Introduction to some COVID-19 pandemic issues

The wildfire of the COVID-19 pandemic is spreading through the world. The arsonists, all while hiding the matches, are offering their help to clean up the burned places by providing some essential protective necessities – all while being praised by the media which has always been in awe of autocratic regimes, starting with German and Italian fascists and their variants. The world has to handle this very much self-inflicted wound.

The tragic death count is on display, and the economic losses are well known, the current quarantine restrictions have changed the lives of people around/throughout the world. However, the unaccounted for result of COVID-19 is apparently a pandemic of fear. As a normal protective mechanism of living species, fear becomes damaging in excess for individuals, and is dangerous for politicians who are operating in the public eye of the masses.

These introductory words preclude my presentation of some issues pertaining predominately to safety in anatomic pathology laboratories under COVID-19 conditions. However, the observations and recommendations can be extrapolated to other individual and collective safety issues. They are written from the perspective of my experience as a Chief of Sanitary-Epidemiological Station back in Karelia, Russia, an experimental immunologist (PhD program), a clinical and anatomic pathologist (Leningrad-St. Petersburg), a pathologists’ assistant (including morgue attendant) and grossing technologist (Chicago).

As an epidemiologist, I was obliged to manage all ranges of actions during local epidemics including dysentery, hepatitis, and some sporadic cases of anthrax, tularemia, and others. While working in anatomic pathology, I tried to follow the safety rule, although I managed to accidentally stick my finger during an autopsy of a deceased acute HIV patient. The variability of conditions in individuals’ lives and work across different countries are incomparable, but the common denominator remains to be the rationality of actions under current circumstances.

Every experience is limited and personal biases are inevitable. It does not make any sense to repeat well known issues. Perhaps, a different perspective might be useful.

ICD-10 code for COVID-19

The correct medical statistics is crucial during an epidemic. The mortality data are particularly significant during COVID-19 because it is one of the unusual signs of this epidemic.           

National Vital Statistic System (NVSS) issues COVID-19 Alert No. 2 letter on March 24, 2020 that “a newly-introduced ICD code has been implemented to accurately capture mortality data for Coronavirus Disease 2019 (COVID-19) on death certificates.” “The new ICD code for Coronavirus Disease 2019 (COVID-19) is U07.1.”

The letter includes also a puzzling paragraph: “The WHO [World Health Organization] has provided a second code, U07.2, for clinical or epidemiological diagnosis of COVID-19 where a laboratory confirmation is inconclusive or not available. Because laboratory test results are not typically reported on death certificates in the U.S., NCHS [National Center for Health Statistics] is not planning to implement U07.2 for mortality statistics”. (Bold and [ ] brackets added).

Epidemiological diagnosis exists only in WHO’s heads. There are clinical and post mortem/autopsy diagnoses. The latter is not mentioned at all. Clinical and autopsy diagnoses can be a source for the epidemiological assessment but not otherwise. So called, epidemiological diagnosis makes mortality rate more discretional and to some degree inflate the numbers of death during COVID-19. The last thing that we need in this coronavirus pandemic which is accompanied by an epidemic of fear.

The World Health Organization allowed China (the second after USA donor) to hide real the COVID-19 outbreak’s numbers in December-January. The cavalierly approach to death statistics is not helpful, moreover counterproductive.

Excerpt from Center for Disease Control and Prevention (CDC) official document on COVID-19

https://www.cdc.gov/coronavirus/2019-nCoV/lab/index.html

The CDC 2019-Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel is a real-time RT-PCR test intended for the qualitative detection of nucleic acid from the 2019-nCoV in upper and lower respiratory specimens (such as nasopharyngeal or oropharyngeal swabs, sputum, lower respiratory tract aspirates, bronchoalveolar lavage, and nasopharyngeal wash/aspirate or nasal aspirate) collected from individuals who meet 2019-nCoV clinical and/or epidemiological criteria (for example, clinical signs and symptoms (the difference between signs and symptoms?) associated with 2019-nCoV infection, contact with a probable or confirmed 2019-nCoV case, history of travel to geographic locations where 2019-nCoV cases were detected (except Antarctica and Arctica in the pandemia?) , or other epidemiologic links (couple examples ?) for which 2019-nCoV testing may be indicated as part of a public health investigation). Testing in the United States is limited to laboratories certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. § 263a, to perform high complexity tests. Results are for the identification of 2019-nCoV RNA. The 2019-nCoV RNA is generally detectable in upper and lower respiratory specimens during infection. Positive results are indicative of active infection with 2019-nCoV but do not rule out bacterial infection or co-infection with other viruses. The agent detected may not be the definite cause of disease. Laboratories within the United States and its territories are required to report all positive results to the appropriate public health authorities. Negative results do not preclude 2019-nCoV infection and should not be used as the sole basis for treatment or other patient management decisions. Negative results must be combined with clinical observations, patient history, and epidemiological information.

Bold, italics, and question mark are mine. Many question marks are in the CDC official document.

Lungs infection and lipid metabolism

With many apologies for the intrusion in the internal medicine realm, a reminiscence from my PhD program old days. This is somehow related to COVID-19 outbreak. It is obvious that the main problem is lung damage due to virus itself or a bacterial pneumonia which is followed.

My teacher, professor L. R. Perelman, an extraordinary pathophysiologist, always repeated that lungs are one of the main lipid metabolism places. Chylomicron’s catabolism plays a significant role in activation of alveolar macrophages and the phospholipids synthesis of the pulmonary surfactant. He insisted that diets that are rich in fat are advised in lung infection. The folks medicine used bear or dog lard for tuberculosis treatment. And indigenous Arctic circle people’s diet is rich in fat.

Perhaps, this is well known to the internists in charge for treatment. Again, my apology for these remarks on the subject that is not area of my expertise.

To the Hydroxychloroquine controversy

Some remarks to the hydroxychloroquine controversy which left the medical field toward politically charged public discussion. I am not going to participate in it but want to share some reminiscences which I inherited from my internal medicine teachers 50 years ago.

As it is well known Hydroxychloroquine is a synthetic form of an old alkaloid drug Quinine, the veteran malaria treatment remedy. I remember my late aunt’s yellow skin during her treatment of malaria onsets.

However, Quinine was a drug of choice for treatment different forms of pneumonia including lobar, which is disappeared now, 100 years ago. Before antibiotics, Quinine and different forms of it, were injected intramuscularly for more gradual prolonged action (otherwise it was destroyed in the liver).

It was thought at that time that Quinine drugs work the best in a case of pneumococcal pneumonia. Perhaps, post coronavirus specific anti pneumococcal Hydroxychloroquine’s action is optimal. Experience of treatment pneumonia using Quinine drugs before antibiotics era is valuable when there is pneumonia complication of coronavirus course of disease.

FDA authorized Hydroxychloroquine only for coronavirus patients but not as a prophylactic measure . There are the doctors’ reports about positive results of COVID-19 treatment in the early stages of infection. Usually, it is administered in combination with an antibiotic azithromycin.

Quinine drugs are not indifferent to liver function and heart rate. I’ve seen a video when a doctor administrated Hydroxychloroquine treatment on Skype.

Unusual development of COVID-19 in some young adults

A quote: “It’s young folks, previously healthy,” said Eric Wei, an emergency room doctor and chief quality officer at NYC Health + Hospitals, the city’s public hospital system.  “They look like they have the flu. Within hours, they need oxygen. Within a few more hours they need a ventilator.” (Blomberg. Many New York Coronavirus Patients Are Young, Surprising Doctors by Michelle Fay Cortez and Olivia Carville, April 1, 2020).

With apology for the intrusion in the internal medicine realm, a guess from an old experimental immunologist. Maybe, this is the Arthus reaction, Type III hypersensitivity pneumonitis.  Internal medicine and ER people know what to do in this situation without my advice.  

Personal Protective Equipment (PPE) and Beyond

Watching the health workers in China, I always doubt that they could work in their protective attire efficiently for a long time. They looked more like intimidating alliance from a space ship. What are their boots for? As I can see on the TV, people, who are working in the patients wards in USA,  are ”packed” in Personal Protective Equipment (PPE), which does not contribute to efficient work.

Is SARS-CoV-2 different from other previously known Corona viruses? As far as we know from the open press, this virus is not different except more transmittable and contagious, which is still questionable, and unfortunately more excessive morbity and obviously mortality, like in Italy. The Italy’s case still is waiting for sober analysis.

As far as Personal Protective Equipment (PPE) is concerned, Occupational Safety and Health Administration (OSHA) in Guidance on Preparing Workplace for COVID-19 states: ”Workers, including those who work within 6 feet of patients known to be, or suspected of being, infected with SARS-CoV-2 and those performing aerosol-generating procedures, need to use respirators.”

The most popular is NIOSH-approved fit-tested N95. On the paper this looks easy. OSHA recommends the employer, the employer requires the employee, but it is extremely difficult to work by using a N95 respirator for a prolonged time.

No any anatomic pathology laboratory work meets the mentioned above requirement as well as “close contact” situation. The weak place is the frozen section procedure which requires a separate presentation.

Center of Disease Control and Prevention (CDC) defines “close contact” as being about six (6) feet (approximately two (2) meters) from an infected person or within the room or care area of an infected patient for a prolonged period while not wearing recommended PPE. Close contact also includes instances where there is direct contact with infectious secretions while not wearing recommended PPE. Close contact generally does not include brief interactions, such as walking past a person.

CDC does NOT currently recommend the general public use face masks. Now (3/3/2020), the CDC changed their approach. The use of mask in general population will be addressed in one of the post the next week.

When I see medical personnel in an Italian patient’s ward, my feeling is that they cannot provide an effective care in such attire despite ventilators and best in the world medication. They require special personnel to dress and undress them. They are living people who have physiological needs. In my understanding, such PPE can be used for a short time during procedures which include placing or removing from a ventilator, suctioning air ways, bronchial lavage, etc.

In the complete adherence to OSHA for COVID-19 recommendations, a workable attire should include following items: a disposable plastic gown (tied on the back), cap (covering ears completely), goggles type glasses, a protection mask with a shield, and disposable gloves. In my view, double glows are obligatory (explanation later). Is the shoes cover advisable?During an epidemic yes, just to prevent spreading infection outside the laboratory. This is not a cavalierly rather a realistic approach.

In the gear

For many years, I used the Upsidedown Kimberly-Clark FLUIDSHIELD mask on a regular basis during my work in the surgical pathology grossing room. (See more details The Protection Masks post).

The main crucial point of using PPE is how the attire is taken off. In this regard, the ways for infection transmission would be appropriate to present. This knowledge would be useful for the general public as well.  

The SARS-CoV-2 virus, which is the source of concern, dwells in wet surroundings of more or less size invisible droplets. It comes from their human carriers (ill or not). The virus does not jump, but the semi-dried out virus, which is attached to the protective attire (otherwise why the attire is used), can reach the “entrance gates” (medical term) for infection (nose, mouth, eyes) just at the moment when the attire is taken off. This brings us to the rational mode how to take off PPE.

On the TV, I’ve seen how a doctor took off his protective gown and gloves (first) with fast movements while placing them into an open large bucket. This is dangerous for him and the environment, especially in the limited room space under air conditioning circulation.

There are certain common-sense rules which I have inherited during my training and work as an epidemiologist.

First, the attire should taken off be in a slow motion manner.

Second. Following a certain sequence of items, which are taken off :

with still gloves on, the gown is taken off the first; it is slowly folded with external side inside and rolled before place in the collection bucket; then the double glow is taken off slowly,rolled exposing their internal side, placed in a trash bucket; then the cap is taken off in the same manner; then protection of eyes/face goggles/glasses/mask with internal gloves still on. The internal gloves are taken off slowly, rolling the glove from one hand and taken off from the second hand using the rolled glove as a tool. Both rolled gloves are slowly placed in the trash bucket.

Hand wash and all open face’s hair areas (eyebrows, mustache, beard) by closed eyes.

The process of taken off the protective attire is very important in preventing self-inoculation. The most significant is the contamination of the laboratory environment. This issue will be addressed in following post/s.

The presented PPE principles are applicable in private life. Understanding of the rationale of infection protection can be helpful in different everyday life situations. The angel is in understanding of the details.

Protection mask under COVID-19 condition

While observing the protection mask in laboratories, I’ve noticed that some are “overdressed” making work uncomfortable by leaving areas of potential exposure unprotected. Below is the excerpt from my Grossing Technology book’s Occupational Safety section Protective Mask. This observation is especially significant during COVID-19 epidemic.

In the case of potential exposure to tuberculosis, AIDS, SARS – coronavirus, Methicillin-resistant Staphylococcus aureus, etc., a different kind of protective mask should be used. The Kimberly-Clark FLUIDSHIELD mask is definitely advisable,

however,

by wearing it in the upsidedown mode (Figures 15-6 and 15-7).

Figure 15-6.

Obligatory glasses.
Figure 15-7.

First, two internal layers are made from unwettable material. Designed to prevent penetration of splashes, the mask is not suitable for a prolonged use. The breathing area is overheated because the mask hampers evaporation. There is also over saturation with exhaled carbon dioxide that decreases the percentage of oxygen in the inhaled air. If we add undesirable reflections of the plastic shield (WrapAround SPLASHGUARD Visor), the conditions of using the mask become more unfavorable. It is more reasonable to wear the Kimberly-Clark mask with the plastic shield upside-down. In this situation, the area of air circulation is larger.

Second, while using the “modified” Kimberly-Clark mask with the shield down, I noticed that many droplets of blood, stain, and other fluid could be found on the plastic shield. It means that the chin and the neck, as more vulnerable to contamination than the forehead, are more protected from splashes and spatters. The shield reaches the ubiquitous blue protective gown like Convertors (ALLEGIANCE’s Impervious Gown w/Thumbhooks, Universal). One lower fold of the mask can be loosened to make the mask longer or the plastic shield can be cut to make it shorter if it is necessary for the individual adjustment. The lower strings can be tightened or loosened depending on the type of the processed specimen.  The use of protective glasses with solid side shields at the grossing table is a necessity and the OSHA’s requirement without any exception.

If an air permeable light fabric extension to both sides of the mask were added with strings tight behind the neck, this design would make the mask more protective and comfortable for a prolonged work.(Figure 15-8). This “improvement” would not substantially increase the cost of the mask.The Kimberly-Clark FLUIDSHIELD mask line production had already been established for many years.

Figure 15-8.

Perhaps, some other vendors will come across this post and implement this principle of a protective mask design.

Such type of a protective mask would be useful now and after the tide of deaths and fears. Only a simple design is workable.

Reflections on Formaldehyde Carcinogenicity

Formaldehyde carcinogenicity is now a commonly accepted notion in society, as well as in anatomic pathology laboratories. Guilty on arrival. However, the background of this concept is far beyond a reasonable doubt.

There is not now even an echo politically charged dispute of 1980s between U.S. Environment Protection Agency (EPA), Occupational Safety & Health Agency (OSHA), College of American Pathologists (CAP), Formaldehyde Institute, DuPont, and labor unions on the evaluation of formaldehyde occupational exposure risk, which was based on the assessment of formaldehyde as “probable carcinogen” at that time. 1 In 1989, the American Medical Association (AMA) summarized the literature data through 1985 on occupational exposure to formaldehyde. Mentioning that regulatory agencies as OSHA, regarded formaldehyde as a possible human carcinogen, AMA observed that “this is a controversial opinion in the view of many industry and academic scientists.”1

Times have changed. The main organization influencing the assessment of reagents as carcinogenic is the World Health Organization’s (WHO) International Agency for Research on Cancer (IARC) based in Lyon, France. IARC summarizes literature data predominantly epidemiological research, as well as some experimental studies. According to IARC Press Release No 153, 15 June 2004 formaldehyde is placed in Group I – known carcinogens- along with such substances as asbestos and benzene.2 The dispute is over.

However, the Monograph Programme, the IARC’s main document, presents cohort and case-control epidemiological studies predominately manufacturing and garment industries, as well as exposure in mobile homes to formaldehyde- containing materials.3 The main conclusions are based on studies of industrial workers, although there is a group of professionals which included pathologists, anatomists, and funeral homes workers. The data are quite contradictory due to the misclassification and the inadequate methodology of the dose-response relationship. Most data represent epidemiological studies, including cohort analyses which cannot be now repeated due to changes in manufacturing and environment.

There are conflicting literature data on this subject which cast doubt that the IRAC conclusion is balanced and can be accepted as a scientific fact. Despite attempts of scientific objective discussion, there is a trend to leave out some publications and opinions that contradict the group’s conclusion.4-9 Most references reflect data before 80th even if the articles are published after 2000. The long list of references represents limited groups of authors which publish articles in different combinations.

There is a discrepancy between the statistical epidemiological data and minimal clinical evidence from physicians who observed particular or groups of patients. Neither otolaryngology, nor other surgical manuals even mention formaldehyde as a possible ethological or contributing factor of cancer in their clinical observations. The fundamental “Cancer Principles and Practice of Oncology” do not mention formaldehyde either in carcinogenicity or in other clinical chapters (head and neck, lung).10Pathologists haven’t observed higher morbidity or mortality of colleagues and technical staff in contact with formalin. (See details at post “Formaldehyde carcinogenicity as safety concern” at Safety section).

The divide regarding formaldehyde carcinogenicity has a remote analogy with global warming/climate change. Nobody dare to challenge this notion. The deleterious effect of formaldehyde makes carcinogenicity so obvious that it is even impolite to question its credibility.

In practical sense, however, the dispute over formaldehyde carcinogenicity is meaningless at this time. We have to accept the conclusion of IARC until it is proven wrong. Moreover, there is barely a chance that such studies will be conducted in the foreseeable future. The USA regulatory agencies, the EPA and the OSHA assume formaldehyde as a potential occupational carcinogen with appropriate regulations. 1 OSHA mandated the notice in any laboratory or industrial area where formaldehyde mixtures or solutions capable of releasing formaldehyde into the air at concentrations reaching exceeding 0.1 ppm are used:” Danger: Formaldehyde: irritant and potential cancer hazard.”

Manufacturers have accepted regulation and measure improvements in the work place environment, instead of engaging in costly altercations with the EPA and lawyers, as well as sustaining public relation losses with the aggressive coverage on formaldehyde carcinogenicity subject by the mainstream media. The American Conference of Governmental Industrial Hygienists (ACGIH) has more stricter requirements for time weighted average (TWA) short-term-exposure limit (STEL) (0.3 ppm) than OSHA (2 ppm), although the recommended exposure limits do not have a legal application in the USA in opposite to OSHA. It is remarkable that the ACGIH 0.3 ppm limit is set on irritation, not carcinogenicity.

Clinical laboratories and other facilities (anatomical, research) have accepted the OSHA requirement for 8 hours time weighted average Permissible Exposure Limit (PEL) of 0.75 ppm. There is not in public domain 8 hours TWA by the ACGIH. The management of local laboratories accepts this measure without any question. The institution’s authorities would not forgive the laboratory management’s failure to meet these relatively simple requirements because there would be some consequences of accreditation which nobody needs.

This rosy picture, however, obscures very important question. The regularly scheduled monitoring reflects more or less the general environment in the work place but the devil of formaldehyde exposure is in the details of every day work practices– how the splashes and spills are handled, as well as wet specimen disposal; this is when the most overexposure occurs, but nobody monitors and even pays attention. The everyday practice occurrences of overexposure are more important than quite theoretical carcinogenicity.

During overexposure, the workers lose, temporally or permanently due to sensitization, the natural defense of the upper respiratory tract or skin. Given by evolution, both are, especially upper respiratory area (nasal mucosa, paranasal sinuses, conches) with the tiny cilia movement mechanism, very important immunological line of defense not only against pathogenic infection although the latter is the main beneficiary. (See more details in ”Formaldehyde exposure safety rationale” in the Safety section  ).

Toxicity of formaldehyde overexposure is not urban legend. Due to my silly behavior during a cleanup of a formalin spill, I lost once my voice for a week. Of course, it was a chemical injury. However, some “micro burns” occur in practice on a permanent basis. For example, when the working tissue processor is opened for some reasons (add/take out a cassette/s, check something, etc.)in formalin phase a vapor of formaldehyde from the warm formalin goes in the person’s breathing area. Separation of specimens from formalin during specimen disposal is a different example. In my pathology youth, I had many eye injuries by formalin splashes.

Regarding formaldehyde carcinogenicity everyone is entitled to his/her opinion, especially the question is unsolvable at this stage of society’s development.

In my opinion, this is an unproven concept. However, the harmful effect of formaldehyde exposure is indisputable. Efforts should be concentrated as much as possible on the prevention of negative consequences, by improving working conditions, introducing and following safe work practices. It should be made clear to everyone that personal responsibility is matter of paramount importance.

(See also posts “Monitoring formaldehyde exposure ”, “Formalin Spills and Splashes”, as well as the summarized article”Formalin safety in the surgical pathology laboratory” in the Safety section. Although the article is too long for a website, it provides a comprehensive approach to formalin safety topics that are presented in separate website’s posts. It is an “uncensored by reviewers” variant of the article which has been published in LabMedicine in 2009 )

References

1. Council Report. Formaldehyde.  Council on Scientific Affairs. JAMA 1989; 261:1183-1187

2.  IARC Press Release No 153, 15 June 2004

3. World Health Organization International  Agency for Research on Cancer IARC Monographs on the Evaluation Carcinogenic Risks on Humans Volume 88 , 2006 Formaldehyde Monographs Programme  http://monographs.iarc.fr/ENG/Monographs/Vol88/index.php

4.  Collins JJ, Acquavella JF, Esmen NA: An Updated Meta-Analysis of Formaldehyde Exposure and Upper Respiratory Tract JOEM, Vol 39, Number 7, July 1997: 639-651

5.  Gardner MJ, Pannett B., Winter PD, Crudas AM.  A cohort study of workers exposed to formaldehyde in the British chemical industry: an update British Journal of Industrial Medicine 1993; 50: 827-834

6. McLaughlin JK. Formaldehyde cancer: a critical review. Int Arch Occup Environ Health (1994) 66: 295-301

7. Chang ET. Adami HO The enigmatic epidemiology of nasopharyngeal carcinoma. Cancer Epidemiol. Biomarkers Prev, 2006; 15 (10); 1765-1977

8. Hauptman M, Lubin JH, Stewart PA, Hayes RB, Blair A: Mortality from solid cancers among Workers in Formaldehyde Industries. American Journal of Epidemiology, 159; (12): 1117-1130

9. C. Bosetti C, McLaughlin JK, Tarone RE, Pira E and La Vecchia C: Formaldehyde and cancer risk: a quantative review of cohort studies through 2006. Annals of Oncology 2008; 19; (1): 29-43

10. DeVita VT, Hellman S, Rosenberg SA. Cancer: Principles and Practice of Oncology.  Lippincott Williams & Wilkins 7th Ed, 2008

 

 

 

 

 

 

 

Controversy of Infection Exposure in Surgical Pathology

While working in anatomical pathology in different positions, I gradually developed more serious attitude towards many aspects of safety, especially infectious exposure. This change occurred in parallel with changes in the surgical pathology laboratory environment.

Specimens are more often grossed when in the fresh state. The amount of frozen sections has increased dramatically. Central air-conditioning is a friend but it might be an enemy if the around pathogenic microorganisms are dispersed in aerosol form in the case that the laboratory rooms are not meticulously cleaned by “scheduled” housekeeping.

On the other hand, are not the harmful effects of infection exposure in the surgical pathology laboratory exaggerated? Do we have sufficient data to support the protective measures such as wearing PPE that cost money and impose “hardship” while wearing them? These questions cannot be dismissed without further clarification, but there is a controversy. We do not have data of increased infectious diseases in the surgical pathology laboratory 1,2,3,4,5.

In fact, microbiology laboratory data are the focus of the most biosafety literature.  It has been reported that the risk for laboratory-acquired infections in the microbiology laboratory is higher than that for the general population. However, these data cannot be extrapolated to the surgical pathology laboratory for the obvious reason that the latter does not handle microorganism cultures. In a surgical pathology laboratory, the infectious material is dispersed at incomparably lower concentrations, although, unfortunately, in the potentially dangerous aerosol form.

In the surgical pathology laboratory, the clarification of the controversy will be never completed for two reasons. First, the amount of infectious material might not be enough to generate a clinically apparent disease that can be included in significant statistics. Second, fortunately, the OSHA requirements will prevent laboratories from collecting data for statistically reliable cohort studies. If a laboratory worker contracts tuberculosis (TB), a single occurrence would not prove anything.  I performed dozens of autopsies on cadavers with cavernous lung tuberculosis wearing only a lab coat and gloves on. I remained TB negative; nevertheless, this does not suggest that TB encounters are harmless.

There might be some disputable approaches to the effects of infection exposure in the surgical pathology laboratory (see in “Immunological perspective of infection exposure in surgical pathology laboratory” ).

Does the controversy matter? While working in the surgical pathology laboratory, it does not make sense to risk exposure to infection. Implementation of the OSHA Bloodborne Pathogens Standard through rational work practices with personal responsibility is the key.

(See these issues in the summarized form in “Prevention of Infection Exposure  in HistologyLaboratory” article in Safety section  of our book Grossing Technology (Amazon.com).

References

1. Pike RM. Laboratory-associated infection: incidence, fatalities, causes, and prevention. Annu Rev Microb. 1979; 33: 41-66.

2. Sewell DL. Laboratory associated infections and biosafety. Clin Microbiology Rev. 1995; 8: 389-405.

3  Walker D and Campbell D.  A survey of infections in United Kingdom laboratories, 1994-1995. J Clin Pathol. 1999; 52: 415-418.

4. Lim PL, Kurup A, Gopalakrishna G. et al. Laboratory-acquired severe acute respiratory syndrome. N Engl J Med. 2004; 350:1740-5.

5. Singh K. Laboratory-Acquired Infections. Clin Infect Disease. 2009; Jul 1; 49(1):142-7.