Welcome to the final day of the 2023 Virtual Fall Summit, where we shift our focus to the clinical OEM. We'll be delving into the world of clinical occupational and environmental medicine. It's a pleasure to introduce to you today's experts, including my former mentors and colleagues with whom I've worked with throughout my career. You'll engage with various exposures and learn how to manage and innovate surveillance programs, prevent workplace violence in healthcare settings, and explore different standards of testing and rationales. It's my honor to introduce Dr. Judith McKenzie as today's moderator. Join us as we explore the latest developments and best practices in clinical, occupational, and environmental medicine. Over to you, Dr. McKenzie. Thank you, Dr. Saito, for that great introduction to the day. Good morning and good afternoon, and welcome to the final day of ACOM's 2023 Virtual Fall Summit. Today, our sessions focus on topics central to clinical, occupational, and environmental medicine. I am Dr. Judith Green McKenzie, professor at the University of Pennsylvania Perelman School of Medicine in the Division of Occupational and Environmental Medicine, and a medical officer at the Occupational Safety and Health Administration, OSHA. Today, we will cover a variety of topics important to occupational and environmental medicine clinicians. Our first presenter is Dr. Judith O'Donnell, who will present on the 2023 updated COVID-19 vaccines, use, timing, and co-administration. Questions will be answered as well. Dr. O'Donnell currently serves as a hospital epidemiologist and director of the Department of Infection Prevention and Control, and as the chief of the Division of Infectious Diseases at Penn Presbyterian Medical Center. She is an associate chief medical officer for healthcare epidemiology at the University of Pennsylvania Health System. She's been a faculty member in the Division of Infectious Disease at Penn Medicine since 2007, and currently holds the rank of professor of clinical medicine at Penn Medicine. She is board certified in infectious disease with more than 25 years of clinical experience in her specialty, and maintains an active practice in infectious disease, along with ongoing commitment to student and graduate education. Her specific areas of clinical expertise include hospital acquired infections, endocarditis, bone and joint infections, and sexually transmitted infections. Since the beginning of the COVID-19 pandemic, Dr. O'Donnell has been leading Penn Medicine's efforts around infection prevention, and has served on several committees and working groups over the last year to address all aspects of the pandemic. Hello, my name is Dr. Judith O'Donnell, and I'm going to be talking to you today about the 2023 updated COVID-19 vaccines. So to start off, I have no relevant financial disclosures, and I have no conflicts of interest regarding today's discussion topic. And I will not be discussing off-label or investigational uses of the vaccines today. I do also want to disclose something that's a little bit humorous, but also true. 50% of everything I'm teaching you probably is wrong, and the only problem is I don't know which 50%. And this is a quote from Sir William Osler, who's pictured here. And I came across this about a year into the pandemic, and I was struck by how very true it was and how applicable it was in particular to COVID-19. I look back on some of the presentations that I did in 2020 and 2021, and I do realize that a lot of what I talked about is either not relevant or frankly wrong at this point. And so I think it's just an important fact to remember that at one point in time, this may be cutting edge, but it could actually turn out to not be correct moving forward. And that's the beauty of science and the beauty of being able to move and move things forward with science and what we know. So today's talk will consist of several different areas, and I hope by the end of the talk, you'll have a clear understanding of each of these sections. I'm gonna talk a little bit about what is in the updated 2023 COVID-19 vaccines. I'm gonna talk a little bit about what some of those older 2021 terms like fully vaccinated and up to date mean in 2023 and 2024 and beyond. We'll talk about timing questions with respect to giving the COVID-19 updated vaccines. I will definitely go into some detail about vaccinations with special populations. These are the types of individuals who may have questions or have concerns or need additional dosing. And so we'll talk through that. I want to go over some of the counseling tips that you can use in your hesitant patients. We'll talk about co-administration with other vaccines, what's safe, what's not. And we'll talk finally about preparing for the winter respiratory virus season. One thing I won't be talking about today at all is pediatric use of the vaccines, dosing in pediatrics or other unique pediatric issues surrounding the COVID-19 vaccines. I am an adult infectious disease physician and I do not see peds practice. I don't practice in pediatrics. And so I don't feel like I'm an expert in being able to discuss that particular use of the vaccines. So top line, here's what you need to know around the 2023-2024 updated COVID-19 vaccines. And these are what you need to know directly from the ACIP. CDC is recommending that the 2023-2024 updated COVID-19 vaccines that include Pfizer, Moderna and Novavax protect against serious illness from COVID-19 and everyone five years of age and older should get one dose of an updated COVID-19 vaccine to protect against both serious illness and death from COVID-19. For those who are moderately or severely immunocompromised, they may qualify and we'll talk about this in more detail for additional doses of the updated COVID-19 vaccine. But these vaccines are work, they're effective, they protect against serious illness and hospitalization and death, and everyone five years of age and older can benefit from receiving one dose of the updated vaccine. So there are now two options regarding COVID-19 vaccines that we can choose from with two different technologies. So I'll start first with the mRNA technology vaccines, and those are the Moderna and Pfizer vaccines. So on this slide, talking first about the Moderna vaccine. This updated vaccine is a monovalent vaccine and it is targeting the XBB sub-variants of the Omicron strain of COVID-19. As we all know, Omicron rapidly took over at the end of 21 and into 2022, and has continued to evolve in sub-variants and has continued to really dominate in terms of what has been circulating across the globe. And so the XBB sub-variants were what was chosen back in the late spring, early June timeframe by the manufacturers to target that particular strain. The Moderna vaccine was FDA approved for use in early September of this year. And that's important because prior versions of the Moderna vaccine is certainly the original version. And at the beginning of the booster, bivalent vaccine version, it was under an EUA or emergency use authorization. The vaccines have subsequently been FDA fully approved and this updated strain is also fully approved. So you do not need to go into additional steps around use of an emergency use authorization product. These are fully FDA approved. The FDA has recommended in their approval that anyone who's previously vaccinated and 12 or older receive one dose of the updated Moderna 2023 vaccine. Never vaccinated people 12 and older also only need one dose of the updated 2023 Moderna vaccine. And the trade name for the Moderna vaccine is Spikevax. And I just want to remind everybody looking at the graphic on the right-hand side of the slide how the mRNA vaccine technology works. And what happens is a piece of the spike protein from the COVID-19 virus, the protein, the mRNA that is used to translate the actual development of the spike protein is enclosed in a lipid nanoparticle to keep it stable. That becomes the vaccine. The vaccine is injected with the mRNA encoded in the lipid nanoparticle. That lipid nanoparticle takes the mRNA to the antigen presenting cell. Once there it attaches, the mRNA is released. It then begins to produce the protein and that protein is then acted on as foreign and both B cells and T cell immunity then go into play to make the person immune. Now, the Pfizer vaccine is very similar. It's a monovalent vaccine, again, targeting the XBB sub-variants. It is also FDA approved as of September, 2023. And it has the same recommendations as the Moderna vaccine. If you've previously been vaccinated and you're 12 or older you need one dose of this vaccine now. If you've never been vaccinated and you're 12 and older you also only need one dose to be fully vaccinated. The trade name for the Pfizer vaccine is Comirnaty. Now, what about Novavax? So the Novavax vaccine is also monovalent. It is also targeting the same XBB sub-variant of Omicron and it was FDA approved for use in adults in October of 2023. Previously vaccinated people who are 12 and older and are recommended for one dose of Novavax. Never vaccinated people 12 and older are recommended for two doses of the updated Novavax vaccine. And in terms of the sequence of getting the first and then the second dose, the second dose is recommended to be given eight weeks after the first dose for never vaccinated individuals 12 and older. Novavax has two trade names, Nuvaxovid and Covavax. It's the same product. I believe the different names are for where it's marketed in different parts of the globe. And just to remind you, this is a protein subunit vaccine. So this is a very traditional vaccine development technology that has been used to create the Novavax monovalent COVID-19 vaccine. And the protein subunit vaccine is also using the spike protein from COVID-19 and it essentially picks up that protein. It actually encapsulates it and attaches it to an adjuvant that makes the components attached to your antigen presenting cells and then drives those antigen presenting cells to start to develop immunity both on the antibody side as well as T-cell immunity. And this is the same type of technology that we see in hepatitis B vaccines and pertussis and many others. And so this is a well-known and well-established type of technology. So you may be wondering, is this 2023, 2024 updated COVID vaccine a good match for what's circulating with respect to COVID-19 right now? And as I mentioned, it's the XBB sub-variants, specifically XBB 1.5. That particular sub-variant of Omicron emerged early in 2023 and became the dominant strain and continued to be the dominant strain really through the first half of 2023. But what's going on right now and what do we expect as we move into the winter and early 2024? Well, there's a good way to see what's going on by using the CDC's data tracker and specifically their NowCast data. And so the information that you see on this slide was downloaded from CDC NowCast data through 930 of 23. And what this is really telling us is that XBB 1.5, which is sort of, if you look at earlier in the bar graph, is sort of a cornflower blue color. That particular sub-variant has been going down in terms of the makeup of all COVID variants that are circulating in the US over time through the end of September. And what you see becoming more prominent is this mid-yellow color, EG.5, and that particular strain, EG.5, is becoming more common in the United States and is estimated to continue to become more common as we move through the remainder of the fall and the early winter. Preliminary data from both Pfizer and Moderna tell us that the vaccines are actually very good for this EG.5, as well as another sub-variant, BA 2.86, which is less common right now, but could take off in the near future. And neutralizing antibodies from patients with recent XBB infections have been looked at in the laboratory and have demonstrated good protection when you look at the EG.5 virus sub-variant in lab experiments. So these are not in humans, but we've been able to, scientists have been able to show that if you take the antibodies from someone who's recently had XBB and use those antibodies in a scientific lab environment, they show that they actually have good neutralization against the EG.5. And so with that data, as well as the preliminary data from the manufacturers, the answer is yes, this updated COVID-19 vaccine is expected to be a good match for what we see circulating now and into the early winter. Now, things could change. A new variant could quickly emerge and it could be different enough that we are not going to have a good match. So I don't wanna say it's 100% slam dunk, but the hope is that if things continue as we predict they will, this will be a good match and will provide good protection against serious illness, hospitalization, and death. You may be wondering why the manufacturers have made a monovalent vaccine for the updated vaccine as opposed to a bivalent vaccine. If you recall back to 2022, when the original vaccines were updated and the new vaccine was brought out to market in early 2022, that version of the COVID-19 vaccines were bivalent. And they targeted spike proteins from both the original coronaviruses that were from the original vaccine, as well as spike proteins from BA4 and BA5, which were sub-variants that were common and were being seen more commonly across the globe. So at this point in manufacturing these 2023, 2024 vaccines, the manufacturers looked at what was circulating and recognized that the original strains are long gone. And so there was really no benefit to putting that particular spike protein into a reformulated new vaccine. The other thing that we learned after we started using the bivalent vaccine was that the inclusion of the original strain may have diminished some of that bivalent vaccine's ability to produce antibodies to BA4 and BA5. And this is due to a sort of complicated phenomenon that I won't talk about much, but it's known as immune imprinting. And what it basically says, and you may have seen this because it did get a lot of lay media play as well, it's the idea that once your immune system or a person's immune system has seen an original strain, that it will continue to focus on that original strain and perhaps not make or recognize the newer strains that are only subtly different. And so for those reasons as well, it was determined that a monovalent approach for these updated vaccines was best. I do just wanna say though, that even though there may have been some diminished ability to produce antibody to the BA4, BA5 components of the 2022 bivalent vaccine, that booster was shown in many studies at this point to be very effective. It provided durable protection against serious illness, hospitalization and death for three or more months. It prevented, it's been shown and demonstrated in scientific studies that have been published to prevent emergency department and urgent care visits for COVID-19. It prevented COVID-19 related in-hospital death as well as hospitalization for COVID-19. So the benefits of the bivalent booster were real and we expect similar benefits with the updated monovalent. Now, as you're getting ready to administer the updated vaccine, you wanna counsel your patients about the common vaccine side effects. And so what are they? Well, first of all, there are local reactions and most individuals can expect some degree of a local reaction within the first 24 to 48 hours. And that includes pain, swelling and sometimes redness at the injection site. In addition to local reactions, there are systemic reactions and many people will have systemic reactions. They usually start within the first 24 hours. They usually last for about 48 hours at most and then they're gone. But those systemic reactions are not necessarily minimal. Individuals may have fever, fatigue, headache, chills and myalgias and arthralgias. They may not have all of those, but they may not make it one or two along with the local reaction. And so both the local and systemic reactions start within 24 hours are usually gone by 72 hours. And we should counsel our patients to expect some degree of local reaction and systemic reaction. In addition, there can be rare reactions and these usually happen within about a week and localized axillary adenopathy is one of those rare reactions that we should at least let women know about. And that is because this localized axillary adenopathy has been picked up on screening mammograms and has sometimes led to concerns about interpretation of mammograms. And so this localized adenopathy, we should just let people know about this with respect to the vaccine and timing of certain types of imaging studies. The other rare reaction I will mention, because again, we should just be aware of it. Some people with dermal fillers in their face, usually dermal fillers are used in cheeks or lips, that particular individual can get temporary swelling at the site of the fillers. And that's only associated with the mRNA vaccines. It is not associated with Novavax's vaccine, but it is something to let people know about in case they recently had dermal fillers. So one common question that I get a lot about the side effects of COVID-19 vaccines is this. I didn't have any side effects. Does that mean that my vaccine didn't work or that I need to go back and get another dose? And my answer to this is no, it does not mean that your vaccine didn't work. Everybody's immune systems are different and unique to them. Some people will have minimal or no side effects and others will have everything on the list that I just showed you. But that difference does not predict whether the vaccine is going to be effective and protective for that individual person. And so we just have to remind our patients, even if they had no side effects, the vaccine was still effective and is still going to protect them. They do not need an additional dose. What does fully vaccinated mean now in 2023, 2024? So let's kind of think through this going to the bottom of the pyramid. Originally, the foundation of COVID-19 vaccines was in 2021 and 2022. And fully vaccinated at that point meant that an individual had to have completed a series with the original 2020, 2021 Moderna, Pfizer or Janssen J&J vaccines. And the series had different numbers of doses for different people of different ages. And as long as they had completed one of those three series, they were considered fully vaccinated. Then in March of this year, the old original vaccines had been taken off the market for a while. The only vaccine that was out at that point, the beginning of this year was the bivalent vaccines manufactured by Pfizer, Moderna and Novavax. And during the early part of this year, March through August, you would be considered fully vaccinated if you had completed either a single dose of the bivalent Moderna or Pfizer vaccines, or you had completed the Novavax series, which was two doses. Moving forward, September on of 2023, fully vaccinated means completing a single dose of the updated Moderna or Pfizer vaccine, or two doses of an updated Novavax vaccine for individuals who've never been vaccinated before. So fully vaccinated now is just a single dose of an mRNA vaccine or two doses of Novavax as we talked about at the beginning of the talk. And I just wanna mention here, and we'll talk about it a little bit later, unvaccinated individuals who have by far and away all had at least one COVID infection by now will still derive benefit from receiving COVID-19 vaccination. And we should be encouraging those individuals to accept a vaccine. And we'll talk a little bit about why they might be hesitant and how we can counsel them to hopefully agree to a dose of the updated 2023, 2024 vaccine, and why it's actually good for them to do so, because there is real benefit for them to get a vaccine, even though they've been infected once or twice. So when your COVID-19 vaccinated patient asks, when am I up to date? What's up to date mean now? Up to date basically means now that you've had an updated vaccine dose. That's all it means. And so in 2023, 2024, what that will now mean is that if you're five and older, you've had one dose of an updated vaccine, whether it's Pfizer, Moderna, or Novavax. If you've previously been vaccinated, one dose of any of those three, and you're now up to date. A couple of things I do wanna mention, this may come into play with your work and what you do when you're onboarding new employees, especially in the healthcare settings. How do you track whether new hires have been vaccinated? So as we all know, on the right-hand side of the slide is an image of the COVID-19 vaccination cards that we all carry and still all had. And the CDC announced in September of this year that they will cease printing COVID-19 vaccine cards, and they are not requiring vaccinating sites to complete the latest dose on the vaccine card. So people may get rid of their vaccine cards, they may not carry them with them anymore. If individuals do bring their COVID-19 vaccine card to a commercial pharmacy, commercial pharmacies will still fill those out if they're brought in for the updated vaccine. But this could mean that on the hiring side, when you're onboarding someone, if they don't still have their card and they present, and they say that they've been vaccinated but don't have proof, how do you really adjudicate that? Verification of adult vaccination may be available through some state departments of health. So depending on what state in the United States you are practicing, you may be able to get that information. If your state keeps a good adult vaccine registry, you can query that registry and receive verification of a future employee's vaccination. If you are in a state though, that does not maintain an accurate registry or a COVID-19 vaccine registry, then you may run into some difficulties in trying to verify. And I just want to mention that there are no antibody tests that you can measure to differentiate prior vaccination from prior infection. And so there is not a way from a blood test perspective to confirm someone's reporting of prior vaccine. So if they have their card, they should present it. If you're in a state where you can get verification from an adult vaccination registry, you can try that. But if you don't have either, there is no other way to make that determination. What about the timing of giving these updated COVID-19 vaccines? There've been a lot of questions about this. And so let's break that down. All right, so if you are in the top box and your last dose, you want to know when the last dose of the person's bivalent booster was. And as we know, the bivalent boosters were on the market through August of 2023. So if somebody got a bivalent booster in the summer of 2023, they would need to wait at least two months before they would get an updated 2023, 2024 monovalent vaccine dose. They just won't get any benefit from receiving it sooner than that. The bivalent boosters are no longer available, so you don't have to worry about this as you get further and further out into the end of 2023 and into 2024. But this is a relevant question even right now because there may be patients who received a dose of bivalent booster in August and those individuals should not get vaccinated until at the earliest November of 2023. What about the person who's had a recent COVID-19 infection? As we all know, there was a late summer surge. It was really a national summer surge. So many people did get COVID-19 in late July, August and through early September of this year. If you are one of those people or if your patients are in that group of people, then they should wait at least three months until they get the updated COVID-19 monovalent vaccine. And I do wanna acknowledge that some immunologists actually think that waiting four to six months might be even better in terms of your immune response to the updated monovalent vaccine or to any vaccine after a recent COVID-19 infection. And so I think it's something that you would need to counsel your patient about and there's some nuances to this as well. I would certainly counsel individual patients based upon what I know to be their risk of severe disease. Certainly if they're immunocompromised, they would probably go sooner at like three months than waiting the longer period of four to six months. It could depend on what's going on in their individual lives, if they're traveling, et cetera, where you may wanna time the dose differently if they've had a recent infection 90 days ago. And finally, the last thing to take into consideration here would be if in three months from now or four months from now, if there's a new variant circulating, then you would wanna take that into account with respect to timing of the vaccine dose. Many patients are asking questions about timing their vaccine to maximize their protection. And my answer to that is really, if you're asking that question, you really should be getting vaccinated right now. October, 2023, November, 2023 are peak times to get vaccinated. Getting that vaccination in that timeframe is going to provide you with the highest levels of neutralizing antibodies for three months. And so it's really going to protect the individual right through the winter holiday and peak flu season. And so people who are asking should get the vaccine right now. I'm gonna switch into a conversation now about different special populations and how the updated COVID-19 vaccine will impact or what the recommendations may be for these special populations. And the populations that I'm going to go through are listed here around the slide, starting at the top, immunocompromised individuals, individuals who are pregnant, lactating, or have questions around fertility, persons with a history of or concern about myocarditis, persons with a history of or concern about Guillain-Barre syndrome, individuals who have allergies, either allergies to vaccine components or multiple allergies and individuals who have experienced or are experiencing long COVID now as the result of an infection or have had a history of multi-inflammatory syndrome in adults or Miss A. So we're gonna go through each of these groups one by one. I apologize for the wordiness of this slide, but there was really no way that I could get it to be less wordy. This is the list of individuals who are defined as moderately or severely immunocompromised or having immunocompromising conditions. These groups of individuals have a different recommendation in terms of dosing and redosing and additional doses than do the general population. So the people that qualify as moderately or severely immunocompromised include individuals who are undergoing active treatment or solid tumor or hematologic malignancies. Individuals who have a diagnosis of hematologic malignancies with poor responses to COVID-19 vaccines, specifically CLL, non-Hodgkin's lymphoma, multiple myeloma, acute leukemia. Individuals who've had a solid organ transplant or islet transplant and are taking immunosuppressive therapy. Individuals who have undergone CAR-T cell therapy or hematopoietic cell transplant within the last two years. People who have a diagnosed moderate or severe primary immunodeficiency such as common variable immunodeficiency disease, severe combined immunodeficiency, DeGeorge syndrome and Wiskott-Aldrich to name a few. Persons who have advanced HIV infection or untreated HIV infection, they're not on antiretrovirals, would be considered moderately or severely immunocompromised. Individuals who are undergoing active treatment with high dose corticosteroids defined as greater than or equal to 20 milligrams of prednisone or equivalent per day for two or more weeks, as well as individuals on alkylating agents, antimetabolites, immunosuppressive agents, cancer chemotherapeutic agents that are classified as severely immunosuppressive, TNF blockers and other biologic agents that deplete B cells. So that's a big list and it requires us to be informed of and what different drugs really are categorized here. All of this really is nicely outlined on the CDC's website and I have included that at the bottom of the slide. And the things that you need to know in addition to whether your patient does fall into one of these moderate or severe immunocompromising conditions categories is that when you're making recommendations about how to use the updated vaccine now in 2023 and 2024, you wanna know how many prior vaccine doses your patient has received, when they've received it and which type of vaccine they've received. All of that is really important. And once you have that information, you should go to the CDC website, which is linked here and determine the additional doses that may be needed for your patient as well as the dosing interval. It's different depending on what type of condition you've had, what type of vaccine you've had, when your last dose was. And so I can't really give you the details but I can refer you to the tables at the CDC website, which will guide you to the correct recommendations for this population of patients. What about individuals with pregnancy, lactation or fertility and COVID-19 vaccination? Here again, the CDC has an excellent resource that we should all be using as clinicians to help in familiarizing ourself with these particular clinical scenarios as they relate to COVID-19 vaccine. And there's a lot of good information that you can hand out to your patient who's pregnant about COVID-19 vaccine. So here's the high level information that we all should be very comfortable to discuss with any patients around this particular topic. In women who are pregnant, lactating or seeking to get pregnant and are concerned about their fertility, we know from scientific data that has been published that the COVID-19 vaccines are both safe and effective for use in individuals who are pregnant, lactating or seeking to get pregnant. Further, we know that the benefits of COVID-19 vaccination really outweighs the very small risks of side effects. There have been no studies that have suggested that the vaccination has led to an untoward effect on the pregnancy. Maternal vaccination has been demonstrated and published to protect infants who are zero to six months of age from severe COVID-19 and hospitalization. So moms who get vaccinated during pregnancy are providing protective immunity for the first six months of their infant's life. And that protective immunity is preventing that infant from developing severe COVID-19 requiring hospitalization. There have been several documented studies that have demonstrated that side effects are no worse in pregnant versus non-pregnant patients. And we can recommend acetaminophen for any of those post-vaccination symptoms that you will counsel your patients on. So we should really be encouraging vaccination for our pregnant and lactating female patients. And we should be encouraging individuals who ask about whether or not the vaccine will affect their fertility to go ahead and get the vaccine. Additional special populations. So what about myocarditis and COVID-19 vaccination? We do know that there is a real and measurable rare association side effect of myocarditis with all of the COVID-19 vaccines, including the Novavax protein subunit vaccine. When myocarditis occurs after vaccination, it usually occurs about seven days after the second dose. And it is usually seen in adolescent and young adult males, specifically between the ages of 12 and 39 years of age. So this is a real potential, but rare side effect. If an individual has a history of myocarditis unrelated to COVID vaccination, including if it occurred as part of their COVID-19 infection, then in those individuals, vaccine is recommended there's no concern in that setting. However, if an individual did develop myocarditis within three weeks of any dose of a prior COVID-19 vaccine, then additional doses, including with the updated vaccine, are generally not recommended. And so if you have an individual who has a documented history of myocarditis within three weeks of a prior COVID-19 vaccine, that person is not recommended to go ahead and get the updated vaccine. One quick caveat though, there could be some patients in special populations with a very high risk of severe COVID-19. So for example, some of those very severely immunocompromising conditions. And in those patients, there could be a conversation about risk versus benefit. And then you could perhaps, you could perhaps move forward with getting a dose, even though there has been a history, but it is a very, it's a joint decision-making in special populations risk benefit type of conversation. Now, what about the person who has a history of Guillain-Barre? There has been no association with the mRNA vaccines and subsequent Guillain-Barre syndrome. So if a patient raises concerns because they've had a history of GBS, they should still feel comfortable and we should still be recommending that mRNA vaccines can safely be given. There's no association. They can go ahead and get the vaccine. There are no data about Novavax vaccine and Guillain-Barre. So I can't say anything about that at this time. Additional special populations, individuals with a history of multi-inflammatory syndrome in adults, history of MIS-A. So what do we think about these folks? So this is a rare complication of COVID-19 infection, and it's really a dysregulated immune response to the infection. It's rare, especially in adults. We are seeing it even less now than we did in the first two years of the pandemic. And that is because we know that in individuals who are vaccinated, they're less likely to develop this. And many in the population have now been vaccinated and infected. And so we suspect this will happen less commonly as time goes by. But for those who have had a history of documented MIS-A, the benefits of vaccination still outweigh the theoretical risk of developing a MIS-like illness after vaccination. And so the vaccines are recommended as long as the individual has clinical recovery from MIS-A, including return to normal cardiac function if that particular organ system was infected, and as long as 90 days have passed since the diagnosis of MIS-A. And so if you're beyond three months, the patient's clinically recovered, and they're coming in now for an updated COVID vaccine conversation, you can feel confident in recommending getting an updated COVID vaccine now. What about the groups of people who are suffering from long COVID? Well, this is a complicated topic, and I don't have time to go into all of the details, but I do wanna share these particular points. Multiple studies have now demonstrated that being vaccinated for COVID-19 reduces individuals' risks of developing long COVID after a COVID infection. And there are two different studies, including the RECOVER study published in Nature Communications, and a separate study published in JAMA Internal Medicine that have shown those data, and they are persuasive. And so for individuals with a history of long COVID, especially if the long COVID occurred in the context of their original infection before there were any availability of vaccines, most long COVID experts do recommend vaccination with a risk-benefit discussion, but we should acknowledge that at this time there are little research data available. So for individuals who had long COVID after a 2020 infection before there was any vaccination, there probably should still be a conversation about the benefit of vaccine. And at this point, we do recommend that the studies are demonstrating that being vaccinated reduces the risk of long COVID. And so if somebody has not had long COVID, they really shouldn't understand that getting vaccinated reduces their risk of subsequently developing it should they get a COVID infection in the future. Moving to patients with allergies and COVID-19 vaccination. So what does the CDC say now about how we manage patients who have histories of allergies? So in this table, at the top of the table, you've got medical conditions, CDC classifications and guidance, and CDC recommendations. So let's start with individuals who have a history of anaphylaxis or a severe allergic reaction after a previous dose or to a COVID-19 vaccine component like PEG. So if an individual has a documented history of anaphylaxis or a severe allergic reaction, they are contraindicated from getting that vaccine that has previously given them that type of a severe reaction, or if they are known to have an allergy to one of the components. So the recommendation for those individuals is that you do not vaccinate that person again with the same COVID-19 vaccine type, but you can give an alternate vaccine. So for example, if somebody has had an anaphylactic reaction to an mRNA vaccine, they are okay to receive a Novavax vaccine. It's a different type of technology, different component and makeup of the vaccine, and there shouldn't be any cross-reactivity. For individuals who've had a non-severe allergy to a COVID-19 vaccine component, there's a precaution, but you may administer the alternate vaccine type for those individuals. And for individuals who had a non-severe, immediate onset, less than four hours allergic reaction after a previous COVID-19 vaccine dose, again, it's a precaution, and now that we have an alternate type, you can give the alternate type. The bottom half of this slide, the second box defines severe allergic reaction and non-severe allergic reaction. Severe allergic reactions are defined as anaphylaxis, hives, shortness of breath, wheezing, angioedema of the airway, hypotension, or Stevens-Johnson syndrome. Any of those would qualify as a severe allergic reaction and would lead to a contraindication with that particular product. Non-severe allergic reactions, either immediately or delayed, are urticaria beyond the injection site, lip swelling, facial or skin angioedema, but not angioedema of the airway. And so those are the definitions. If you've got patients with allergy histories, how do you really manage them when you wanna try to discern what to do? I think the main takeaway is that now that we have two different vaccine types, it really helps us in having these conversations. Individuals who have not been able to tolerate or have had these reactions to the original mRNA vaccines now have the availability of Novavax. And so that vaccine does not have cross-reactivity. It's a totally different vaccine type. And I would drive patients to that vaccine for COVID-19 vaccination. Excuse me. When you are giving a patient who has had a prior allergy, even a severe allergic reaction, a different type of vaccine, you do not need to provide special observation period. You do not need to have a special setting. Those individuals receiving an alternate vaccine can get vaccinated anywhere in any flu or vaccine clinic, and there's no need for special observation when they're getting an alternative type of vaccine. I do wanna mention that if you have the availability to consult with an allergist immunologist, you should do so in these complicated patients. Further, the American Academy of Allergy, Asthma, and Immunology has a very helpful website with resources that are directed towards allergists and immunologists, but actually have a lot of good information for the rest of us. And so if you're curious, or if you know you're going to be having a conversation with a patient with allergies, take a look at this website. They provide some very nice information that can help you in having conversations with your patients with multiple allergies. The other thing I'll mention that is available to clinicians is this. If there are difficult, unusual, or complex questions about COVID-19 vaccination, the CDC provides consultation for healthcare professionals with these complex vaccine safety questions. And to do so, you simply visit the CDC's website, and I've included the information here on this slide, and you actually can request a clinical consultation from the CDC through submitting a form, and they will get back to you. And the form does have a lot of detailed information in it that you would need to put in, but you would then get a call or response back from a consultant at CDC. This is a nice additional resource to have if you're really stuck with a conundrum. Now, what about counseling on vaccinated patients? We touched on this a little while ago when I showed you my pyramid slide of what fully vaccinated means now in 2023, 2024, but I want to dive into it a little bit more. First of all, top line, people who are unvaccinated should understand that we now know these vaccines are safe, and they are effective, and they provide real-world health benefits. Just to drive that home, individuals should understand that between December of 2020 and March of 2023, more than 672 million doses of COVID-19 vaccines were given just here in the United States. That number goes into the billions when you think about the global use of COVID-19 vaccines. These are one of the most widely used products ever in the history of medicine. So we have lots and lots of real-world experience and data with these products. We know that they're safe because they've been used in billions of people. So this is really, I think, one important point to help your patients when they're weighing their concerns because they're not vaccinated. Really letting them understand how common and how widespread this product has been used and how safe it's been should be reassuring, point number one. Point number two when you're counseling patients is really to get them to understand that getting a COVID vaccine even after you've had COVID really does provide added protection against the virus that causes disease. The type of immunity that an individual may produce after they've had an infection is variable. Different people have different immune systems and those immune systems respond differently. It is not, and there's no way of knowing that. But what we do know is when we give a vaccine in a prescribed dose, we can expect a prescribed response. And we know that the vaccines make a good amount of neutralizing antibody. And so individuals should understand that there's real benefit to getting a COVID vaccine even if you've had COVID infection once or twice in the past. Moreover, there are data that you can show to your patients that tell us that if you have had COVID and remain unvaccinated, you are more likely to get COVID again as compared to individuals who were unvaccinated, got COVID and then got vaccinated. So those data exist. The COVID-19 vaccine causes a more predictable immune response than an infection. And so it really does provide predictable protection moving forward. What about patients who have specific concerns about mRNA vaccines? We have heard from all of these patients many times now. I just wanna point out what is in the mRNA vaccines. And we touched on this at the top of the talk. First component is the actual piece of messenger RNA that is then wrapped in the lipid nanoparticle. So you've got your piece of messenger RNA, you have your lipid nanoparticle and then you have some sugars and acid stabilizers to keep the product safe and stable during storage. That's it, that's what's in there. I've listed each of them in detail and what the purpose is. There is nothing else in there, but just to drive that home because there've been a lot of misinformation and disinformation spread about mRNA vaccines. Neither the mRNA vaccines nor the protein subunit vaccine made by Novavax none of them interact with or change your DNA. They do not contain any preservatives like thimerosal or mercury. They do not contain antibiotics. They do not contain tissues like aborted fetal cells, gelatin or materials from animals. They do not contain food proteins like egg proteins, nut proteins or gluten. They do not contain latex even in the packaging and they do not contain metals. You're not gonna be magnetic. There's not a tracking mechanism. There is nothing in these vaccines other than what's listed on the right-hand side of the slide for the mRNA vaccines. If your patients are still concerned about mRNA vaccines, then you really wanna drive them to getting vaccinated with the updated Novavax COVID-19 vaccine. This is, as we've already talked about, a protein-based vaccine. This is an older traditional vaccine technology which you can highlight to your patients, acknowledging that they've already been vaccinated with vaccines that have used this exact type of technology to get immunity to a pathogen. Hepatitis B vaccines, influenza vaccines, pertussis vaccines all use protein subunit, protein-based technology. The adjuvant that Novavax uses to drive the immune response and get a reaction to the product is something called Matrix M and it comes from saponins which are naturally occurring compounds derived from the bark of a soap bark tree. So there's really not much in these vaccines that should be of any concern. And as in the prior slide, the Novavax vaccine contains none of those additional things that people may be concerned about. So if you have a patient who remains concerned and unwilling to get an mRNA vaccine, they really should be considering strongly getting vaccinated with the Novavax 2023 updated vaccine. If they have never been vaccinated, then it's two doses, three weeks apart. If it's previously vaccinated, it's a single dose. Now we're gonna move into how you may want to manage individuals who have not been vaccinated but who are working in healthcare. In the past, we've used three different mechanisms for these types of individuals, including testing, masking and social distancing at work. At this point in time, most programs that I know of have really stopped doing routine testing for their vaccine exempt healthcare personnel. So that is a technique or a strategy that you can use, especially if we have another wave of infections, you could bring this back. But right now, I think most places are not using this. Masking does become the key strategy for managing your COVID vaccine exempt healthcare personnel. It's very effective both at keeping your employees safe as well as keeping the patients or others who they're working with safe from them in case they get COVID-19. And so masking has become more of the cornerstone now of managing both flu vaccine exempt and COVID-19 vaccine exempt healthcare personnel. Social distancing at work still is beneficial. We do recommend it. We can't police it, but individuals who are vaccine exempt should try to socially distance at work. And this could include eating alone as opposed to in large groups. The other things that you can do, certainly if you get into, again, a big wave of COVID would be to consider reassignments, whether reassigning them with a less compromised patient population or reassigning them outside of clinical work altogether. So that's the other strategy that you can try to use when trying to keep your vaccine exempt healthcare personnel in the workplace, but safe for them and safe for your patients. In terms of preparing the workforce for the winter respiratory virus season, our goals are really twofold. We want to keep our workforce free of respiratory illness so that we limit employee absences. And we also want to prevent the transmission of respiratory viruses from employees to patients or other vulnerable populations in healthcare settings. So the tools are really the same more broadly, just like they are specifically in the COVID-19 exempt personnel category. The tools that we would use during winter respiratory virus season to maintain these two goals of keeping our workforce healthy and preventing transmission of viruses within the healthcare setting are masking, testing for COVID-19 and influenza, both among employees and patients and managing workplace meetings and gatherings. And so these tools are things that you can use one or layered upon each other to try to maintain a really safe winter respiratory virus season in your particular healthcare or workplace setting. Finally, the last thing I'm gonna touch on is co-administration of COVID-19 vaccines with other vaccines. And I've listed in the chevrons on the left, the different vaccines that have come up most commonly over the last couple of years. And the questions have been raised about co-administration with COVID-19 vaccines. So you can safely co-administer your COVID-19 vaccine and your flu vaccine. You can safely co-administer COVID-19 and RSV vaccines. And you can safely co-administer COVID-19 vaccine with Tdap. Couple of points. We know that there's safe co-administration with flu. Generally given in the other arm, one arm gets flu, one arm gets COVID. There shouldn't be any doubling or tripling of side effects, but people just need to be aware. You should expect some side effects with COVID-19. If you've had prior flu vaccines where you've had a fair amount of symptoms, you may be getting symptoms from both. So patients should just be aware when they're getting both at the same time that they could have two sore arms and maybe feel lousy for 24 or 48 hours if that's what they've experienced in the past. But we know that they can safely be given together. And we know that the efficacy is not diminished when they're given together, most importantly. So if it works for the patient and they wanna get them at the same time, it's safe to do so. What about RSV? As the slide states, it is safe. As you know, these are newer vaccines just coming out onto the market in the last year. These vaccines, there have not been as much data about co-administration because RSV vaccines are so new, but CDC and others are recommending that you can safely co-administer them. Last thing I just wanna mention, the final chevron, is the Jynneos smallpox vaccine. And many of us began administering this vaccine as a way to prevent monkeypox or mpox from spreading in our communities. This is a vaccine that has been used for smallpox, but has now been shown to be beneficial in preventing mpox. There is no required interval between administering Jynneos smallpox vaccine and a COVID-19 vaccine. However, there is a small risk of myocarditis in young adult males when given the Jynneos smallpox vaccine. And as we've talked about already, there is a similar risk, small but known, of myocarditis in young adult males who receive a COVID-19 vaccine. And so CDC and others recommend that you may wish to separate the dosing of a smallpox vaccine and a COVID-19 vaccine by four weeks. The good news is that mpox has really, for the moment, essentially disappeared, so we are not doing a lot of smallpox vaccination at this time, so this shouldn't be a big issue, at least right now, this fall, across most places in the United States. But I do wanna mention it because it is a conversation you should have for that patient who may need both. And at this time, I am going to end and we'll go into our question and answer period. Thank you so much. Thank you so much, Dr. O'Donnell, for this up-to-date, informative, amazing talk. I see we have quite a few questions in the chat. I'm not sure what the hosts want to do necessarily. We did run over time a little bit, but the first question I see is, if you had one manufacturer's product previously, is it as effective and safe to mix them on a subsequent booster? Thank you, Dr. McKenzie, and thank you for that first question. And it is safe to mix products. There's no downside to doing so. And it has been shown that efficacy when you're switching products is essentially similar. So you don't have to stick with just the same product that you got back in 2020 or 2021. You can feel free to mix. Okay, cool, thanks. I'm gonna go with the Q&A first. There are some in the chat, but the next one in the Q&A is, how should we think about revaccination in 2024? Especially for high-risk people, should they be revaccinated every six months? That's also a really good question. Thus far, CDC and the manufacturers have not provided any specific guidance with the updated vaccines. However, I expect and anticipate that they will do so in the next few months. As we all know, and as I mentioned in the talk, people with immunocompromised conditions do benefit from additional doses because they do not maintain high levels of neutralizing antibodies for as long, and they don't have as much of a T-cell immune response to the vaccine. So what I would say is that we should keep an eye, everybody who's interested in that should keep an eye out for updates from CDC as we get into early 2024 about redosing. Okay, awesome, thank you. Do you have any further info on rate of adverse effects reported? Shoulder pain following high injection delivery is not uncommon as a presentation to workers' compensation clinics. Any information on neck pain following injection? Any resources to look into? I don't have any specific resources that I can think of off the top of my head. You know, the main adverse reactions were the ones that I did outline on that slide that I addressed earlier in the talk. Most of the time, the site of injection soreness or swelling or pain does fully resolve. I do recognize that sometimes if the vaccine has been delivered a little bit higher, patients may get more persistent shoulder pain, but I don't know that I can give you any resources right now. I would certainly direct people who are interested to start at CDC. The website is full of really useful information, although sometimes you have to scoot around for a while before you find what you're looking for. It can be a little bit challenging to navigate, but you will eventually get that information if you keep looking. Thank you. And I would just wanted to add about a two high. What we did in our clinic was we posted exactly where the injection should go, and that dropped our rate tremendously. I would say almost a zero, but of course it was just sort of a observational type of a thing. And the last question I see here is when you say masking for aerosols, do you mean fit tested for N95s or better is the question? Okay, so I'm assuming that means when we were talking about masking for vaccine exempt personnel. And we are actually, most places are recommending a well-fitted surgical mask as the minimum masking requirement for employees who are COVID-19 vaccine exempt. Certainly the individual may choose to use a fit tested N95. I would not recommend a higher level of respiratory protection such as a PAPR. I think that would be probably not feasible to come to work eight hours a day and to wear a PAPR, but employees who are vaccine exempt can wear a well-fitted surgical mask as the standard masking. And that has been shown to be reasonably effective and also in most cases more comfortable to wear for long durations of general care. Okay, great. I think that's the last question. Thank you so much. And I did appreciate your first comment about us not knowing everything all at once as we learn more and the message changes, which is a good thing. We get better. So thank you so much, Dr. O'Donnell. Thank you for having me. Our next speaker is Dr. Robert Harrison. He will present on silicosis and engineered stone. Dr. Harrison is a public health medical officer with the California Department of Public Health Occupational Health Branch and a clinical professor at the University of California, San Francisco in the Division of Occupational and Environmental Medicine. He established the UCSF Occupational Health Services where he has diagnosed and treated thousands of work in environmental injuries and illnesses. He has designed and implemented numerous medical monitoring programs for workplace exposures and has consulted widely with employers, healthcare professionals, and labor organizations on the prevention of work-related injuries and illnesses. Dr. Harrison has led many work in environmental investigations of disease outbreaks. He has served as a technical and scientific consultant at Federal OSHA and CDC NIOSH and was a member of the California Occupational Safety and Health Standards Board. His research interests include the collection and analyses of California and national data on the incidence of work-related injuries and illnesses. Dr. Harrison has authored or co-authored more than 70 peer-reviewed journal articles and more than 50 chapters, contributed articles, and letters to the editor. He is the co-editor of the most recent edition of the Textbook of Occupational and Environmental Medicine. Hello, everybody. It's great to be with you and to share my presentation about lung disease caused by engineered stone. Or another way I could title this is how our kitchen countertops are causing severe lung disease in the workers who are fabricating them. I have nothing to disclose. So the story really starts here. This is one of a very well-known big box store. And if I'm ready to renovate my kitchen and I want a new kitchen countertop, I would walk into this store and I would look at one of these samples. You can see that they're about a foot square, each one of these little samples here. Or down here, I can buy smaller chips and there are drawers here down below. And I can pretty much get a very, almost infinite variety of different colors and designs of this kitchen countertop. And it goes by various names. They're manufactured by several large global manufacturers who sell in this big box store. Sometimes they're known as Caesarstone generically, but in fact, Caesarstone is a manufacturer. You can also buy products made by Cambria, by Cosentino, a large Spanish manufacturer, and by over 50 companies around the world that sell these products. They come from a combination of 95% fine silica sand that's mixed with a 5% concentration of an epoxy resin binder. This product was invented in 1975 by an Italian manufacturer by the name of Breton, that's B-R-E-T-O-N, and their engineer, Marcello Tancelli, developed a process called vibro-compression under vacuum. These products are mixed together and placed in large molds and then in a high temperature oven where they're slightly shaken and put under vacuum. And then when they're cooled, becomes this very hard scratch and stain and chip resistant surface. Since 1975, this particular Breton patent has been licensed by dozens of global manufacturers who sell it under various brand names with different designs and colors and patterns. But if I go into this big box store and I pick out one of these patterns, I'm picking out the same product in terms of the same ingredients. The fundamental formula of these products is almost exactly the same and they contain very high amounts of silica. So then I go back and I check out and I buy the product by the square foot. And sometime in the next few weeks, a contractor will come to my home and take a template of my counter. I'll get the design and the measurements. And then a few weeks later, we'll come back with the countertop with the kitchen sink cut out and the rounded corners, the dimensions that exactly fit my kitchen. What I don't typically know as a customer or consumer that there are workers who are cutting and grinding and polishing these big slabs that get imported from around the world and are covered in and are exposed to very large amounts of fine silica dust. Here's a photo taken by a award-winning photojournalist, Earl Dotter. Earl has been covering occupational health for over four decades now, has many books that have wonderful photos of workers. Earl got his kitchen counter replaced and he went out and followed the job from the warehouse to the fabrication to the installation in his home. And this is a photograph that Earl took of a worker who's sitting in the middle of a kitchen cutout. You can see that he's polishing and rounding the corners. He's wearing a half-face mask cartridge respirator. You can see that he's covered with this very fine white dust that has very high concentrations of crystalline silica at a very fine particle range that can be inhaled into the alveoli and cause interstitial fibrosis or silicosis. This particular respirator that he's wearing is also covered with dust. I'm not completely convinced of the adequacy of the face seal. If you look over here, you can see the two cartridges right here. Hopefully that he's been fit tested, but if he has to wear this for six, eight hours a day, this is particularly difficult. And when he takes it off, you can just see the general housekeeping here. There's no local exhaust ventilation and there's no water that's being sprayed onto the surface. So he's doing what's called dry grinding, which is particularly hazardous. Since this product was invented in the mid 1970s and began to be licensed first by Caesarstone in Israel, and now by, as I mentioned, dozens of manufacturers, it's taken the lion's share of the countertop market in the United States and in many other countries. I don't have great estimates on the percentage market share, but I've been told by people in the trades that it may be up to 60 to 70% of the product that's now being purchased. So natural stone, which is granite and marble, has between about a 30 to 50% silica content. So about half that of engineered stone. But granite and marble are now a much smaller percentage of the market since engineered stone has taken over. You can see here it's upwards of 600%. So in 2012, a paper was published in the journal Chest by researchers from Israel at Tel Aviv at a major medical center. They published a case series of 25 patients, all of whom were evaluated or had undergone lung transplant for severe silicosis. They described a rapidly progressive, very severe form of the disease. Some of the cases have what's called progressive massive fibrosis or alveolar prognosis, a very aggressive terminal without lung transplant form of silicosis. The very first case in that series was in 1997. And the last case was in 2012. And over those 15 years, they had seen 25 cases. They were all stone cutters. They were all fabricating engineered stone in Israel. And they were primarily using Caesar stone. And in fact, the original title of that paper was called Caesar stone silicosis. The journal Chest though retracted and altered the title of that paper after pressure from the Caesar stone manufacturer. I read that paper in 2012 and along with colleagues from the National Institute for Occupational Safety and Health published a blog in 2014 called Silica Hazards from Engineered Stone Countertops. And in this blog, we called attention to quartz surfacing materials that contain right here, you can see up to 93% crystalline silica. And we asked basically has anybody in the United States seen a case of silicosis from engineered stone? Lo and behold, I'm sorry, let me go back here. Gary Friedman, who's a pulmonary specialist in Houston wrote into the NIOSH blog and said, yes, I am examining a case, I'm treating a case of very severe silicosis and he works in a stone fabrication shop. I contacted Dr. Friedman and in the following February, he and I and colleagues from NIOSH and New Jersey wrote the first case published in the United States of silicosis in a countertop fabricator. And this was in Houston, Texas. This particular gentleman is featured right here in the upper right in an article that was written in the New York Times in April of 2016, which is the year that Federal OSHA updated the silicosis standard. What Federal OSHA did was drop the permissible exposure limit from 100 to 50 micrograms over an eight hour shift and from 50 to 25 as a short-term exposure limit. And this particular gentleman was looking at his X-ray and was featured in that story. He happened to work at Cosentino, which is the largest Spanish stone manufacturer. They had a fabrication shop in Houston where he was working. And so that was in 2015, that note's from the field. And my colleagues and I at the California Department of Public Health began to look for cases of silicosis in engineered stone fabricators in California. And in 2019, my colleague, Jennifer Flatter, an epidemiologist, was looking at the hospital discharge records in California. Every time somebody is hospitalized, they get a diagnosis that's recorded and sent to a state database. It takes about a year and a half before that data is processed and gets to our department. And in January of 2019, I actually will probably never forget when Jennifer emailed me and then walked over to my office and said, I have a question. She emailed me and then walked over to my office and said, Bob, we have a young man with silicosis. Maybe he's a stone, an engineered stone fabricator. His hospital records indicated he had been hospitalized and discharged in 2017 for silicosis. We got his medical records and interviewed the next of kin because it had turned out that, I'm sorry, that in 20, I guess I don't have it on the slide here. In 2013, he was diagnosed with silicosis. He was hospitalized in 2017, but had died in 2018. And so when we interviewed his brother, he told us he had been employed at a stone countertop fabrication shop beginning in 2014. And his brother told me that his other brother worked with him in the same shop and he thinks he had also died of silicosis. But the doctors told him on his autopsy that he had a big heart and he died of heart failure. We were able to retrieve his autopsy result. That showed that on autopsy that his lungs were very hard to palpation. There was no microscopic pathology done on the brother's autopsy. And we were able to retrieve the pathology from the coroner's office after tracking down his father who was in Guatemala, getting permission and having the pathology analyzed by a colleague, Dr. Kurt Jones at UCSF, who confirmed the diagnosis of silicosis. So we had two brothers died of the same severe disease in the same shop. So that led to a 2019 morbidity and mortality report publication, along with colleagues from three other states who were starting to see these cases emerge in Colorado, Texas, and Washington. And we published 19 cases in September of 2019. At the same time, we referred this to Cal OSHA who launched a statewide inspection program of stone countertop fabrication shops in California and look to see how many of these shops had exceeded or were exceeding the OSHA permissible dust levels. You can see it here of 50 micrograms per cubic meter of air. And we're complying with all the other necessary elements including dust controls, training, offering medical examination, keeping records. And you can see here the results of the Cal OSHA 2019 inspection program. This was compiled by a colleague Krishna Sarasi when he was an EIS officer. Cal OSHA inspected about a hundred companies of which 47 had more than one exposure measurement for silica dust. Half of those 47 had one or more exposures above the permissible exposure limit. 15 had one or more exposure above the action limit and the permissible exposure limit. So a total of, you can see 31 of the 47 companies exceeded OSHA standards. You can see here on the slide that some of the samples were incredibly high, okay? Here's the 50 limit. Some of these were just absolutely off the chart. So very dusty shops consistent with the photo that I showed you from Roald Dauter. 92 workers were interviewed by Cal OSHA. All of them were young. They were all had worked less than four years. A quarter were cutting the stone dry and none had undergone silica medical exams. They had never had a test, no chest x-ray, no spirometry, no questionnaire. So something little happened in February of 2020, and of course that was the COVID pandemic. And I put our research, our investigations on hold for the next three years, although I was checking in with the trade association and asked them, how is the stone countertop business going? Are people still installing kitchen countertops? Are workers still employed in this industry? And the answer was, now more than ever, because as you'll remember, there was a lot of home renovation during the pandemic. And in fact, the challenge of many of these companies was really just not even being able to find enough workers to fabricate kitchen countertops. So in May of 2022, Dr. Jane Fazio, who's pictured here in this photo with her attending, Dr. Kamangar. Dr. Fazio is a pulmonary fellow at UCLA. And her clinic is at UCLA Olive View, which is the county affiliate in Northern Los Angeles. And Dr. Fazio, as a pulmonary specialist at the county hospital, also bilingual, began to see patients with silicosis from the stone fabrication shops in Los Angeles. Probably 15 or 20 within a five mile radius of the county hospital. And Dr. Fazio met us at an American Thoracic Society meeting in May of 2022. I have to say it was almost serendipity, although we both had mutual research interests. And Dr. Fazio has really become the center of what has now emerged as the largest epidemic of silicosis from this product in the United States. Between May of 2022 and August of 2023, when we published this paper in JAMA Internal Medicine, there were 52 cases in total of silicosis among countertop fabrication workers. This is different, as I mentioned, from the usual simple silicosis, the slowly progressive mild form of the disease. These patients have progressive massive fibrosis, 15% fatality rate. You can see here, chest CT of a very, very extensive reticular nodular disease with fibrosis in the lower right hand side of this slide is what I call the epidemic curve. From the paper in August of 2023, you can see these 52 patients, the first one we identified at CDPH actually was initially diagnosed in 2010, although we didn't uncover this case until much later, and the last cases in 2022. And you can see the shape of this epidemic curve matched with the shape of the epidemic curve in the chest paper in 2012, the first case in 1997, the last cases in 2010. And they look like basically I could overlay one on top of the other. And this is Israel, and this is California. What's common between these two is the marketing of engineered stone to the consumers, the rapidly progressive nature of the disease due to massive and toxic exposure to silica dust among these fabricators. As of today, when I present these cases to you, we're now over 90 cases in California of silicosis. And I think we're on track by early 2024 to be over 100, which would be double the number that we reported in the August JAMA paper. So that epidemic curve is going to rise even more steeply. And I expect will continue at its current pace, given the widespread sales of this product and the large numbers of workers in California who are fabricating. We estimate that there are over 1,000 shops in California and over 10,000 fabrication shops nationwide, with an estimated 100,000 workers who have been exposed or are now exposed to silica dust from engineered stone. So what do we do? The first in the hierarchy of controls is product substitution. That is manufacturing and selling a product that has 95% silica with 5% epoxy resin. The toxicology evidence is becoming quite clear that both the particle size distribution, when the product is sanded and ground, along with the epoxy resin, changing the charge characteristics on the crystalline silica particle, is leading to much greater toxicity than natural stone. So finding ways to substitute this product with something that's non-toxic, Cosentino has manufactured a product that has 10% or 40% crystalline silica. The other 90% or 60% contains a mixture of other stone. We don't know yet whether that product is less toxic than 95% engineered stone. We would need to see toxicology and air monitoring data before determining whether that's the case. That has not been provided by Cosentino, the manufacturer, or submitted to any regulatory agencies. Breton, remember I told you that this product was patented by Marcello Toncelli in 1975. Breton has recently released a silica-free product. Their website is promoting this as the answer to silicosis worldwide. But again, until we have toxicology or air sampling data, the jury will still be out. But certainly product substitution would be number one. Next would be community employer and worker outreach. You can see that one of Dr. Fazio's patients on the left, he was waiting for a lung transplant. He had lost about 100 pounds, was on oxygen. This particular gentleman was working for himself. He was what I would term in the informal economy. He would get calls from contractors and ask them to fabricate a slab. He would pick it up from the wholesaler, take it to a shop that he rented, brought his own tools, and would deliver it back to the contractor and get paid cash. So he had no health insurance, was not covered by workers' compensation. We were able to get him on a limited access Medicaid, or we call it Medi-Cal, in California. Dr. Fazio referred him to Cedars-Sinai, and he underwent a lung transplant, and you can see on the right what he looks like today. So we saved his life with a new set of lungs. But this is obviously not a solution. There are many workers who have died waiting for lung transplants. The cost of these transplants are picked up by the taxpayers, not by the responsible insurance carrier. So this is clearly not a solution. So we need to get the word out there to find these cases early, to get exposures under control early, to register these shops and enforce. And let me talk a little bit now about registration. This is the concept that if a manufacturer is selling their product in California or anywhere else in the United States, that they should ensure that their product is only being fabricated in shops and by workers that protect them from silicosis. So this can also be called product stewardship. There are many examples throughout the world of large companies taking responsibility that their products are utilized safely. And I urge the manufacturers to take responsibility in the same way so that if I'm a consumer, if I'm a homeowner and I'm wanting my kitchen countertop to be installed, that I would know that the workers who are fabricating my kitchen counter are doing it safely with all the necessary precautions and protections. That has to be accompanied by enforcement. So there is a strict set of silica standards on the books, and there's going to be an emergency standard in California, I'll show you that in a minute, providing education and assistance to small shop owners to help them comply with the OSHA silica regulations. The manufacturers globally, when this product was invented and it began to be marketed, utilized the existing system of fabrication of stone. So it was marble and granite that was being fabricated. Engineered stone then begins to be fabricated in the same shops using the same tools, the same technologies for marble and granite. Well, these tools and technologies are not adequate and adapted to the toxic nature of engineered stone. And the workers, the same labor force, largely immigrant workers who are in these fabrication shops begin to use engineered stone, but in the same way, and unknowingly become the victims of this new product. Very few workers have undergone medical testing based on the OSHA required silica standard for medical testing. There are many obstacles to getting medical testing, including a fear that there'll be an abnormal result and that there might be job loss because if somebody has silicosis, their doctor may say, well, you can't work in that shop any longer, which may be one of the proper advice to give. And then the worker can no longer work. And moreover, there's a pretty tight network between shops, word of mouth, and that worker may not be able to get a job anywhere else. So there's an unintended consequence of medical testing. There are also just very simply obstacles to finding a clinic or a doctor who knows how to do OSHA required silica medical exams. And then finally, making sure these cases are reported. In California, we're in the process of making silica a mandatory reportable disease. This is going to be the first non-infectious reportable condition in California. Some other states have silicosis reportable. In California, it's been reportable only if there was a diagnosis and a worker's compensation claim filed. But now it's going to be just like the many infectious diseases and become a reportable condition. This will allow us, I think, a good entree to do healthcare provider education. And then finally, the importance of social media outreach. This was a paper. Sorry, this was an article published in December of 2022. You can see that at that point, there were 30 who had been diagnosed in the Los Angeles area. I think in LA alone, I think we're over 60 cases since this article was published in December. Dr. Fazio did a Univision interview that has 2 or 3 million views and reached, I think, a really important target audience among the shop owners and the worker fabricators. We've initiated a really important partnership with Los Angeles County Department of Public Health. This is a Google map that portrays where all the stone fabricator shops are located or many of them. UCLA Olive View Hospital is at the very top of this map. And you can see that there's not an even distribution of fabrication shops in Los Angeles County. You can see that there are many of them located along literally a single street or series of streets. And this is in the San Fernando Pacoima area. The LA County Department of Public Health has contracted with a community organization called Pacoima Beautiful. They've done trainings of their staff and they are sending their public health outreach workers to drive or walk the neighborhoods and do health education at the street level inside these shops. The Western Occupational and Environmental Medical Association, of course, a chapter affiliate of ACOM, filed a petition to the California Safety and Health Standards Board for an emergency standard. And that was passed unanimously by the Standards Board in August. Here's a screenshot of a victim of silicosis who testified in August at that hearing. And I have to say, I think a combination of his testimony with Dr. Fazio's towards the end of the couple of hours was probably the single most important message to the Standards Board that this was a crisis that needed to be fixed. And what this standard will be doing is initiating a series of trigger tasks. The 2016 federal OSHA standard, which has been adopted by California, requires that air sampling document overexposure of either the action limit or the PEL before OSHA can issue a citation. That can be time consuming. And there are companies where after the OSHA inspector meets the first day, shuts down any further fabrication. So when the OSHA inspector comes back, there are no tests to be monitored. And so this is going to be mirrored by Table 1 in the OSHA construction standard. Those of you who are familiar, it's a table based on just a series of tasks. So these will include grinding, cutting, chipping, polishing, anything that's being done that disturbs that engineered stone slab and generates silica dust in the air. That's going to automatically trigger the need for wet methods, medical testing, parity or purifying respirators, training, automatically. And if those are not in place, and the Cal OSHA inspector deems that there's an imminent hazard, they will be able to shut the shop down. It's called an order of protective use, or OPU, also known as just yellow tagging. Basically, the shop is closed until the problem is fixed. So this is going to give a much more useful tool for the OSHA inspectors when they go in and inspect the shops. As I've started to do in the fall. So there's another special emphasis program and a reinspection of California fabrication shops. I wish I could leave you and say that the emergency standard and all our other efforts is the answer to this problem. I don't think it is. There are simply not going to be enough OSHA inspectors either in California or nationwide to simply inspect our way out of this problem. I think it needs to be a worldwide effort in conjunction with the manufacturers to take product responsibility and ensure that when an engineered sewn slab winds up being fabricated, that it's only being done in a shop that complies with all the adequate worker safety protection. I think that's going to be, in reality, only a fraction of the current stone fabrication shops that are in business currently. The shops are working on relatively small margins, making the investment in that controlled technology in wet methods, ventilation, respiratory protection, medical testing, is going to be prohibitively costly for many shops. Today, which is October 22nd of Friday, a couple of weeks before the national webinar, the Australian Workplace Safety and Health Authority, WorkSafe Australia, has made their final recommendation to the Australian government, and that is to ban engineered stone from Australia. I recommend to any of you who are interested in this subject to get that report that was issued today, Friday, October 27th, which is probably the best summary of the literature to date. The Australians have gone through this experience in the last three to four years. They've had hundreds of cases, many transplant, many deaths, and their regulators and scientists have concluded for Australia that the best way out to solve this problem is to ban engineered stone completely. The Australian government will be taking that under advisement, and I think we should know in the next few months what, on a government level, their response will be. This is a picture of Bernardino Ramazzini. He's considered the founder of the modern field of occupational medicine. He was born in 1633, died in 1714, and he's thinking to himself in Italian, what took you so long? Because I think Bernardino, his chapter in his book on silicosis among the stone cutters of Italy, and I think if he came back today and he saw that we were still having silicosis of such large numbers and scale globally, I think he would be in anguish and he would say to us, why is this still going on today? I think Bernardino didn't recognize that there's been global migration. The victims of silicosis in California have been only immigrants to the United States who are coming to our country in search of better jobs and pay, and in many cases are willing to accept the risk of silicosis in order to make money and provide food and sustenance to their families in this country and back in their home nation. International capital flow, I think Bernardino might not have realized that with a push of a button, there can be transfer of global capital and investment all over the world in engineered stone manufacturer, putting those slabs on container ships and sending them throughout the world with advertisements to gain market share. And he certainly wouldn't have anticipated that Marcello Toncelli in 1975 would have had the vision to take stone, grind it up into fine silica sand, mix it with this new polyester resin that certainly didn't exist in 1633, put it in a high temperature oven under vacuum and mix it with pigments and dyes to make a new form of countertop. Probably in Bernardino's day, there was perhaps some stone, but it was probably wood. I don't think he would have had the vision, but he maybe would be understanding of our challenge today. So with that, I wanna thank you and be happy to answer questions. Thank you so much, Dr. Harrison, for that fascinating, comprehensive, important talk about the modern day preventable tragedy. I do see a few questions in the chat. That was excellent. Thank you. The first question is, how does the epidemiology and exposure compare between shop workers and onsite installers? The onsite installers often are the same workers that do the fabrication. I'm not aware that there are data on the epidemiology between the onsite installers, the workers that are just coming out and doing that versus the workers that are fabricating back in the shop. There's gonna be so much overlap between those two groups. I would say in general, the bulk of the silica dust exposures is occurring inside the fabrication shops, as opposed to the final install where the workers are cutting the sink, making the final polishing on the sink, maybe cutting out the soap dispenser. The short answer is there is none. I'd be concerned about both, but the bulk of my concern is inside those fabrication shops. Thank you for that. The next one is more of a comment, it seems like. It says, thank you, such a tragedy. For the wider audience, including international, earlier detection of pneumoconiosis in general from surveillance and early diagnostics includes emerging AI applications to lung imaging and biomarkers, example, blood and urine. Kindly use your case presentation today of the perpetuation of silicosis to address these possible remedies. Do you wanna comment on that, doctor? Yeah, I think it's a great, fascinating question about whether use of AI or other advanced technologies can help identify workers early. I can think of a couple of approaches. One is we're using, this is not exactly AI, but in California, we're using electronic health records and a public health platform, it's called RCKMS. I won't go through what the acronym means, but it's basically a new ability for us to pull diagnoses into the public health system so that we're not totally reliant on healthcare providers filling out a form and reporting it, which is very difficult. I call it sort of the nag the healthcare provider from the public health system. So that's not exactly AI, but I'm also thinking, are there advanced data recognition systems that could be applied to electronic health records to find cases early? The second is whether diagnostic tools, chest X-ray or CT scans. There's a lot of interesting data that CT scans are a more sensitive tool for the diagnosis of early silicosis and whether or not we could start applying. I know I'm not a radiologist, but I am aware that some of my radiology friends that they may be replaced by AI techniques. I would just say a word of caution though, at this point, very few workers are even getting basic chest X-rays or breathing tests. I think I had a slide in there on our survey of workers who were interviewed during the OSHA inspection and not a single one of them had even gone to the doctor and get like even the basic, basic tests. So before I'm thinking about AI, I'm thinking about how we can even get workers medical testing and connected with our basic healthcare providers in the community. Thank you for that. There's a request if you can send a link for the Australian paper. And another question is Dr. Harrison, thank you for the fascinating talk. You mentioned the difficulty of getting an OSHA silica medical exam. How much of this difficulty would you ascribe to the lack of certified B readers specifically? Very little, to be honest with you. I don't think the problem is the certified B readers, although I understand that there are relatively few and their numbers have been declining. I think there are two problems, which are larger ones. One is that we need a really robust national system for connecting small, these are small employers and small fabrication shops to healthcare providers, occupational healthcare practitioners who can do silica medical exams. We have posted on the WOMA website and thank you to my colleague, Paul Papenak for spearheading this effort. So if you go on the WOMA website, you can find a list of those providers for California. And we're beginning conversations about how we can do that on a national level for employers across the country. So that's number one. Number two is that for small employers, they have to pay for silica medical exams. That's written into the silica standard. If a silica medical exam, let's say runs between $500 and $1,000, which I think would be pretty typical for the package required. And a small company has between five and 10 employees. It's a chunk of change for a company that's working on a small margin. So, and then if they find something abnormal, let's say there's an abnormal B read and the worker needs a pulmonary consultation, the OSHA standard requires the employer to pay for that. And now we're talking a few thousand dollars for a pulmonary consultation and a CT scan. So it's not cheap under the silica standard. So that's another big obstacle that employers are facing. I don't think, I would love it if the B reader was the problem because then we'd be dealing with so many exams that we didn't have enough B readers. Now the stoppage is not the B readers, it's just getting the exams. Yeah, sounds like an issue that we need to think about. The next common question is great work, Bob. Is it likely that cases are being missed across the nation and disease attributed to idiopathic pulmonary fibrosis? And as an add-on to that question, I wonder, you talk a lot about California. I wonder what the magnitude of the problem is across the United States, if you have any idea of what that could be and what we as occupational medicine providers can do to help to identify cases which are hidden, but are present. I have no doubt that the silica exposure levels are the same in these fabrication shops in most parts, if not every part of the country. I can't imagine it's just a California problem. Engineered stone has to be fabricated in exactly, the technology is exactly the same in every shop. And I estimate there are probably between 10 and 15,000 of these shops across the country. Based on the Australian data, the prevalence of silicosis is probably between 10 and 15%. So where are all the cases? There are case reports from Florida, New York, Wisconsin, Washington, Colorado, Texas, but they're individual case reports. Few, a few in a series, but mostly individual case reports. I think the reason is access, education, outreach, fear in other parts of the country, fear by the part of workers that if they have a positive X-ray, if they have silicosis, they're gonna be out of a job or they're otherwise gonna be hassled or harassed. And it's a pretty tight community in some of these fabrication shops. If you go out and look at the warehouse districts in these large cities, shops are within literally just a mile of each other in a large concentration. So I think these cases are undoubtedly out there in the United States. I am waiting for the other shoe to drop nationally. I was waiting, as I said in my presentation for several years in California and the shoe dropped. And I think we have to just be really vigilant, do a lot of outreach to healthcare providers, primary care, just where a lot of the cases are seen and to your point are misdiagnosed as tuberculosis, sarcoidosis, idiopathic pulmonary fibrosis. But as I say, it's pretty easy. Just take the occupational history. Is somebody a stone cutter? Do they work on stone? Do they fabricate? Are they around silica dust? It's not a huge lift, but I think, as we all know in occupational environmental medicine, but we just have a lot of outreach and education to do among our peers. Yeah, and you're starting with a stock or you have already started with your publication. So thank you. There's more in the chat. Just to give, I think Dr. Richard Lewis credit. He's the one who said misdiagnosis, not me. And Dr. Gassert is saying, most importantly, the applications need rapid rollout to low and middle income nations where pneumoconiosis is severely epidemic and cost and access for diagnosis is still quite limited. Can take this offline if you would like. That's Dr. Gassert. Thank you, great point. I agree. And it seems like Dr. Hedges gave us the link to the Australia report. It's in the chat. Thank you very much, Dr. Hedges. I appreciate it. And the other questions came from Dr. Goldberg and Dr. Hack and Dr. Chang. So give everybody credit for their questions. And I don't see any other questions. You know, this is very informative, a real tragedy. And, you know, like you said, so much is unknown and we're gonna find out sooner or later that people are getting sick and dying from a preventable old illness. Thanks, Dr. McKenzie. I also wanna thank Dr. Montapoli for translating my Italian. I hope I didn't get it wrong. Sounds like you got it right. Okay, good. Okay, thank you again. I think at this point we have a break until 3 p.m. So we can all do, you know, some stretching, whatever you need to do. And we'll see you back at three. Our third presenter of the day is Dr. Michael Hodgson. He will present on violence prevention in healthcare. Dr. Hodgson has been Chief Medical Officer at OSHA and the Director of the Office of Occupational Medicine and Nursing since 2013. Previously, he led the Veterans Health Administration Employee Occupational Health System with responsibility for critical patient care, employee health, and safety programs, including violence prevention, safe patient handling, occupational health, and infection control. He was involved in the work organization activities at VHA through its National Center for Organization Development after 2001. Previously, after a year in the NIOSH Director's Office as a Senior Scientist, he served as faculty at the Universities of Connecticut and Pittsburgh. He was an Epidemiology Intelligence Service Officer in the Morgantown, now Respiratory Health Division. His interest in workplace violence in healthcare dates back to his own assault in the Emergency Department at the Washington, D.C. VA in 1979. He is board certified in both internal medicine, occupational medicine, and was a 2019 recipient of the ACOM Lifetime Achievement Award. Good afternoon. I'm Michael Hodgson. I'm the Chief Medical Officer at OSHA. This talk is entitled Healthcare and Violence. What do you need to know? I have no disclosures. So the objectives here arise out of my personal experiences and the three sections of this talk really reflect what I've done over my career since. So we'll first review what we know and how we explore and define violence and program elements nowadays. And that is pretty much standard across organizations, the Joint Commission, the Veterans Health Administration, and the like. A second part will reflect my experiences at the VA from 1999 to 2012. I was the Director of the Employee Occupational Health System there and violence prevention was one of the big programs that we refined and improved to try and address major problems. And then a third part, we'll talk about what we know about important kind of implementation issues and we'll explore the current Joint Commission checklist and some other important pieces. The take home messages, the things I hope you leave with here are at the personal and the organizational level. For personal safety, people need to have a framework to understand violence in healthcare. They need to know the resources in their own system. They need to understand some basic aspects around violence prediction. They need to recognize the de-escalation techniques and there's a great tool put out by the Joint Commission as an introduction and thinking that through, whether with your organization and informal training or even just alone is critical. And finally, the issues of personal safety skills, also called extrication skills or breakaway skills. How do you get out of holds if someone attacks you? It's a critical skill. Every police station has courses like that. If you have to rely on your institution, make sure they teach that. But institutions have to do certain things. They have to have an infrastructure that supports violence prevention. And as we'll see at the end, a critical element by the Joint Commission standards is to have a program, a written program with a designated program manager. Your institution really should have formal training on de-escalation because reading in a document is not enough. You have to have practiced that. You have to recognize your own anxiety. You have to recognize what impression you will make on the person you're talking to. You have to think about how you can look calm with your head to a side, keep your voice down, have thoughts about where you're going to go and when you're gonna pull the emergency brake. De-escalation has to be practiced. Breakaway skills, personal safety skills similarly have to be practiced. When somebody tries to grab you by the neck, it's very easy to say you just run your hands up and break their arms apart. But until you've practiced that, it's pretty hard to do. It's very easy to say somebody grabs you by the hand and you know to pull your hand away and break their thumb hold. Unless you've practiced that, it's hard. Every institution should have a very formal risk assessment and management process where the institution looks at where violent events have happened, where there are vulnerabilities and how to manage that. To do that, a system must have a data system. So incidents have to be recorded, they have to be examined, they have to be understood and prevention stuff has to be developed. And there has to be emergency response planning. When something goes wrong, who's going to come to the rescue? Therapeutic containment is the formal term. Sometimes people talk about takedowns. How many people do you need to control a 300 pound wildly hitting person who's on drugs? And critical is whether people adhere to the joint commission standard. Is this an old problem? And what do we think about that? From what I can tell, the first efforts at thinking about violence that are published are the 1975 Gold Award to St. Thomas Psychiatric Hospital in Canada that had developed a very formal program on violence program management, training staff and keeping them safe using basal martial arts theory. That recognition that martial arts, the use of other people's efforts and strength to keep yourself safe has been the basis of effectively every violence prevention program that I know of. It's an important recognition. Most people don't do judo, karate, jujitsu or Taekwondo or Aikido, but the principles are important. The next year is an American Journal of Psychiatry paper documenting that over 40% of psychiatrists remembered and described being assaulted at least once. The first violence clinic was set up that same year. A few years later, Larry Lehman, a community psychiatrist at the VA developed a one-day workshop with colleagues on the broad kind of program elements, identification and verbal de-escalation and physical management. The first randomized controlled trial of interventions in 1989 published in JAMA. Whoever heard of that until the last five years, but a randomized trial, Dave Drummond, a psychologist at the Portland VA established what was then called and later became CORD VA program, Disruptive Behavior Committees under senior clinical leadership with training, assessing a first violent incident and then seeing what you can do about that. The Portland VA also created the first kind of flag, electronic system to put on charts to warn about things. John Howard, then the Cal OSHA director, now the NIOSH director, in the mid-1990s came up with very formal regulatory approaches to violence prevention. And we did, though, what was until then simply enumeration of violence events to a classification system of types. And then in the early aughts, 2005, a federal conference, Department of Justice, NIOSH, OSHA, number of other organizations took that definition and made it the national standard, including in surveys by the Department of Justice. Definitions, what is a violent act? So early on, a very simple definition from NIOSH, physical assault and threats directed towards persons at work or on duty, home health being an issue. OSHA came in next with an additional list of verbal abuse and bullying and harassment or intimidation. And then at some point, the Joint Commission had a far longer, more complex definition. Bottom line, if it feels like violence, it probably is. So what is violence? How do people think about that now? The standard approach these days is to classify violence by four types. So before 1992, there was simple enumeration of assault, threats, simple assault, assault with a deadly weapon. But the description, the Howard Cal OSHA federal definition then classified these four types of violence by perpetrator, recognizing that understanding the perpetrator and the setting was a critical issue. So type one, criminal intent in health care, lots of reasons, drug, trying to get at somebody's morphine. Type two violence, what DOJ called customer client and in health care is commonly called patient-on-provider violence, is certainly thought nowadays to be the most common event in health care. It generally includes not just patients, but also family members and visitors in the context of patient care. And it occurs primarily in emergency, or most frequently in emergency departments and psychiatric treatment settings, although it can happen anywhere, in geriatric wards, in the geriatric outpatient clinic. Not unimportant in health care is worker-on-worker violence, type three violence. We think of bullying and harassment as important parts. They are certainly major contributors to burnout. They're huge contributors to stress in the workplace. And we'll talk a bit more about that as we talk about some of the VA data that are published that are useful to remember. And then finally, the spillover of personal relationships into the workplace can be a real problem. And certainly, during my time at the VA, there was a homicide of someone who had been dumped by their supervisor and then came in with a long gun and shot her. So the four types are important to remember. The problem is they're not so useful for prevention. As we think about assaults and violence, the biggest issue, or one of the big issues, is understanding how they happen and predicting the next one to prevent that. And the type of violence by type one through four doesn't really affect the prevention theory. So stalking behavior on the part of a patient and stalking behavior on the part of a co-worker are different types of violence, type three and type two. But they require a threat assessment that is very different from affective violence. Jay Reed Malloy, a psychiatrist who had, for many years, studied stalking and instrumental violence, worked on classification systems. And one of the critical things that threat assessment roots to is distinguish between affective or reactive and predatory or instrumental violence. Predatory or instrumental violence. They look different, they feel different to the victim, and they require different intervention strategies. Predatory violence generally presents with no autonomic arousal, no visible anger, and it's like a cat stalking. There are people who use the image of a cat or a lion crouched waiting to pounce. There's no conscious emotion that gets in the way, and it's cognitively planned and very purposeful. As opposed to affective violence that is associated with intense autonomic arousal, the perpetrators are clearly affected and generally there's something going on there. What kinds of rates are there? This is an old slide from 2019 on the Bureau of Labor Statistics. Many of you know, conducts the annual survey of occupational injuries and illnesses, the SOE. And that slide presents the rates of violence reported by facilities in the SOE. So the range of rates goes from in workers in general in the range of two and a half to three per 10,000 workers per year to 120 per 10,000 workers per year in psychiatric and substance abuse hospitals, down to about 80 in residential mental retardation facilities, down 70 in other residential facilities, down to about 30 in geriatric facilities. So the rate overall varies tremendously across institutions, but in fact, they vary equally widely within institutions. And unless facilities look at their own institution and identify where those events happen, they can't develop appropriate intervention strategies. Who becomes a perpetrator and how? Well, there are, we think, protective and predictive factors. The things that make people less likely to assault are having socioeconomic strengths, having psychosocial strengths, having being in physical good condition. Those are data that come from VA screening tools and formal surveys. The issues of predictive factors, who is more likely to assault? The single biggest predictor is having assaulted before. Substance abuse, some personality disorders, PTSD. So there are things that we all recognize, but there are very formal risk prediction tools, and facilities really should have those trained somewhere in a system that they apply. So there is the Association of Threat Assessment Professionals now, the Threat Assessment Professionals Worldwide. The URL is hidden behind that slide. There's a very well-known Oxford Risk Assessment tool that's commercial, that's free. The existing organizations that do violence prevention programs, Veterans Health Administration, Western Psychiatric Institute and Clinic have tools, and you'll see in the Joint Commission references at the end in that, the escalation tool. There are a series of risk prediction tools that are also described. What's going on across the country right now that you can resource? So first, the National Patient Safety Foundation and Institute for Healthcare Improvement has for the last six years had an action plan and website on rejuvenating patient safety. And one of the four big activities under that plan is integrating employee safety into patient safety. And violence prevention has been at the top of that list. So the NPSF's website has a whole series of tools to help people get started. As part of that, there's a CEO collaborative. It became clear that in the absence of top management commitment, as it's called at OSHA, very hard to do something effective. And so a series of CEOs got together and modeled implementing violence prevention programs. And then I think most importantly for most healthcare providers and healthcare workers is the knowledge that the Joint Commission has meanwhile released a crosswalk across its standards of environment of care, leadership, and education. And we'll talk about those at the end. Because understanding how those standards work and how you can use them is a useful thing. OSHA is working on a standard on violence prevention. It sometimes takes OSHA a while to promulgate standards. So that standard has been under development for some time. So some people know that in 1999, I went to the VA, to the Veterans Health Administration, to establish an employee occupational health program in the national office. And one of the first things that happened was, actually not the first thing, but eight months after I started there, seven months after I started there, a second physician was shot and killed. And so there was pressure to think about how to improve violence prevention in the system of 150 hospitals and 700 clinics. And at the time, we didn't know how big the problem was. People generally knew violence in healthcare was an issue, but none of the big surveys had been published. So we used the survey that had been done, I believe the year before, by the Califano Center, looking at violence in the post office and in the US population at large in a large trial. US population in yellow, post office in orange, the VA in green. And you can see the verbal abuse frequency, what proportion of people had experienced at least one episode of verbal abuse or assault in the prior six months. And when we showed those data to our chief operating officer, Laura Miller said, oh, so it's going VA, not going postal. And that got us 10 years of performance measures for top leadership. That of course becomes a really useful thing because you can then start looking at what the problem is in your institution and you can design programs appropriately. That survey also told us who the perpetrator of that most recent incident was. This is a slide of the frequency of incidents by occupation with the color of the bar representing the perpetrator. So in purple, patients in buff, coworkers in baby blue, the supervisor. So about 6% of physicians, 4% of surgeons, 10% of dentists, RNs about 22%, LPNs about 28%. So as you go down the wage scale, it looks like there might be more supervisor on subordinate violence. We thought that was pretty interesting. These are assaults, not verbal abuse. The verbal abuse patterns looked similar. So over the next years, the VA developed a, or rejuvenated a program that had been around but had decayed and critical to that was making sure there was in fact a data system. One of the first things it had done when around the time I joined was create an injury tracking system that didn't do just OSHA recordables but looked at all incidents, including near misses. That data system no longer exists but that clearly helped us track things. It rejuvenated the cascade trainer system. We've talked about martial arts, unless you practice those, unless somebody skilled trains you in those. So the VA had as a cascade trainer system for its violence prevention program and based on risk assessment, unit by unit and profession by profession, different people get different training. Everybody got awareness training. People in the outpatient setting got deescalation training. People on units with a reasonable risk of assaults got formal extrication training. And the whole therapeutic containment becomes a critical issue that we'll get back to shortly. A major element of the VA program is the presence of a disruptive behavior committee at every hospital, led by a senior clinical trained mental health professional, nurse practitioners, mental health nurses, psychiatrists. But there's a mini residency, a one week onsite residency that trains them in threat assessment and multidisciplinary assessment of safety, law enforcement, clinical management, and makes sure that they have the skills to look at events that have happened and think about how to deal with that. There's then a flag that goes, a note that goes onto the electronic patient record that says, here's how you prevent the next one. The rest we've talked about, those are no different for the VA than for, I mean, they may be functionally different, but the elements become critical. And for people who care, this was part of a paper that actually never, I ran out of time, so it actually never got published, but the different, when what program element was put into place, and then the rates of assault among nurses and among staff, there was one more year that continued to decline, but at some point, the VA has dismantled that system and I don't know what the rates are now. So the second thing that, a tool that people should know about short of the Joint Commission assessment is OSHA's guidelines for preventing workplace violence in healthcare and social services. That's a formal publication reissued in 2015 that has those five program elements. We'll talk about those in a minute. They're critical, how you label the different programs and how you label the different program elements. It's a little tricky, but just remember that document, OSHA publication 3149 is a how-to guide. There are commercial programs out there that people can buy. How good are they? We wondered whether we could evaluate those and Sheila Arbery, who is a nurse in the Office of Occupational Medicine and Nursing, spent a fair amount of time organizing this project. We assembled a group to develop a consensus list of critical elements and then came up with, I think it was 30, 28 elements of by which we could evaluate the different programs. We actually got, actually, yeah. We wound up getting copies of the training programs of 12 of the commercial violence prevention programs and reviewed them. We got those only with the promise, obviously people don't like to give OSHA anything. And so we had to promise to give them back without copying them at the end and to never talk about the individual programs by who did what. So this is a published paper. We destroyed our records and we gave all of the records back to the organizations. But as you'll see on the next slide, the majority of the programs did use a train-the-trainer approach, a cascade trainer. So you send somebody off to be trained, they come back. Is there retraining? Do they get recertified? Critical question. Do they teach de-escalation? Do they practice de-escalation? What's the extrication training on restraints and holds? Is there a team approach to containing violent assaultive patients? And they mostly did all that in some way or another, but the most of them did not help individual facilities customize their program to the local needs. They really didn't have content on predatory violence. They had no content on working alone, which is a huge issue in healthcare. Very few had things on worker post-event follow-up and almost none had evaluations of program effectiveness. So if you care about those, there's a summary in blue. Some things look pretty good. Some things look pretty bad. Most didn't structure ways to report assaults. So in fact, if you rely on those programs, you don't report, you don't track, and you can't meet the Joint Commission standards, recognizing that. So I think these slides are available. So just by way of background, OSHA has done a fair number of inspections in health care facilities since 2004. I think now we're up to about 900. This graphic presents the numbers through 2018. In yellow, the number inspected each year. In red, the number that received a hazard alert letter, where we went in and said, it's probably not good enough, but it's not bad enough for us to issue a citation. In blue, the number where we didn't do anything. And in gray, the number of general duty clause citations that were issued each year. Some perceptive people have seen a change in direction between 2016 and 2018. So because of the OSHA guidance document, we thought we should use a checklist and see where we got. And Sheila Arbery, again, led a program to develop an OSHA checklist, assembled people, including nationally recognized violence experts, somebody from the Joint Commission, some people from VHA, some people from NIOSH. And we developed this pilot checklist. We identified all of the inspections from a master list and then took a convenience sample of hazard alert letter facilities and citations and conducted semi-structured interviews with Koshu shows and looked at how that checklist performed. And just so that people know it exists, this is what the checklist looked like. Practically, that was developed in 2017, 2018. We conducted the interviews. It took till January of 22 for that paper to be published. It sat somewhere for a long time, not at the journal. By the time it appeared in January of 22, in fact, the Joint Commission released their own checklist. And I think if there's nothing else besides the recognition that you need to have individual skills, you should please look at these at the Joint Commission checklist. The references to this slide show have the living document, but you can also find that if you type Joint Commission and violence prevention and standard into your search engine, you'll find the four standards that the Joint Commission says can be pulled together out of a crosswalk. And if you meet all those, you will have an effective program. So the first is that there has to be education. So staff participate in some form of education at the time of hire, annually, and whenever changes occur. It should be customized. Remember, many of those commercial programs don't do that. And there are some elements of what that training should include, and the training should include the reporting process. We'll get back to that. People who have dealt with Joint Commission inspections know they can be tricky. But it's in the preparation for those that this checklist becomes useful. And the leadership standard says there is a workplace violence prevention program led by a designated individual developed by a multidisciplinary team that includes. So that's pretty clear what you need. So who has that kind of a program? Well, again, this is going to sound parochial, but long after I left the VA, Lynn VanMelt led a revision of the VHA Violence Prevention Directive. That's still a very good document with program elements, detailed instructions, thinking through at which level people should really be able to do things. And then the environment of care standards. Those environment of care standards are what should it be doing? Is there an annual worksite analysis related to the prevention program? So that standard doesn't say whether this is a walk around or a quantitative analysis. But it doesn't take much for somebody to say, gee, well, we know what we're doing if we haven't looked at it. And well, we know what we're doing if we looked at it, but we haven't measured frequencies. So environment of care standards are useful things to rely on. And then my favorite is collecting information. So what are the procedures and processes to monitor, to do internal reporting, and to investigate? So that requires something like a committee that is led by someone who knows what it means to investigate. Because the problems here overlap between clinical care. So in a hospital, obviously, the first thing that you have to think about is the adequacy of care. Is it the right care at the right place in the right way at the right time? But there are criminal aspects. There are patient rights. There are safety and security issues. So these investigation processes really have to have all of those skills involved. The VA put together a mini residency one week on site for the team leads to do this. I don't know how they do that now, but that's a useful thing to remember. So just pull the Joint Commission checklist and use that. It's better, I'm sad to say, it's better, I think, than the checklist we developed. They had the advantage of having seen what we had done. We've recently compared the two in a series of enforcement actions. And the point spread between the hospitals that got cited and the hospitals that got hazard alert letters is much bigger when we use the Joint Commission checklist than if we use our own. Is that because we have unnecessary things in there? That could be. The bottom line is, this is a critical checklist to use. Before I go to other known effective interventions, I just wanted to mention a big project that people should know about. Judy Arnett's and some people at Michigan State, they started, I believe, when they were still at Wayne State. But they moved to Michigan State and developed a block randomized controlled trial using a NIOSH grant to look at whether if they implemented the OSHA guidelines, they could show benefits. It's a great project, a ton of papers from it, useful knowledge and lessons from that. So if you search Judy Arnett's, many of them in JOM, some of them, you'll find a series of papers that are very useful for interventions. Even if the primary project, as I understand it, failed to show statistically significant intervention benefits in the time frame of the original runtime. Remember, the VA program didn't really lead to benefits for about seven years. What are the known effective interventions based on clinical trials? Disruptive behavior committees, the Dave Drummond trial from 1989, the Disruptive Behavior Committee's work is still a really important paper. The Cochrane Review of Violence Prevention and Health Care argued that the CRU project, another VA project, Civility, Respect, and Engagement of the Workforce was one of the few well-documented interventions. That actually had the lead authors, Linda Belton, and well, the authors were able to show large benefits of co-worker interventions on patient and employee satisfaction with kind of workplace mental health interventions. It's a worthwhile thing to know about if you're worried about burnout and co-worker stuff. How effective are the OSHA guidelines? We think they're critical. The Arnett's and Hamlin papers are worth having looked at. And there's a NIOSH online education tool that's worth knowing about. I think people should know about the disruptive behavior committees and think about those. There are two papers on that that are worth looking at, Dave Drummond's 89 paper, and then a paper in the American Journal of Industrial Medicine where we surveyed the chiefs of staff in the hospitals to get their view of how those had been implemented. The VA directive lays out how you can actually structure those, the issues of minutes, and how you document those is important. And an essential element of those is how you warn people. So the VA with an electronic record has a category one flag that's visible across the system. I don't know about other electronic records. I haven't seen patients now for 10 years, so I don't know whether Epic lets you do that kind of thing. And there are some other things in the slides that talk about the ways hospitals deal with problems. There are two slides of references that are useful, and the ones I hope people look at carefully are the OSHA guidelines, the Joint Commission checklist by itself, and the de-escalation tool that's a Joint Commission publication on QS quick safety 47 that has pretty detailed structured approaches to that. Those are online and free, so this is not commercial bias, and it's not mine. Oh, sorry, I think I just got rid of the going away slide. But my time is up. Thanks for listening. Thank you so much, Dr. Hudson. We do have some questions in the chat. First, I will go to Dr. Magali Lopez Sorba. It says, we talk about a threat of violence in the workplace and concentrate on the patient provider. Nobody talks much about the chronic culture of exposure to the virus, but we do talk a lot about the impact Nobody talks much about the chronic culture of accepted verbal assault and abuse threats in the medical profession. And in parentheses, she has attendings, nursing, and medical students and residents. So most of the organizations that do this, take this seriously, do address that. The Joint Commission actually has long had a patient safety alert out on that topic on bullying. NIOSH has a big training program on bullying recognition. It's pretty clear that this is a problem. And if the hospital in which you work doesn't deal with that, that is clearly a problem of hospital leadership. That's what the CEO collaborative around the National Patient Safety Foundation is trying to address. It's a huge issue. There are solutions. One of them, certainly the one that VHA tried, was the Thru Initiative. There are publications on that. It started out as a recognition that people are incivil. It showed up because a bunch of nurses in an orthopedic OR out on the West Coast were complaining that the surgeons were throwing scalpels around. And when they complained, the surgeon said, we're not throwing it at the nurses. And so the leader of the organizational development group came up with a program. And we sent a psychologist or a psych intern to, I think, 3,000 different working groups that created small group interactions, starting with, how did people want to be treated? And the introductory topic was, what is culture? Finishing people's sentences in Manhattan is active listening. And you'll get shot for that in Savannah. In parts of the US, learning to stand in line is part of civil behavior. And in other parts, edging your way in is just part of the fun of the daily. And in some city hospitals, many of the nursing assistants name each other Mr. and Mrs. And in high-end hospitals, doctor and nurses use first names only in the Malcolm Gladwell first name only cockpit safety rule. So culture is clearly local and clearly defined by leadership. And the CEO and the board of directors need to address that. How you get there, that's a really big issue. And whether the workforce is organized, whether leadership has an understanding, whether you go back to the Joint Commission on one of the early patient violence, workplace violence, bulletins, yeah, clearly, it's something that takes a lot of work. Thank you for that. And Dr. Rosenthal mentions that we were just talking about this topic in our JEDI committee. We have two other questions. We're running a little short in time, but they don't sound too long. This one's from Dr. Greig. Is there data to confirm the theory that the presence of security officers will decrease the threat or number of violent events at medical facilities? So are there data that would go with this theory? I'm not aware of data. Certainly, the presence of police and security help intervene promptly, but I'm not aware of those data. Thank you, Dr. Hudson. And finally, does the Accreditation Association for Ambulatory Health Care have similar standards to the Joint Commission for Compliance in Ambulatory Clinics? This is from Dr. Amel. Don't know. People may know that there are now, I think, 10 organizations that have accreditation processes, that one of which hospitals must have met to receive reimbursement from CMS. So I don't know whether all of them have violence prevention standards. OK, I think we have a little bit more time, actually, we can continue till 4. I misread the schedule. I don't see any other questions. So Dr. Hudson, if you have any other comments, if not, I think the host will have us move on. Thanks for listening. Thank you so much for coming. We appreciate it. Our final presentation of the day is Dr. Jeffrey Weaver. He will present on occupational color vision, standards, testing, and rationale. Dr. Weaver is optometry director for Cornerstone Care, a federally qualified health center in his hometown of Waynesburg, Pennsylvania. He is also a medical review officer and consultant on occupational eye and vision issues to government agencies and other organizations. He is adjunct professor at the University of Missouri St. Louis College of Optometry and in group private family practice in St. Louis, Missouri. He is a graduate of Pennsylvania College of Optometry and the Ohio State University. Throughout his career, he has balanced clinical, academic, administrative, and military health care roles. He is triple boarded as an optometrist, health care executive, and association executive. He is a past year of the American Academy of Optometrists section on public health and environmental vision. He currently serves on the board of directors of VOSH International and is finalizing his dissertation on his latest pursuit, a PhD in industrial and organization psychology at Liberty University. Hello, my name is Jeff Weaver, and welcome to my presentation on occupational color vision, standards, testing, and rationale. I have no disclosures to disclose. The outline of our course today is this. We're going to talk a little bit about the history of standards and testing, what occupational vision testing is like today, emphasizing color vision deficiency, as well as the importance of color vision and specific color vision testing that we will do in practice. Probably the most common vision standards are related to some level of visual acuity. Usually, standards are written for corrected visual acuity, but sometimes uncorrected, especially for roles where spectacle or contact lens corrections could be dislodged, such as in law enforcement officers. But we do want to emphasize color vision, as I said. So let's go back into the history first thing. So when did we start testing for occupational purposes? Chinese civil service examination date back to as early as 2200 BC. And initially, the examinations were conducted only for the purpose of evaluating civil servants to determine whether they should continue in office, a practice that took place every three years. At some point, however, the Chinese rulers decided that examinations should also use to choose candidates for civil service positions. And these examinations were continued from that time until 1905, at which time they were superseded by university credentialing. So these examinations represent the earliest documented use of testing for widespread selection or evaluation purposes, and they did it for re-evaluation versus initial, interestingly. Early research in experimental psychology was focused on the study of physical sensation. German psychophysical laboratories of the early 1800s, such as that of Wilhelm Wundt, were concerned with obtaining precise estimates of obtaining precise estimates of reaction time, visual and auditory perception, and other physical sensations under various conditions. A major influence on research at this time was the publication of Darwin's Origin of Species in 1859. But it was actually Darwin's cousin, Francis Galton, who wrote several works on the hereditability of scientific aptitude. Galton is well-known for the establishment of laboratories, starting at the 1884 International Health Exhibition in London for the collection of physical measurements, such as height, weight, strength of pull, and, for our purposes, discrimination of colors. Here was Galton's recording form from 1884. It was not so different from the occupational medical exam forms you might use today. And note on here where it does say, color sense, goodness of. And this multiple-figured figure, figure two here in the bottom right, is Galton's color vision test. They used wound-colored wool. The drawing is a schematic showing the test cut open, but the person being tested was instructed to place a peg in the hole in front of any wool that included any shade of green. In our roles, we're looking for physical competence for a position. In Lohman's position competency model, it's based on determining the knowledge, skills, and abilities, or KSAs, and other attributes needed for functioning in a particular role. What we now refer to as job task analysis may be attributed to Munsterberg in his studies in the early 1900s, first examining sea captains. In his textbook, Munsterberg argued that the best way to improve efficiency and productivity is to match the character and mental abilities of people in position, which certainly makes sense. Munsterberg's early application of his theories were prompted by safety concerns because train workers, their fatality rates had skyrocketed near the turn of the 20th century. Safety is also the primary concern for today's vision standards. The typical vision categories for employees of all types, or as I mentioned before, visual acuity, the most common, visual field, depth perception, and color vision. This holds true for employees of the Department of Homeland Security, for which I review applications on an ongoing basis. Our safety concern, especially in law enforcement, which CBP is primarily, is not just to the employee, but the public. So for each of these important attributes, if they're going to require a standard, it's important that they are evaluated in relation to essential job function. Remember that safety and efficiency are really the two critical reasons that we have these standards, whether it's pre or post-hire evaluations. So back to visual acuity, it's really the best measure that we have to measure a person's ability to see fine detail. So that's why it's assessed for so many occupations. Unfortunately, in occupational medical settings, we often use one of the worst devices to assess it, the chart inside the occupational vision testers. Better assessment can be obtained with log-mar charts that are the standard for measurement in clinical trials. And that's what's shown there on your bottom right. So some of the common pitfalls that we run across in visual acuity testing is inadequate visual acuity chart. And the log-mar chart is certainly ideal. It was designed to eliminate pretty much all the pitfalls that we would come across, and that's why it is used in all the randomized clinical trials that are funded in the U.S. these days. Poor contrast is a problem for any chart outside the vision tester. That's one thing that the vision tester gives us, is good contrast. But if you are using a chart outside, use either a computer-generated backlit chart or otherwise assure some bright glare-free light to illuminate the wall chart. There is a lot of variability in guessing and confidence on how a person does on visual acuity, whether they like to guess and maybe they will get most of them right just based on the shape of the letters or whether they don't wanna be wrong. And unless they're 100% sure, they're not gonna even take a guess, thus their acuity will be recorded as worse. So assure the candidate that it's okay to miss, take a guess, and you'd be surprised how many lines of acuity may improve just by giving it their best shot. One of the problems within the vision tester is called proximal accommodation, because as we get close to these testing instruments, our brain thinks that we're close even though we're doing a distance visual acuity, so we accommodate or focus our eyes for near, creating a false myopia, thus creating worse visual acuity than is actually there. So if that is the case, if you get worse acuity than expected for whatever reason, go to that backup acuity chart that's outside the instrument, ideally a log bar chart. Wearing contact lenses, a person can be wearing contacts and not tell us, I know we asked that question, we should be asking that question, are you wearing contacts? Sometimes the applicant just want, or the employee want to get or keep their job, so they're not gonna disclose that they are in fact wearing a contact lens. Sometimes one bad eye is not detected, particularly if the good eye is tested first, and then the bad eye is tested on the same line, so just repeat the same line, make sure you have controls in place for that. And squinting can be a problem, certainly squinting should improve the visual acuity of most individuals, so even people with high refractive error can get incorrectly good acuity. Based on squinting. So let's take a look at a correlation chart here on the next slide. This was a recent study by Kleinstein, correlating uncorrected refractive error and distance visual acuity, this was done in children, but it does certainly apply to adult population. And so certainly refractive error can be a means to indirectly determine visual acuity. On this box and whisker plot, it does show a refractive error as a function of visual acuity. I've added a couple of visual acuity lines that can be used for comparison, probably the most important one is that 2100, which is a cutoff for law enforcement officers, and in some cases uncorrected has to be 2100 or better, either individual eyes or both eyes together. And if you look at myopia, it's unlikely that a person who is worse than about a minus three diopters of myopia would have 2100 or better. So if you see somebody with a prescription of minus seven and or even a more reasonable number and has much better than 2100 visual acuity, they're either squinting a lot or whoever's doing the testing is helping them out in some way. And hopefully that won't be the case. Okay, on to depth perception or stereoacuity. True depth perception or stereopsis is the elegant sense of relative depth or the ability to see fine bulge or surface irregularity, not the depth that you might see from even at a distance where many of the clues there are monocular. But when the eyes are aligned, you can see detail from two directions at the same time. So this is important for inspection tasks and in law enforcement because it's useful to see hidden weapons or contraband and helpful to sort out fine detail such as discriminating a weapon from a distractor, which can definitely be a safety issue. Another point on this slide is global or local stereopsis. And if you've seen those terms and don't know what that means, the local stereoacuity are the circles on the left where you pick out which circle looks like it's elevated, like a button you could push down on versus global stereoacuity are the hidden figures on the right in that test there. And the global test is a larger area of disparity, the local stereoacuity, just as a very small area of the retina that's being tested. So they're measuring different things and both are important. The most tests you will see in most vision standards are requiring perhaps 70 seconds of stereopsis and that's typically the local stereoacuity. But pitfalls in here are memorization because there's not really any randomization we can do here on visual acuity. We can randomly generate slides if we're doing computer visual acuity and it just randomly puts different letters up there, not so on depth perception. So maybe you can use multiple tests if the results are questionable. One of the things that happens sometimes in visual acuity testing, so you have to put on the 3D glasses for the stereo tests that are done outside of the vision test. So when you put these on, it's often the case to remove the glasses, but that should not be the case. It should be done with best correction in place so they can be just placed over top of the habitual eyeglasses. We did talk about local versus global stereopsis already and sometimes you'll see distance versus near stereopsis. Distance stereopsis is not tested very often. Some of the vision testers do have a distance, but most depth perception is monocular at distance beyond a certain distance that has yet to be ascertained, but certainly beyond about arm's length, we have very little retinal disparity or true stereopsis and anything there is true, really monocular in nature. All right, onto visual field. So the human eye can see temporally about 100 degrees, mom's even further behind, but nasally about 60 degrees if looked when the eyes are looking straight ahead. So temporal 100, nasal about 60 and the shields of binocular visual field of upwards of 200 degrees with 120 degrees of overlap. Our vision screening testers, the ones that flash the lights nasally and temporally in each eye can detect a significant vision loss, but it's not really incremental in any way. So the screening can be improved with an arc perimeter, the one in the bottom center there, if you can find one of these dinosaur instruments, that actual measure the horizontal meridian to the closest one degree. There is a new one in the bottom right that's called a Brunel hand disc perimeter that simulates that arc perimeter and these aren't very expensive. I have one, I don't know where it is, I haven't used it recently and it's in this place, but I think it was only about $50. So that is a pretty nice device to have for testing just along the horizontal meridian, which is what we're doing in many cases. The future may be head-mounted virtual reality visual fields which we're using even for sophisticated visual field tests like for glaucoma. So common pitfalls in visual field, I said there's some limitation in some of the vision testers, particularly the occupational vision testers that we have in our test centers. It only measures two or three different specific points. And sometimes if the individual is expecting one of the lights to flash, they're gonna say, yes, I see it, even if they don't. There are some limitations or unfamiliarity with threshold visual field tests, if you're going to test that level and oftentimes, especially if we're testing a regular clinical patient for glaucoma, in many cases, we just throw out the first test because it's the learning curve of doing that test. So let's do it once, come back in a week or whatever time period, it's not real good for occupational, maybe even later that day would be fine, but just do a repeat test if you're doing a threshold because there's definitely a steep learning curve there sometimes on when the button should be pushed, when the stimulus is presented. There's some ambiguity on recording forms. And I think this is most common with the fact that there are 50 states, other jurisdictions, and they're not on the same page. So I'll see this on driver's license examinations where they're sent in and they'll say right and left. So does that mean what's the right eyes visual field, which could mean 90 degrees temporal, 100 degrees temporal, maybe 60 degrees nasal, or do they mean the right field, which means from centration point over, which is gonna be 90 to 100 degrees. So when I see right, do I put 90 or 100 or do I put 90 or 100 plus that 60 nasal? So the full right field of the right eye in fact is closer to 150 or 160. So I'm sure you get an understanding of what you should be recording there. One of the worst pitfalls is the CDL requirement. If you look at that, or if you're doing any CDL testing, you'll notice it's only 70 degrees in each eye, which is just dead wrong. When they first came and set a CDL standard for visual field, the experts that were recommending it said we want 140 degrees binocular. Well, then people saying, when we're doing the testing, they said we can't have a binocular standard, we need monocular. So 140 divided by two is 70. So if you have people driving with 70 degree fields in each eye when a normal visual field is 150, 160 in each eye, 70 degrees is extremely limited and they just won't change it. So I wanna mention briefly pre-hire and post-hire testing. Remember the main reason we're testing division standards are to assure safety and efficacy. And the number of vision impaired individuals in the workplace is higher than you might imagine. So whether pre or post-hire, jobs where safety and visual efficiency are needed should have vision standards and be tested. The big four categories may be those related to transportation, law enforcement, military, or any inspection roles. When we're doing pre-hire testing, there are some Americans with Disabilities Act limitations on the information prior to getting a conditional job offer. So remember, you can't ask whether there's been any medical procedures related to vision done, whether it's eye surgery or refractive surgery, strabismus surgery. Whether they use any prescription medications related to the eye, which might be glaucoma, or if anybody has a condition that affects the vision or causes vision impairment, diabetes, hypertension, can't ask those. Post-hire, you definitely can ask those questions and you really should do that to determine whether they can perform essential job functions in ongoing, in addition to that, find out if there's any aging effects on previous results. That said, I think on the pre-hire, the government can get away with some of these things because I know within Homeland Security, it seems like we definitely ask some of these questions. All right, we're emphasizing color vision deficiency. So now on to color vision deficiency. So what is the most common single locus genetic disorder in humans? Well, it's red-green color vision deficiency. And color deficiencies may be categorized in numerous ways. One is differentiating whether it's congenital or an acquired deficiency. And the ones we're usually testing for are congenital, present from birth, stable, bilaterally symmetrical, and they affect the entire field of vision. Acquired ones, which we could see from time to time, don't have these same attributes. And these can be ongoing with aging related to cataract, glaucoma, diabetes, optic neuritis, certain medications. A lot of different things can give you an acquired deficiency. That said, they're not all that common. We can also categorize color deficiency by the number of cone receptors. So for monochromats, if a person has no cones whatsoever, called rod monochromats, or have just one cone type, they are cone monochromats. Dichromats have two cone types. Anomalous trichromats have the normal three cone types, but something is wrong or different at least from normal human color vision, making them anomalous. But certainly the monochromats have the worst color vision deficiencies. Dichromats, next worst. And anomalous trichromats actually can be pretty mild. So which of the following color vision deficiencies is most likely to be encountered? What's due to anomaly, and it's really not even close, there are five times more due to anomalous individuals than any other category. These percentages here from the Caucasian population, in which larger studies have been done, about 8% of males and about half percent of females have a color deficiency of some type. The reason it's so much less on females is remember that color deficiencies are on the X chromosome, so females have to have two defective X chromosomes to be color deficient. Other races seem to have lower prevalence of color deficiency, but the studies are smaller, certainly adequate in numbers, but much smaller than the Caucasian studies have been done. But 4-5% or about half that of Caucasians for most other races. So this graph shows the peak absorption of each of the four receptor types, SM and L cone, probably for ease of use we'll call them blue, green, and red cones, even though that drives the scientists crazy. But that's what we'll call them. And then the rods in between, interesting, the rods have sensitivity in between the blue and the green cones. I want to show you a simplified demonstration of what we classically understood to explain the variations in the degree of color deficiencies. So here we have the short, middle, and long wavelength cone absorption, blue, green, and red of a normal trichromat. And if any of the curve's peak absorptions would be shifted, then that would signify an anomalous trichromat. So if it was shifted just slightly, then there would only be a mild defect. But if it shifted further, the color discrimination would be worse and worse until, what do we have here, a dichromat. So the green and red cones would be basically overlying, so no green cones essentially, two contypes of the individuals of dichromat and much worse color deficiency than any anomalous trichromat. However, with color vision genetics advancing, it's not really a single normal absorption curve. There's different classes in the yellow or red class cones, more variability in that than there is in the M or green class cones. And just based on how much variability there is affects the amount of color vision deficiencies. One thing on the horizon is that there may soon be color vision treatment, nothing that you may have heard of, including the fancy and chromaglass's work. But when genetic material has been injected into monkeys, missing the L red cone gene, so they have protanopia, they were able to discriminate colors. So we're already to primate research here. So maybe sometime in our lifetimes, we'll have something to help color deficient humans. So as we move towards the discussion of function, I would like to remind everyone that individuals are not color blind. Well, maybe one group is, if they're truly broad monochromats have no cones whatsoever, which is really pretty rare. Some of color blindness in that case is the least of their concerns. They have very poor visual acuity as well, but the vast majority of individuals are just color deficient. And we should use that terminology. They do see color. They just see it differently than others with normal color vision. In terms of color vision function, each cone can pick up 100 gradations of color. So even that person with, that's a cone monochromat that only has one cone type, can see 100 colors. A dichromat, remember a person who still has pretty poor color vision compared to a normal functioning individual, can see 10,000 different gradations of color. And a trichromat, even an anomalous one, can see 1 million colors. If they're anomalous, they may just see it a little differently than those of us with normal color vision. So that's a lot of crayons. On the extreme side, the other way, there are some tetrachromats out there that basically have four cone types, not just three. And then they can see 100 million colors. There's an artist that's a tetrachromat out there, Conchetta Antico. Check out her website. It looks like she either has something going crazy wrong with her color vision or she's using LSD, but very colorful drawings. So why is color vision important? Well, three main reasons. It codes and transmits a message. We know from traffic light with red, yellow, and green. It can organize complex visual displays, which is the main thing I want to demonstrate here momentarily. And to a lesser extent, it evokes an appropriate mood or emotion. There are certainly some colors that are more aesthetically pleasing than others. If you're trying to get a nice, relaxing mood in your bedroom, you probably don't want to paint it bright purple. So let's take a look at why we need color for discrimination. So if you're looking at both coding and organizing complex displays, there may not be a more hectic place than on the deck of a U.S. Navy aircraft carrier. And on deck there, each job type has a specific color-coded uniform, which is especially important in an environment that it's not just visually demanding, but where noise makes verbal communication impossible. So on this demonstration, some of you have seen this before if you've seen my presentations. We're going to do a demo here. The first slide is going to have four shapes, squares, circles, diamonds, and triangles. You're going to have a full second to count. What I want you to do is count the number of triangles, and then for bonus, count the number of circles. So first we're looking for triangles. If you get those, count the number of circles. Here we go. All right. So that was a full second. How many triangles did you see? Did you get them? Overachievers, how many circles? I'm not going to tell you yet, but remember those numbers that you selected. So on the second demo here, we're going to code by color. These are all going to be diamonds, but they're red, green, blue, and yellow. So when I show you the first slide, I will show you the slide. You have a full second on this as well. Count the red diamonds, and for the bonus on this one, you want to count yellow. So first count red, then yellow. Here we go. All right. Same amount of time. Did you get this one? A little bit easier, wasn't it? So what happened here, here's the answers for the first slide. Six triangles, two circles. Hope some of you got at least one of them. Did you get either? But watch closely what we did. It didn't move the positions at all, but the positions were coded for color instead of shape. So even if you got them all and both, you have to admit that the slide coded with color was easier, and it certainly took less reaction time to determine the correct answers. So for color vision testing, we have several different types of color discrimination testing, and we'll discuss some of the more common types with which you should already be familiar. Color plates have some of the highest detection accuracy of any screening. They're very close to 100% sensitivity and specificity when they're administered properly. So no matter which test we use, it's important to administer the test using the proper light sources and to follow the testing instructions so we get this high sensitivity and specificity that we would like. With all color tests, the type lighting we use is important to ensure that the proper colors are represented. And the proper lighting used for color vision testing is described as northern daylight. So you could take a person outdoors on a reasonably sunny day and have a good light source there in the sun. The classic light source indoors is the Macbeth easel lamp up in the upper left there, and it's hard to find one of those these days. You can get a booth that's shown there in the center, but we want a light source, whatever we use, that has a color temperature of greater than 5,000 degrees Kelvin with a good color rendering index, at least 90. So this ensures a light source encompassing the entire visible spectrum with a color of white similar to daylight. And these values are labeled on the bulbs. So you could certainly use even a incandescent type bulb or a fluorescent, but just look at the color rendering index and correct the color temperature and confirm with any visit to your friendly Lowe's or Home Depot. But your cool white or warm white fluorescents may not be adequate. So Ishihara plates, which are probably most familiar, these should be held at a distance of 30 inches. That's something that people tend to hold them in closer. This is like a near-point test, right? No, it really should be about 30 inches. Patients should be allowed three seconds to respond. You don't give them 30 seconds to hem and haw over what they might be. If they can see them, they should be able to see them within three seconds. So as I said, the Ishihara is one of the most common pseudo-isochromatic plates out there, so you're probably familiar. What you might see in a 14-plate edition is a demonstration plate. Here, number one, that is what everyone should see, even a coned monochromat, because those are not coded by color at all. There's a luminance difference there, so everyone should be able to see those. If they don't, then think something might be going on cortically here, malingering or otherwise. Two to ten are the basic test plates. Twelve and thirteen plates are diagnostic plates that are used for those failing the initial test. However, the way we do testing occupationally is typically run the whole gamut of tests and then have the experts figure it out at the end if there happens to be a fail. You also see the trace test, sometimes called an illiterate for individuals that don't know their numbers. They can trace these. I don't think you'll be using this commonly. If you do have someone trace it, please let them use a Q-tip, not their finger, or otherwise you'll get oils on your plates and ruin them. This figure is the R.D. Rand Riddler HRR 4th edition, to which many agencies are moving. It provides results equivalent to or better than the Ishihara when it's done properly. It can help eliminate cheating or memorization. Since it's not numbers, they're figures, we can rotate the test four different directions to have the person say, what are these shapes and where are they located, so you know that they're just not memorizing unless they're really good and can memorize all four positions. On this one, most organizations use all 24 plates. In fact, on these, there are four demo plates, six test plates. The test plates are five through 10. The other ones really go into the diagnosis, but you will see most agencies testing all of them and then figuring things out at the end. It helps if there's any inconsistencies just to do all 24 plates regardless. I don't think that's a bad policy. Another common type of color test or color arrangement test, these really are not standalone screening tests because passing does not mean that the color vision is normal. I'll see this even from some of my colleagues. It frustrates the heck out of me. Pass the Farnsworth D15 normal color vision. No, that is not the case at all. A Farnsworth D15 test will pass 50% of defectives. The D means dichotomize. That's what D15 means. It dichotomize 15. There's 15 caps and it separates or dichotomizes the mild or moderate color vision deficiencies from the severe. If you have a job where the essential job function can be done adequately by somebody with a mild or moderate defect, but not with a severe, this might be a good test because you can separate the mild and moderates who can pass this with the severe deficiencies who cannot. There's also the Lanthony D15 that'll separate those moderates and milds if you like. For real fine color discrimination, for people that work with paint pigments for instance, the Farnsworth Munsell 100 hue test might be even better than this. The FM100 trick question, 100 caps, right? No, there's only 85, but this is a very detailed test that can really find very small color differences between the caps. It's very challenging for individuals. Jewelry appraisers is another good example of someone who needs this. As a matter of fact, a master gemologist appraiser needs to pass an FM100 with an error score of 25 or better. 25 is difficult even for a person with normal color vision. If you see these tests coming in and a person has a zero total error score, something is amiss. The availability of tests online or for Amazon purchase can make our jobs more challenging because the applicants who really want a position and know that they have a color deficiency will buy these tests and memorize them. Again, that's an advantage of the HRR fourth edition. You can rotate them 90 or 180 degrees, administer the test, and see if the correct responses are still given. That's not the case with the issue. You can certainly randomize the order of presentation. You don't have to go through plates 1 through 14. You can mix it up. Now for a practical application of color vision, pilot is one occupation for which good color vision is important. Looking at this, is this a modern or older aircraft? It's a little bit of a trick question. This is a Concorde, certainly a very sophisticated aircraft, but it first flew in 1969. You still see a lot of white on black gauges, not a lot of color tasks in the cockpit. Compare that to a modern glass cockpit, which uses a lot more color. Color vision is becoming even more important than it has been in the past. One of the acceptable alternate tests for FAA color vision testing is the Farnsworth Lantern or the Phalanx. This was designed by the Navy and it simulates the signal light gun that's used to signal planes from the control tower. Its presentation is a series of two lights that are red, green, or white, one above the other. There's a more modern version called the Optech 900, but the presentation is the same. This has some problems and I'll tell you what the problems were and hopefully we won't have to deal with it much longer. If you've ever watched outside when landing in a plane, you'll notice a series of lights along the edge of the runway and these are called precision approach path indicators or PAPI lights. There's a series of four horizontal lights and pilots will look at the incremental guide to determine whether they're on the correct glide path for landing. If you see four whites, they're definitely too high. Four reds, way too low. An ideal glide path is two whites and two reds. What happened back in 2002, yes over 20 years ago now, a FedEx plane crashed on landing in Tallahassee, Florida. The story is that the first officer told the captain the PAPI lights were four white so it was too high. Without looking apparently, the captain adjusted, went lower, crashed the plane short of the runway. They both survived fortunately. I think you may have lost a package there if you had anything on that FedEx flight, but the individuals lived. Further testing could be done and it revealed that the first officer had a severe deuteranomaly. Remember deuteranomaly based on he has still three cone types but very severe and the only color vision test that he could pass was the far north lander, the phalanx, and the signal light gun. So then at that time, 20 years ago, the National Transportation Safety Board recommended research on the effectiveness of the FAA color tests, and over 20 years later, the phthalate remains. I heard back about the time of AOHC in May, that the FAA had finally gotten rid of the Farnsworth lantern, and here we are in November, and on the FAA website, Farnsworth lantern still exists. So I guess it's taking them a while even to get rid of it in its finality, but be careful of that test. Well, let's look at some of the common pitfalls. Certainly using a Farnsworth lantern is a big pitfall that we don't want to use. We already talked about lighting. Remember, oh, typo on the slide. Sorry about that. 5,000 degrees Kelvin, not 500 degrees Kelvin, 5,000 degrees Kelvin, color rendering index of over 90. Be careful about X-chrome lenses or other colored contact lenses, or unfortunately, I've heard from some testing agencies even allowing candidates to wear the colored glasses. No, that's a no-no. We need to find out whether they have a color vision deficiency. Without aid, make sure they're not wearing anything other than naked eye or perhaps clear spectacles. Memorization, randomize your presentation. Even if you're using the HRR, go in different order, or even if you're using the Ishihara, the HRR makes it easier to randomize your presentation. And watch out these days for replacement candidates. I've seen some trying to infiltrate Homeland Security, unfortunately, and there's been kind of a, well, all of us have been made aware to watch out for this. A person has, in the past, always failed color vision tests, having a pretty severe deficiency, and they'll come in now in 2023 and perfect score on the color vision test. No way. This is a different person. If you fail color tests, you don't get better until we start injecting the things, the genetic things we did into the monkey. So ensure a positive ID check and just make sure that there's, someone doesn't slip through the cracks that way. It can be a safety issue. In Homeland Security, it could be a big safety issue. So, there are some online color tests that are being used these days, and some of them are good. Typically, the ones that are good, you actually have to purchase. All the ones on the left here, you do purchase. There's no freebie online ones, but particularly the Rabin Cone Contrast Sensitivity Test, the bottom bullet there on your left is being adopted by most of the U.S. military, and these other ones are very good as well. But if you see results brought in or even trying to be administered at the test center, by Chroma, they're the ones that make the glasses that can help in some ways that should not be used for occupational. ColorMax, any other online test, because in addition to the color monitors maybe being problematic, they use scan plates, and they're not the same as the plates in the original version that you're testing in your Ishihara or HR fourth edition test. It is not the same. So conclusions, testing to a standard as far from new, the Chinese have been doing it for millennia. Color vision deficiency is common in males. We said 8% of Caucasians. Color vision can be important on the job, coding and transmitting messages very quickly often depends on normal color vision, certainly for times where there is complex visual displays that have to be organized. And you have to do your color vision testing properly for high accuracy. And on a more general note, standards must be based on essential job function. Don't ever forget that or you will have attorneys breathing down your neck. So thank you and appreciate your attendance here. I'd be happy to entertain any questions. Thank you again. Thank you so much, Dr. Weber for that relevant talk. So at the Kabutsu our occupation medicine practice, I am glad that you talked about the online tests because I've had a lot of questions about that. And I think you pretty much clarified it for us. I actually don't see any questions in the chat, I wonder if you have any guidance for medical centers as to what healthcare worker job titles or categories should definitely undergo color vision testing versus not necessary or does everyone get tested? Do you have any general guidance on that question? Well, sure, I appreciate that question. I hope that most of the people that we're testing for have had developed job standards for them. And if color vision is one of those things that affects essential job function will be spelled out, this is one of the things that has to be passed. But transportation, and I think I had a slide related to this. Transportation is probably the biggest one. Anybody in any role of transportation, whether it's on the ground, on the water, in the air, that's probably one of the most important ones mostly because of the speed there. And with that demonstration of how important it is to have color coding versus shape coding, even on that demonstration, you can see how much faster an individual can react when things are color coded. And many things in transportation are color coded, stoplights and any other signaling devices. So that's probably the most critical is transportation. But if you even just think about other individuals, most law enforcement requires a normal color vision too. Mostly for identification purposes, identifying individuals, identifying whether a person is actually carrying a weapon or just some type of device that could be a distractor. It's a life and death situation. So I think any time that the higher the risk of the occupation, the more likely it is that a color vision standard will be important in that color vision testing should be done on that individual to see where they stand and how safe they're gonna be to themselves and to others that they deal with in their job. Thank you for that. There's a question from Dr. Chang. It says, very informative talk, thank you. Is there a standard test and numbers slash metrics used for depth perception testing? I mentioned in the discussion there that the ones that you will typically see are a test of local stereopsis and that it's typically 70 to 80 seconds of stereopsis. The reason that is done is because for a person that does not have strobismus, doesn't have an eye term, exotropy or esotropy, for a person that does not have strobismus, doesn't have an eye term, exotropy or esotropy, anybody with bifovial fixation is a term we use in eye care so that if you're looking at an image, the image is focusing on the maculas, the foveas of the center of the maculas in the center of the retina. So there have been studies that shown that for anybody with bifovial fixation, 98% of those people are going to have stereopsis at least at a level of 80 seconds of local stereopsis. So that's how that kind of comes about. And in most cases, it's a good way of screening for strobismus or esotropy, exotropy or any of the vertical tropias. It's not foolproof. I just talked to an ophthalmologist in upstate New York yesterday because he had done a report on a customs and border protection officer for border patrol. And he reported 25 diopters of exotropia and 50 seconds of stereopsis. And I said, how can you correlate these two findings that you have in your report? He goes, I don't know, it surprised me too. It's like, yeah, because it can't be. The individual probably had to memorize since there are so few test plates that are out there. So the ones you're going to most likely see are randot, titmus, and the ones that are in the, within the testers are variations of those. It seems like more people are getting this, the dipistio, I think that's how you pronounce it, tester versus some of the original titmus testers. So you'll see that on reports if you're not doing it yourself, more commonly. I'm seeing more and more of that, the dipistio, but there's only, I think about six, six of the distinguishing circles there. So it's not a very sophisticated test. But any of those are what we have to deal with. If you have more than one, at least you can try them on, one, make sure they're not memorizing. All right, thank you. There are actually two more questions. One of them is, for healthcare, direct interpretation of colorimeric tests such as dipsticks or CO2 detectors in anesthesia. This is an important function and the restriction which we assign for color impairment is no direct interpretation of colorimetric tests. So that's more of a comment than a question. Don't know if you want to comment on that or there's also another question after this, it's up to you. Yeah, I'll just comment on it. And thank you, Dr. Christensen for that. That is true that there are certainly very specific interpretation type things or correlations that we can do for each individual job. So that's a great example that you use there. Other things, I think where we don't want to go down is some of the tests that had been done in aviation, they used to use these just color threads, coat yarn. And that really was not a very good test because those would fade out and they would get bad. So as long as you've got a good test for whatever specific application there is, including these dipsticks and CO2 detectors, that's great. Just make sure it's a valid test. There's another one, Dr. McKenzie. Yeah, that's a great point. I think there are two more. If we are developing vision standards for a new role, what is a single best test of color vision that should be used? Well, as I said, most of the governmental agencies are moving towards the HR fourth edition. And I think that if you look at the studies, it compares very well to the ICHI-HAR that had been the standard before, but it offers a couple of things that are better. One, there's more plates, where you get an ICHI-HAR with a large number of plates, but it wasn't very common. But the HR fourth edition has a large number of plates and they're not numbers so that you can rotate them in all four directions just to reduce that likelihood of memorization, even if you're not changing the number of the way you're doing the test plates. You really shouldn't do the test plates even on the ICHI-HAR from one to 14 straight, you should mix them up. So you won't have the likelihood of memorization, but it's easier to do. You've got that option and then the rotation option on the HR fourth edition. So I think that's why it's becoming so popular. It makes sense. And another, do the Enchroma lenses for color vision really help? Well, they change the interpretation of the way people see. If you see their commercials, a person will put on the Enchroma lenses and they'll just, their eyes and their face will light up like it's the first time they've ever seen the world, like coming back from the blind. It definitely changes their perception, but it doesn't improve the functional advantage that color vision itself gives. So if you put a person wearing that's color deficient, wearing those Enchroma lenses on that demonstration that I did in this, the shapes versus the colors, they still may not get the colors because they're not gonna see them the way that a normal color vision person would. So they really are, if somebody wants to wear them on the job after they've tested adequate color vision for the job, that's probably fine, but they shouldn't be used for testing because it could help them to pass a color test, but not for functional color vision now. Okay, it looks like there's more interest being generated. Okay. Off the topic of main color vision, do you think the CDL visual field requirement of 70 degrees in each eye will ever get changed? I heard a comment at the ACLH meeting about that, and I think it was a very valid comment. One of the ways that standards get overturned is if there is something like a reason, if there's an accident or a death that makes the requirement be overturned, despite this laughable vision standards of 70 degrees in each eye, which is, I mean, if you think about that, would you want to be driving on the same road as somebody that only had 70 degrees of visual field in each eye? No, not even in a Pinto, let alone an 18-wheeler. So the, but there have not been any accidents, much like the FedEx, the FedEx crash in Tallahassee, may 20 years later, eventually change the FAA standards. There's never been a crash CDL driver that they can say it was based on the fact that they had, they passed the 70 degree field, and because of that, they killed someone. So we need to make that a normal standard. There's no reason to overturn it from a medical legal standpoint. And unfortunately, that's probably, because of that, it's not going to happen until the day that something tragic does happen. One from Dr. Verber-Moore, you mentioned the Logmar is better for visual acuity testing. Are you of the same opinion regarding Jaeger versus vision tester? You know, that's a good question. In terms of near testing, if you have somebody that is correctable to any level at distance, 20 degrees, whatever the standard happens to be, or whatever they happen to be there, there's no reason you shouldn't be able to get that same person to that same 20, 40, or 20, 20 at near with the appropriate optical device, typically a bifocal if they're over 40. So I guess I'm not personally as concerned about the near visual acuity at all. I know there are many jobs that do have a near visual acuity standard, but if I know what a person's distance visual acuity is, I know that I will be able, or someone will be able to correct them to that same near visual acuity. So whatever way we use to test the near is probably not as critical to me, but the Jager is certainly a good test to use outside of the instrument, but you don't have to worry about that proximal accommodation that I mentioned when you're looking, you already think you're at near when you're in a tester, you're not gonna over-focus for near, you're just over-focusing for distance when you're doing that. All right, and one final one it looks like. So could you use chroma lenses for accommodation for someone, such as an electrician, is this possible? No, I'm actually saying you definitely should not use that because the functional, they're not improving, it's not improving function. Things will look different, the wires will look different to them than when they're not wearing the chroma lenses, but it's not going to improve their safety and they could still electrocute themselves, wire something wrong to cause a fire somewhere down the road. So no, and chroma lenses should really not be used, they're a very expensive toy, sunglass equivalent I suppose, if you will for a individual with color vision deficiency, but if you're looking for job function, don't even put them in the equation. All right, well, Dr. Weaver, thank you again, that was a great talk and certainly very relevant. Well, thank you for having me and I hope everybody had a great week at the virtual meeting here. Hope to see you live in Texas, right? Austin, Texas next year? I think it's Orlando. Oh, okay, I'm getting my organizations crossed. That's okay. And I just want to say thanks to everybody for joining us on our final day and whoever was here the past two days as well for the Virtual Fall Summit. Your participation helps us to be successful and we try to give you what you need through ACOM. We will now hear a few closing remarks from our president, Dr. Kenji Saito. And now, as we conclude this fantastic three half day conference, I hope the Virtual Fall Summit has met your expectations. We've delved into the future tool of using artificial intelligence in occupational environmental medicine, recognize the impact of climate change on our field and explore the clinical aspects of OEM. You'll receive an email to claim your continuing medical education credits and provide feedback. So please complete them. Finally, I'd like to invite you to AOHC 2024 in Orlando this May. We look forward to welcoming you there and thank you for being a part of this conference. See you in Orlando. Thank you.

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