether if your health care worker is up to date, that means two shots and boosted, whether that has affected the contagiousness and able to, or have you used the antigen test as another way of trying to get someone back to work rather than the 10? We've used the antigen test for, we were operating at one point under contingency level, and if somebody had a negative antigen test 48 hours before the return to work, they could return back to work as early as day eight if they were asymptomatic or nearly fully recovered, and they were fever free for 24 hours without the use of antipyretics. Yeah, so we have also used antigen testing for return to work in the contingency plan and found that a very small percent of individuals are going to be antigen negative day five after symptoms began. So it does turn out to be more like day eight. It's probably a good cut point if you're going to do one. And what we did find was a difference in symptomatic infection versus asymptomatic infection and how quickly they cleared their antigen for an early return to work. So what we found is that the symptomatic infections took longer to clear. The asymptomatic cleared about a day earlier. We probably just didn't know when their infection began. So you never know with an asymptomatic positive how long they have been positive. Now, we've been drinking from the fire hydrant of COVID literature. So I apologize because someone else either on the panel or in the audience is going to know this, but I'm thinking I saw a study recently that showed vaccinated individuals actually cleared more slowly. Is that correct? Or do you need to call shenanigans on me on that one? I haven't seen that. All right. We're going to put that one out to the panel to investigate and figure out. The one other thing I would add is that it's pretty clear that people can still be shedding virus post day five. And the CDC knew that. It's just that we were in a horrible circumstance and workplaces couldn't function. And the lion's share of transmissions from an epidemiological standpoint seemed to occur in those earlier days. And so while it was not a perfect solution, it was kind of an 80-20 solution. I mean, those data from Japan were pretty clear that people were continuing to shed post five days. We did the same thing, right? I mean, we tested a whole bunch of people. 65% of them were positive at day five. And so we actually never went shorter than day eight either. We felt that day eight was a reasonable compromise. And still coming back with masking. Is this working? Yes. OK. So I would say also that one thing that we have done is we're doing the conventional rather than contingency. But the other thing is that we do allow for contingency in extraordinary circumstances. So we're not really being all or none. So let's say there's a, so we're using the conventional, but we recognize that contingency may apply for a particular department or a particular cohort of employees. So if, for example, all of the technicians in radiologic studies are positive and that would make it impossible for patients to get an MRI, for example, then we would weigh those circumstances and make an exception with consultation with infection control. So I think it's less onerous to not force yourself to be 100% conventional or 100% contingency, but to weigh the risks versus benefits. It's obviously a lot of work, but it's probably the safer way to do it. OK, we have time for one last question. Just a quick, in reference to your non-across-the-board, going back to out of the contingency back to standard operating, how are you publicizing that? Because any time we change anything, it's a public nightmare. And I could only see that getting more complicated if you're saying, OK, this department and that department, you've only got like three people, so we kind of need to keep you in contingency. So yeah, so that's a great point. I mean, the communication throughout this has just been so difficult. And it's so important to be consistent. But the long and short of it is we're not publicizing that, so I just publicized it. So forgive me. But in other words, we're using conventional, but there have been extraordinary circumstances such that we can't, that the risk of sort of shutting down a particular department would outweigh the benefit of being in conventional that we've had to, with infection control, decide that we're going to use contingency. But it is conventional. That is what's publicized. But when it gets escalated to the point of, oh my god, we're not going to be able to provide patient care, then we have a discussion of risks, benefits, and who can go back wearing an N95 at day five. And nobody's just showing up at your office like pitchforks and doors? Oh, they do all the time. Yeah, but don't, you know, that's been 25 months. Yeah, but it is a tricky, it is a tricky situation for sure. OK, well thank you everybody for your participation. There are some questions in the chat that we'll gather up and answer later. And I just want everybody to think about anything that you can take away from this session that will help you in your future endeavors. And if you have any questions, please feel free to reach out to any one of us. Thank you.

occupational health

medical centers

healthcare worker management

infection prevention

return to work programs

physical therapy

immunizations

infectious disease referral

COVID-19

antigen tests