key: cord-0035981-tijpli1a
authors: Tsiodras, Sotirios
title: Promoting Health for Working Women—Communicable Diseases
date: 2008
journal: Promoting Health for Working Women
DOI: 10.1007/978-0-387-73038-7_7
sha: 68950ae2b21b6457fabdfba309d3f15b59f5e0a2
doc_id: 35981
cord_uid: tijpli1a

nan

women maybe exposed to infectious hazards in their occupation during the prenatal and the maternity period. Some exposures may harm the embryo (Crane 2002; Gilbert 2000) , whereas others may actually reduce the risk of certain childhood diseases such as diabetes (Fear, McKinney, Patterson, Parslow & Bodansky 1999) . Certain exposures may be more important than infectious diseases in affecting the well-being of female workers (Krejci-Manwaring et al. 2006; Selvaratnam, de Silva, Pathmeswaran & de Silva 2003; Ward & Day 2006) .

The current chapter discusses the available knowledge of communicable diseases in the workplace, and attempts to elucidate certain features of these entities that are more relevant to the female population.

Infectious diseases arising from the workplace define the term occupational communicable diseases. A subtle difference that is not well-specified may exist between infectious diseases (any disease that can be caused by an infectious agent-e.g., tetanus) and communicable diseases (any infectious disease that can be transmitted directly or indirectly by an infected person). The dynamics of infection may be different from the dynamics of the clinical disease itself. Thus, the incubation period for a clinically visible infectious disease may overlap with the infectious period (period of transmissibility). Moreover, infections may frequently be subclinical but may be transmitted from an infected person. An infectious disease is the result of interactions within a dynamic system consisting of the pathogen, the environment, and the characteristics of the host. Several factors may influence the transmission dynamics related to the pathogen (e.g., antigenic stability, virulence, reservoir), the environment (e.g., occupational setting, climatic conditions) and finally the host (e.g., age, gender, genetic predisposition, immunity, behavior).

The list of occupational communicable infectious diseases is huge. In a formal recommendation (Commission Recommendations 19-09-2003 concerning the European schedule of occupational diseases) the European Commission defined occupational infectious diseases as any infectious or parasitic (sic) disease that can be transmitted to man by animals or remains of animals, as well as other infectious diseases caused by work in disease prevention, healthcare, domiciliary assistance, and other comparable activities for which an infection risk has been proven. These definitions are added in a short list of five agents, including tetanus, tuberculosis, brucellosis, amoebiasis, and viral hepatitis. A classification of communicable occupational diseases can be made according to the pathogen involved-i.e., bacterial, viral, fungal, parasitic (see Table 7 .1). Other classification schemes relative to the mode of transmission may be used, such as contact-(direct or indirect, interhuman vs. zoonotic), vector-(mechanical or biological), or vehicle-(air, food, or water) borne. In this regard, the difference between a reservoir (the agent multiplies within the host) and a vector (just carrier of the pathogen) of an infectious agent may be important. Biological terrorism agents may form a specific subcategory themselves. 

The prevalence of communicable diseases affecting the workplace depends on the specific occupation examined. In work presented by the International Labor Organization, it is estimated that between 1.9-2.3 million work-related deaths occurred worldwide in 2000 (data available at www.ilo.org/safework). In the same work, the lower limit of work-related diseases was 1.6 million and approximately 320,000 (20%) were attributed to communicable diseases (data available at www.ilo.org/safework). The epidemiology appears to differ per country and depends on gross domestic product (GDP) per sector. The type of profession is also very important. The healthcare professions are characteristically associated with an occupational risk from blood-borne pathogens that has led to the implementation of specific protection measures (Beekmann & Henderson 2005; Brunetti et al. 2006; Puro et al. 2005; Sadoh, Fawole, Sadoh, Oladimeji & Sotiloye 2006) . A large study from the Netherlands examining data from a region with a half-million people (and two major hospitals) discovered an incidence of exposure to blood-borne pathogens of 1.2 cases per day-both in the hospital and the community setting (van Wijk et al. 2006) . Athough the incidents were split between the hospital and the community setting, they were related to occupational activities 95 percent of the time and, more specifically, healthcare activities in 84 percent of the cases (van Wijk et al. 2006) . High-risk incidents predominantly involved hospital personnel (van Wijk et al. 2006 ). In another large study from the United Kingdom, known hepatitis C virus or human immunodeficiency virus (HIV) transmissions to health care workers was reported to be at the rate of 1.43 per year. In the same study, HIV and hepatitis C transmissions were occurring at an approximate rate of 0.009 per 1,000 hospital beds per year. The risk of infection when exposure involved sources with no risk factors was significantly lower (less than one in one million for HIV transmission). More work is necessary to correctly identify prevalence and incidence of specific disease entities according to profession, and recent studies have shown unexpected observations (Olsen, Axelsson-Olsson, Thelin & Weiland 2006) . In particular, health care workers have an increased risk from occupational infectious diseases that may occasionally lead to death. The annual death rate for occupational events, including communicable diseases has been calculated around 17-57 deaths per 1 million workers, however more accurate estimations are necessary (Sepkowitz & Eisenberg 2005) .

There is no clear gender-specific predisposition to certain infectious diseases in relation to the frequency of their appearance in women in comparison with the general population. Harmonized case definitions should be used for surveillance purposes and may help in clarifying issues such as an increased prevalence of confirmed cases in the male vs. female population (Stefanoff, Eidson, Morse, & Zielinski 2005) . Occupational communicable disease statistics relevant to women are urgently needed.

The epidemiology of a specific infectious disease in different countries varies and affects its prevalence if it is occupationally acquired, such as is the case with HIV infections (Ghys, Kufa, & George 2006) . Several other examples exist depending on infectious entity, professional activity, and country (Brhel & Bartnicka 2003; Cinco et al. 2004; Golshan et al. 2002; Krejci-Manwaring et al. 2006; Reimer et al. 2002; Vilaichone et al. 2002; Werner et al. 2001) . For example, serological evaluation disclosed antibodies Borrelia burgdorferi sensu lato in 41 percent of the tested forestry workers in Poland, compared to only 7 percent of the control blood donor population. The corresponding figures for the also tick-borne Anaplasma phagocytophilum were 17 percent vs. 5 percent, respectively (Cisak et al. 2005) . A high proportion of asymptomatic cases was noted in the same study. Much lower rates of seropositivity have been described in similar studies examining forestry rangers from Italian regions (Santino et al. 2004 ), although regional variations for some of the pathogens may exist within the same country (Cinco et al. 2004) .

Occupational communicable diseases may have a pronounced economical effect. Costs burden not only the affected population but also the respective industry. They include costs for leave of absence and lost work hours, costs for diagnosis and treatment, and indirect costs (e.g., via family transmission). Countries with poor economical resources experience a more significant financial burden.

Other factors may contribute to the epidemiological characteristics of certain communicable diseases. Climate and climatic changes, for example, may play an important role in the geographical distribution of pathogens. For example, colder than usual temperatures were blamed for the recent H5N1 avian influenza epidemic in Turkey (Giesecke 2006) . Other infections whose epidemiology is especially affected by climatic changes are those that are vector-borne (e.g., malaria, dengue, leishmaniasis), and tick-borne diseases (Kovats, Campbell-Lendrum, McMichael, Woodward & Cox 2001; Lindgren & Gustafson 2001; Lindgren, Talleklint & Polfeldt 2000; Lindsay & Birley 1996) . This is not due to effects of the climate on the microorganism itself, but rather to the vectors of the microorganism. Disease incidence for tick-borne encephalitis significantly increased in a Northern European country, and was highly related to factors such as consecutive mild winters and higher temperatures that favored tick activity (Lindgren & Gustafson 2001) . Climatic changes may have more pronounced effects in vulnerable populations that are protected by low-quality health services (Lindsay & Birley 1996; Lindsay & Martens 1998) . The detection and attribution of changes in the epidemiology of certain communicable diseases to climate change is a difficult emerging task for epidemiologists around the world.

A specific legislative framework has been established to address the issue of occupationally acquired communicable diseases, but several gaps still exist. The European Commission has established a framework for communicable diseases (Commission Decision 2002/253/EC), which lays down case definitions for reporting communicable diseases to the community network. This decision should be further harmonized with decisions or recommendations relevant to occupational diseases (Commission Recommendations 19-09-2003 concerning the European schedule of occupational diseases). The difficulties in comparing the data collected for statutory and nonstatutory surveillance networks should be further addressed. The newly established European Center for Disease Control and its activities (founding regulation 851/2004/EC) may be of paramount importance in this regard.

Activities that include surveillance of health, choice and correct use of personal protective equipment (PPE), environmental monitoring, and adequate education and training of workers potentially exposed to communicable diseases should be among the first priorities set during the establishment of an institutional or legislative framework. According to the framework, the occupational physician will establish priorities in his/her environment. Of great importance in controlling communicable diseases in the working environment are institutional guidelines and standard operating procedures regarding exposure to certain pathogens. Such guidelines have been established, especially for the health care environment, and especially with regard to blood-borne pathogens and agents of biological terrorism. Competent occupational physicians, together with other available specially trained personnel (e.g., infectious disease specialists or infection control nurses for the healthcare environments), implement guidelines and intervention measures when required. Although harmonization of procedures at a global level has not been established yet, guidelines for specific exposures from organizations with an established expertise-e.g., Occupational Safety and Health Administration (OSHA) or other similar organizations and committees (Puro et al. 2005 )-are universally accepted and incorporated into infection control manuals in hospitals and other institutions around the globe.

Specific legislation is required to protect workers from exposure to communicable diseases. Several key actions should be incorporated into relevant legislation, including • There must be adequate health care staffing at all levels of work to provide assistance to the worker • Regulations covering biohazards and communicable diseases in the workplace are necessary for all countries and a harmonization procedure should be discussed at a political level • Settlement of claims related to communicable diseases acquired in the workplace • Establishment of minimum standards to protect air crew members from outbreaks of communicable diseases either of domestic or international origin-e.g., SARS (Breugelmans et al. 2004; Lee, Tsai, Wong & Lau 2006; Vogt et al. 2006) 

Risk factors for communicable diseases in working women appear not to be genderrelated. Rather, there is an association with certain occupations where female workers are traditionally employed (Su et al. 2006; Ward & Day 2006) . All women occupied in professions where there is chance for high-risk exposure are considered at-risk. These include, but are not limited to, health care personnel, workers in research laboratories, workers in the food industry, animal husbandry workers, forest and field workers, construction workers, workers who handle human waste, sex workers, and even funeral service practitioners (Gershon, Vlahov, Farzadegan & Alter 1995) . Other at-risk populations emerge according to epidemiological characteristics specific to certain geographical locations, as is the case with the HIV-1 infection in subSaharan Africa (Zelnick & O'Donnell 2005) . Causal factors include, among others, inadvertent accidents and failure to institute appropriate preventive measures.

Conditions such as overworking and poor socioeconomic status may promote exposure to communicable diseases. Social conditions may affect the risk of occupational infections. Infection with HIV and AIDS has been associated with social class differences in highly affected areas (Ugwu et al. 2006 ). The working conditions of vulnerable populations (e.g., migrant workers, sex workers) may promote the acquisition of sexually transmitted infections (Yang et al. 2005) .

Certain risk factors, such as failure to institute appropriate preventive measures may reflect a lack of education and training. Frequent exercises using real life scenarios are important in eliminating such factors, especially in the healthcare environment (Ganczak, Milona & Szych 2006; van Gemert-Pijnen, Hendrix, Van der Palen & Schellens 2006) . The implementation of specific standard operating procedures according to guidelines is a prerequisite in such efforts. Recent research shows that compliance may be influenced by risk perception of the worker (Ganczak et al. 2006; van Gemert-Pijnen et al. 2006) . Primary prevention is of paramount importance in instances of vulnerable populations where low rates of use of such measures have been reported (Yang et al. 2005 ); however, one should not underscore the importance of education and training in such populations. In a cohort study of 600 female bar workers, a simple intervention consisting of regular screening for sexually transmitted infections, together with syndromic management and relevant information and counseling was offered-it was not only well-received, but also resulted in significant reductions in the prevalence of gonorrhea, HIV, and other sexually transmitted infections (Riedner et al. 2006 ).

Several worksite factors may contribute to occupationally acquired infections. Women working in direct exposure to communicable diseases, or vectors of certain pathogens, have a significantly higher risk for acquiring the disease (e.g., working with animals creates exposure to certain zoonoses like avian influenza and brucellosis). On the other hand, women who work indoors maybe more exposed to airborne communicable diseases such as tuberculosis. Women working under conditions of extreme stress, and in areas where communicable diseases such as HIV-1 are endemic, may experience lapses in appropriate preventive measures and may fail to receive adequate post-exposure prophylaxis (Zelnick & O'Donnell 2005) . Addressing the dramatic shortage of nurses in such environments, as well as involving them in the policy processes, could contribute to a better occupational health and improved quality of patient care (Zelnick & O'Donnell 2005) .

Communicable diseases and even exposure to communicable diseases may have a profound effect on the professional life of affected women. Psychological stress, health impairment with its consequences, and the resulting absence from the work environment, are among the important adverse effects of an occupational communicable disease. In the worst case scenario, such a disease may lead to a permanent event such as chronic illness, loss of employment (Dray-Spira et al. 2006), or even death (Sepkowitz & Eisenberg 2005) . Female gender (adjusted odds ratio 3.1; 95 percent confidence interval 1.1-8.5), together with a nonpermanent job and poor accommodation, were independent risk factors for employment loss in a study of patients with HIV infection in the highly aggressive antiretroviral therapy era (Dray-Spira et al. 2006 ). In the same study, patients with hierarchically higher positions had a lower chance of losing their job (Dray-Spira et al. 2006) , while recent hospitalization and the presence of a chronic comorbidity conferred a higher risk (Dray-Spira et al. 2006) .

Furthermore, in countries with poor recourses, extended unpaid leave from work or job loss may have significant implications on household income. This is particularly true for HIV infections observed in African countries, where failure of the patients to meet basic needs such as food, education, and access to healthcare both in the short and long-term is an undesirable consequence.

A few examples, together with a short description of communicable diseases that could affect women in their work environment, are listed below with representative bacterial, viral, fungal, and parasitic pathogens. The list is not inclusive, as evidenced from the data depicted in Table 7 .1.

Anthrax is caused by Bacillus anthracis, and is one of the most important biological terrorism agents (Bossi et al. 2004a) . Bacillus anthracis produces spores that can be inhaled or ingested, leading to the pulmonary and gastrointestinal forms of the disease, respectively (Bossi et al. 2004a ). Inhalational anthrax is of particular interest for possible deliberate release (Bossi et al. 2004a) , and it was observed during the most recent outbreak in the United States relating to a bioterrorist attack. It affected workers in processing and distribution centers of the United States postal service who handled envelopes contaminated with anthrax spores (Greene et al. 2002; Holtz et al. 2003; Jernigan et al. 2001) . The most commonly seen occupationally acquired form of anthrax is the cutaneous form that occurs through direct skin exposure of people working with sick animals (Oncu & Sakarya 2003) . It presents with the characteristic black eschar. This form of the disease was observed in wool-sorters in the past (Carter 2004) , and occupations at risk include agricultural workers, herdsmen, and those handling sick animals or their products-e.g., hair, meat, bone and bone products, and wool (Oncu & Sakarya 2003; Smego, Gebrian & Desmangels 1998) . In nonendemic areas, imported goat hair, hides (Need author names here, not article name 2006) and wool may be implicated in human cases. If left untreated, all forms may lead to sepsis and death. Treatment consists of supportive care and appropriate antimicrobials that can also be used for prophylaxis over an extended duration (Bossi et al. 2004a) . Vaccines focusing on the protective antigen of the microorganism are available and are used especially in military vaccination programs (Grabenstein, Pittman, Greenwood & Engler 2006) . A lot of research in newer vaccines is ongoing (Baillie 2006; Scorpio, Blank, Day & Chabot 2006 ).

Brucellosis is probably the most common zoonosis worldwide (Pappas, Akritidis, Bosilkovski & Tsianos 2005) , and the causative microorganism is Brucella spp (Pappas, Papadimitriou, Christou & Akritidis 2006) . Occupations at risk include those involving direct exposure to contaminated animals (Pappas et al. 2005; Reid 2005 ), or dairy products (Pappas et al., 2005) , such as livestock producers, slaughterers, (Karimi, Alborzi, Rasooli, Kadivar & Nateghian 2003) , butchers (Karimi et al. 2003) , meat packers, inspectors, veterinarians, and researchers and microbiology personnel working with the organism (Fiori, Mastrandrea, Rappelli & Cappuccinelli 2000; Memish & Mah 2001; Yagupsky & Baron 2005) . In a recent epidemiological study from Ireland, veterinarians, laboratory staff, and workers based in meat plants were at increased risk of exposure to the bacteria (Reid 2005) . Clinically, it can be a multisystemic disease manifesting with fever, hepatic and skeletal involvement, and other systemic signs and symptoms (Pappas et al. 2005) . Clinicians should make clinical laboratory workers aware when brucellosis is suspected to avoid exposure (Gruner et al. 1994) , especially in endemic areas (Yagupsky, Peled, Riesenberg & Banai 2000) .

Plague is caused by Yershinia pestis (Bossi et al. 2004b ). The bacterium is transmitted from infected animals (most frequently rodents or other wild animals-such as infected rabbits (von Reyn, Barnes, Weber & Hodgin 1976)-to humans by its critical vector the flea bite (Bossi et al. 2004b) . After the bite, the microorganism spreads to the regional lymph nodes and causes acute inflammation and pain (buboes). Close contact between humans, rats, and shrews has been described in areas with frequent epidemics (Boisier et al. 2002) . It also belongs to Class A of bioterrorism agents (Bossi et al. 2004b ) because infection with the bacterium may lead to a very serious pulmonary infection and sepsis (Bossi et al. 2004b ). At-risk occupations include farmers, people herding sheep, rabbit hunters, geologists, and other professionals working in the field in endemic areas.

Diseases caused by rickettsia spp are well-known occupational pathogens (Fox 1964) and have been associated with certain field exposures to the tick vectors carrying the pathogen, or research laboratories handling the pathogen (Johnson & Kadull 1967) . More specifically, foresters, rangers, farmers, ranchers, trappers (Heidt, Harger, Harger & McChesney 1985) , and hunters are at risk for contracting Rocky Mountain Spotted Fever-a disease characterized by fever, headache, and a maculopapular rash after a tick bite (Lacz, Schwartz & Kapila 2006; Sexton & Kaye 2002) . Possible disease transmission through needle stick exposure has been described (Sexton, Gallis, McRae & Cate 1975) .

Other ricckettsiae such as Coxiella burnettii-the etiologic agent of Q fever-can be occupationally transmitted. Humans are infected either through direct contact or inhalation of contaminated dust (Carrieri et al. 2002) and develop Q fever an influenza-like illness with pneumonia and hepatic involvement (Parker, Barralet & Bell 2006) , whereas chronic infection is characterized by endocarditis (Parker et al. 2006) . The microorganisms are shed by the genital material of infected animals (e.g., placental tissue) and may exist in the environment for months (Parker et al. 2006 ). Professionals at risk include veterinarians (Abe et al. 2001) , meat processing plant workers, sheep and dairy workers, cattle and livestock handlers (Sadecky 1981) , and staff working in research laboratories using sheep (Simor et al. 1984) . Zoo workers also may be at risk (Ohguchi et al. 2006) . In a recent epidemiological study, two high-risk village areas for positive Q fever serology were identified (Psaroulaki et al. 2006 ). Use of manure in the garden, ownership of animals (especially goats), and the presence of tick-infested or aborting animals were identified as important risk factors for Q fever seropositivity (Psaroulaki et al. 2006) . Outbreaks in slaughter houses have been described (Carrieri et al. 2002; Gilroy et al. 2001 ). An effective whole-cell vaccine is licensed in Australia (Parker et al. 2006 ).

Tuberculosis is caused by the microorganism Mycobacterium tuberculosis. It is one of the most frequent infectious diseases worldwide, and its transmission is airborne. The disease can be extremely contagious. During an occupational outbreak, a single patient working in a shipyard (with an eight-month delay in diagnosis) was the source of a huge outbreak in a small town in Maine (Allos et al. 1996) . Those at highest risk were the ones working closest to the infected person (Allos et al. 1996) . Unfortunately, tuberculosis infections may not be recognized early (de Vries, Sebek & Lambregts-van Weezenbeek 2006) . The infection usually involves the lung parenchyma, but can also present in extra-pulmonary forms such as lymphadenopathy, bone and joint infections, and serious meningoencephalitis. Occupations at risk include health care workers and correctional workers. Nurses are among the professions at highest risk (Tzeng 2005) . Rates of latent infection in health care workers may be extremely high, especially in endemic areas with poor quality of protection (Kayanja, Debanne, King & Whalen 2005) . Transmission, however, has been found to be strongly associated with health care work, even in settings with low incidence of tuberculosis (Diel, Seidler, Nienhaus, Rusch-Gerdes & Niemann 2005) . From 2510 reported cases of tuberculosis during a 10-year study in San Fransisco (1993) (1994) (1995) (1996) (1997) (1998) (1999) (2000) (2001) (2002) (2003) , 31 (1.2%) occurred in healthcare workers (Ong et al. 2006 ). Work-related transmission was documented in about one in three of these healthcare workers, but rates of such acquisition gradually decreased over the study period (Ong et al. 2006) . Delayed diagnosis of tuberculosis (especially if the index case is an older patient) may be one of the main causes of transmission from patient to health care worker (de Vries et al. 2006) . Although several outbreaks have been described in prisons (Bergmire-Sweat et al. 1996; Drobniewski 1995; Jones, Craig, Valway, Woodley & Schaffner 1999; Laniado-Laborin 2001; McLaughlin et al. 2003; Ruddy et al. 2004; Skolnick 1992; ), a recent study identified mainly demographic (rather than occupational) factors associated with the disease in correctional health care workers (Mitchell et al. 2005) . Nevertheless, continued vigilance to control occupational exposure is warranted (Mitchell et al. 2005) .

Unfortunately, conventional contact tracing alone may not suffice to discover recent transmission chains for health care-associated tuberculosis (Diel et al. 2005) . Thus, improved control strategies in the health care environment are necessary (Diel et al. 2005) . The transmission of multidrug-resistant strains in recent years (Portugal et al. 1999; Ruddy et al. 2004; , and the emergence of HIV infection as an important epidemiological comorbidity emphasizes such a need (Masur, Kaplan & Holmes 2002; Mohle-Boetani et al. 2002; Moro et al. 1998; Sonnenberg et al. 2005 ; "Tuberculosis outbreaks in prison housing units for HIV-infected inmates-California, 1995 . New guidelines have been developed to this effect (Jensen, Lambert, Iademarco & Ridzon 2005) .

Tularemia is caused by Francinsella tularensis. The pathogen can be directly transmitted though animal handling, insect bites, or inhalation. The disease is characterized by a febrile syndrome, characteristic skin ulcers, and possibly a serious pulmonary infection with high fatality rates. It is also considered a Class A biological agent. At-risk occupations include farmers and agricultural workers (especially in endemic areas), butchers, cooks, and professional hunters.

The Human Immunodeficiency Virus Type 1 (HIV-1) has been one of the most important pathogens recognized during the twentieth century. The progression of the infection from HIV to the acquired immunodeficiency syndrome (AIDS), and the high mortality associated with AIDS, has dramatically changed our approach to infectious diseases during the last two decades. Professions with a higher risk of exposure to the virus include healthcare workers, emergency response personnel, police, waste handlers, and (last but not least) professional sex workers. The risk depends on the prevalence and other epidemiological characteristics of the disease (e.g., social class) in specific countries, and may be less than that of Hepatitis B (Ugwu et al. 2006) .

Occupationally acquired HIV-1 infection continues to be a rare event independent of the source of the data examined (Rapparini 2006) . Iatrogenic infection has been estimated to occur once in every 8-52 procedures involving HIV-infected individuals. It has been estimated that the rate of seroconversion after percutaneous injury with a sharp device is only around 0.3 percent (Bell 1997 ; Case-control Study of HIV Seroconversion in Health-care Workers after Percutaneous Exposure to HIVinfected blood 1995; Gisselquist, Upham & Potterat 2006; McCray 1986) . From the largest report so far, 56 health care workers were reported to have occupationally acquired HIV-1 infection, of whom 25 developed AIDS through exposure to blood or blood products (CDC HIV/AIDS Surveillance Report 2000).

The probability of HIV seroconversion after exposure to an infected patient depends on the type of exposure and the HIV status of the source patient. Deep injuries, a high volume of visible blood, and an uncontrolled HIV infection increase the risk of seroconversion (Cardo et al. 1997) . Thoracotomy in the emergency department in a population with a prevalence of 7 percent has been estimated to carry a probability of 0.00004 for HIV seroconversion (Sikka, Millham & Feldman 2004) .

Occupations traditionally occupied by women, such as nurses, have a high risk of exposure to blood-borne pathogens, including HIV. In one study examining 601 nurses from surgical wards, operating rooms, and emergency departments, almost half reported a percutaneous exposure during the year prior to the study (Ganczak et al. 2006) . Employment conditions may be associated with HIV-1 acquisition, especially in vulnerable populations, such as immigrants. In a study from China examining 1,543 female migrant workers, those that were sexually experienced (43.2 percent), and either worked in entertainment establishments (e.g., nightclubs, dancing halls) or provided personal service (e.g., beauty salons, massage parlors), were two times more likely to have engaged in risky sexual practices compared to those employed in non-entertainment establishments like restaurants or factories (Yang et al. 2005) . Unfortunately the rate of consistent condom use in the same study was less than 15 percent (Yang et al. 2005) .

Molecular diagnosis has greatly enhanced our preventive and therapeutic efforts for HIV-1 infection, and may shorten the window period for accurate diagnosis. The introduction and increasing use of rapid-HIV testing will assist in future preventive efforts (Franco-Paredes, Tellez & del Rio 2006) . Limitations, however, still exist. A cluster of infections in workers within the legal multibillion adult film industry is the most recent best example. Infection with HIV-1 appeared in 3 out of 13 female partners (attack rate of 23%) of a previously uninfected HIV positive male partner who was undergoing frequent testing for the virus (Taylor et al. 2007 ). This observation underscores the significance of primary prevention for HIV-1 infection (Taylor et al. 2007) .

Suspicion of an occupational exposure to HIV should lead to the immediate application of protocols investigating the incident and providing prophylactic antivirals to those involved in high-risk scenarios, as well as psychological support. Guidelines for management have been published and are widely available (Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis 2001). Careful discussion of adverse effects associated with prophylactic antiviral regimens is necessary (Kiertiburanakul et al. 2006) . These actions reduce the likelihood of HIV disease, as well as concomitant stress and anxiety from the exposure.

Occupational exposure to blood or other potentially infectious material is considered the main risk factor for HBV acquisition in the workplace. Thus, professions with such exposure (and especially healthcare workers) comprise the main risk groups. Hepatitis B has been associated with a higher risk for transmission to health care workers in comparison with HIV or Hepatitis C. The risk of transmission relates to the degree of contact, the Hepatitis B e antigen (HBeAg) status of the source patient, and the serological conversion, which is estimated around 30 percent (Werner & Grady 1982) . The risk appears to be higher during the first five years of employment (Snydman et al. 1984) . Prevaccination with HBV vaccine, and the application of universal precautions in dealing with blood or other potentially infectious material, is paramount in preventive efforts against HBV. Recommendations for postexposure measures have been published, and HBV vaccine (if unvaccinated or with low serological titers), Hepatitis B immunoglobulin, or both, must be started as soon as possible (within 1-7 days) (Puro et al. 2005 Hepatitis C Hepatitis C is also acquired through exposure to blood or other potentially infectious material. Health care workers are again the primary risk group for exposure. The risk of transmission after a percutaneous exposure is in between that of Hepatitis B and HIV, and estimated around 1.8 percent (Range: 0%-7%)(Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis 2001). The risk depends on the type of procedure and the prevalence of the disease in the general population. For emergent thoracotomy and a prevalence in the population of 17 percent, a probability of 0.0027 for chronic Hepatitis C seroconversion has been calculated (Sikka et al. 2004) . Following exposure, close follow-up and treatment of acute seroconversion is indicated because there is no immediate prophylactic action (Puro et al. 2005 

Direct exposure to poultry infected with the H5N1 subtype of Influenza A has been identified as the main risk factor associated with infection in humans. Professions with increased risk for exposure include veterinarians, cullers and poultry workers, farmers or those exposed to commercial poultry, people involved in litter management and carcass disposal in affected areas, zoo and nature reserve workers, gamekeepers, biologists, laboratory technicians, and health workers caring for possible human cases. Poultry workers, especially those involved in activities such as butchering and contact with ill birds in the affected areas, seem to carry the highest risk (Bridges et al. 2002) . The role of occupational exposure for health care workers has not been well established. Serological data from the 1997 Hong Kong epidemic indicate that subclinical H5N1 infections may occur (Swayne 2006) , however others have failed to prove such an association during the recent phases of the outbreak in Southeast Asia (Apisarnthanarak et al. 2005) . Person-to-person transmission is probable and requires close and extensive contact (Ungchusak et al. 2005) . The disease has milder forms that present with influenza-like illnesses and/or symptoms from other systems (e.g., conjunctivitis) (Swayne 2006) and severe forms associated with respiratory distress and death (Beigel et al. 2005; de Jong et al. 2005; Shu, Yu & Li 2006; Tran et al. 2004; Yu et al. 2006) . Occupational medicine has its own role and can significantly contribute in reducing the risk of transmission of avian flu to workers at risk via prevention and prophylactic measures (Halpin 2005; Stone 2006; Whitley & Monto 2006) . Such efforts are of paramount importance because humanity is prepar-ing to face a pandemic caused by a novel influenza strain and the first target group with the highest risk is poultry workers (Stone 2006; Swayne 2006; Whitley & Monto 2006) .

Hantavirus Pulmonary Syndrome People exposed to infected rodents or their droppings are at risk for contracting the new and old world viral agents of hantavirus pulmonary syndrome (Sin Nombre virus) (Mills et al. 2002) . Exposure in closed spaces to active infestations of infected rodents seems to be the most important factor for infection (Mills et al. 2002) . This probably explains the observations of no serological evidence of infection in workers widely exposed to rodents (Fritz et al. 2002) . The virus was first recognized in the United States during 1993 (Duchin et al. 1994) . Farmers appear to be at an increased risk through exposure to rodents or their excreta (Mills et al. 2002; Vapalahti, Paunio, Brummer-Korvenkontio, Vaheri & Vapalahti 1999) , and farm and timber workers were most frequently affected in an epidemic in Chile (Castillo, Naranjo, Sepulveda, Ossa & Levy 2001) . People occupied in hand plowing or planting (Mills et al. 2002) , harvesting field crops (Mills et al. 2002) , or involved in cleaning or other activities of rodent-infested buildings (e.g., barns, vacant dwellings) (Mills et al. 2002) are considered at risk. The disease is a laboratory hazard for personnel working with the virus (Mills et al. 2002; Shi, McCaughey & Elliott 2003) .

The disease may progress to fatal pulmonary infection with or without renal involvement and hemorrhagic manifestations. Person-to-person transmission in the healthcare setting during outbreaks has not been confirmed (Chaparro et al. 1998) . Risk reduction through the use of appropriate PPE and hygiene practices that deter rodents from colonizing the home and work environment is an appropriate control measure (Mills et al. 2002) .

This disease may affect workers exposed to infected animals harboring the virus in their nervous system and their salivary glands (Brookes & Fooks 2006; Warrell & Warrell 2004) . It takes the form of an acute encephalitis, usually with a fatal outcome (Warrell & Warrell 2004 ). Occupations at risk include those exposed in infected rodents (Mendes et al. 2004; Warrell & Warrell 2004 ), veterinarians (Warrell & Warrell 2004 Weese, Peregrine & Armstrong 2002) , animal handlers such as farmers (Brookes & Fooks 2006; Tariq, Shafi, Jamal & Ahmad 1991; Warrell & Warrell 2004) , and people exposed to bats (Brookes & Fooks 2006; Warrell & Warrell 2004) . Although a vaccine is available, animal rabies control and the provision of accessible and appropriate human prophylaxis worldwide remains a challenge (Warrell & Warrell 2004) .

Coccidioidomycoses belongs to the endemic mycoses. It is caused by the fungus Coccidioides immitis (Anstead & Graybill 2006) , and is endemic in the southwestern United States (Anstead & Graybill 2006; Pappagianis 1988) . The disease is transmitted through inhalation and has myriad manifestations (Anstead & Graybill 2006) . It may begin as a flu-like illness that may progress to pneumonia and shock especially in immunocompromised subjects (Anstead & Graybill 2006) . At-risk occupations include farmers and migrant farm workers, construction and excavation workers, as well as workers in archeological sites (Coccidioidomycosis in Workers at an Archeologic Site 2001; Werner, Pappagianis, Heindl & Mickel 1972) because the organism is found in the soil in endemic areas (Schmelzer & Tabershaw 1968) . Physicians should keep this entity in the differential diagnosis in people who developed a respiratory infection after traveling to affected endemic areas (Desai et al. 2001 ).

Histoplasmosis is caused by the fungus Histoplasma capsulatum found in the Americas, Asia, and Africa (Kauffman, 2006; Wheat 2006) . The organism grows in soils enriched by bird and chicken droppings, as well as the guano of bats (Sorley, Levin, Warren, Flynn & Gersenblith 1979; Stobierski et al. 1996 ). People exposed to bats during spelunking activities are also considered at-risk (Lottenberg et al. 1979) .

During an outbreak at a bridge construction site, seeing or having contact with a bat and disposal of bat waste were the main risk factors for acquiring the disease (Huhn et al. 2005) . Infection ranges from a mild self-limiting infection to a more systemic disease characterized by pulmonary involvement that reminds tuberculosis (Kauffman 2006; Wheat 2006) . Occupational risk is observed in laborers at landfills or building construction (Huhn et al. 2005; Jones, Swinger et al. 1999) , as well as people working in the agricultural industry (Outbreak of Histoplasmosis among Industrial Plant Workers 2004).

Professions that require extensive manual work or activities with exposed skin surfaces, such as farming and other field work, have been associated with fungal infections of the skin. Fungal skin disease was the most prevalent infection in a study of migrant Latino farmworkers in the United States (Krejci-Manwaring et al. 2006) . In a study of 467 forestry workers and farmers in Turkey, anywhere from 8-20 percent of the study population was affected by tinea pedis et manus infections and/or onychomycosis (Sahin, Kaya, Parlak, Oksuz & Behcet 2005) . Tinea corporis and tinea inguinalis were also observed (Sahin et al. 2005) . Trichphyton rubrum was the most frequently isolated fungus, and farmers had higher frequencies of superficial mycoses that was likely attributed to the wearing of rubber shoes and nylon socks, and the practice of animal husbandry (Sahin et al. 2005) . Nevertheless, dermatophytoses have a worldwide prevalence and have been described in association with other occupations, including healthcare workers-such as those working in nursing homes (Smith et al. 2002 )-or professional ice hockey players (Mohrenschlager, Seidl, Schnopp, Ring & Abeck 2001) .

Humans serve as the intermediate host of the tapeworm (Echinococcus granulosus) of dogs and other carnivores. Evidence of infection is occasionally found among sheep workers, especially in endemic areas (Moro et al., 1994; Sotiraki, Himonas & Korkoliakou 2003) or veterinary workers (Biffin, Jones & Palmer 1993) . It is the cause of the hydatid disease characterized by formation of cysts in the liver and other body sites. Alveolar echinococcosis is another zoonosis caused by Echinococcus multilocularis (McManus, Zhang, Li & Bartley 2003) that can be transmitted to farmers in endemic areas (Craig et al. 2000) .

Caused by the parasite Giardia lamblia, giardiasis is a parasitic disease (Huang & White 2006 ) that can infect farmers using untreated wastewater in agriculture (Ensink, van der Hoek & Amerasinghe 2006; Srikanth & Naik 2004) as well as other occupational groups exposed to human waste (Hoque, Hope, Kjellstrom, Scragg & Lay-Yee 2002; Sehgal & Mahajan 1991) . Field workers that drink water from contaminated sources (e.g., wells, streams, or lakes) are also at-risk, and prevention efforts focusing on water hygiene should be effective (Rose, Haas & Regli 1991) .

Women should participate at all levels of decision-making in local, national, and international institutions and mechanisms for the prevention and management of infectious diseases in the workplace. The integration of a gender perspective is of essential importance in all activities aimed at communicable diseases in the working environment for successful outcomes, especially with regard to prevention. Occupationally acquired communicable diseases are not limited by the borders of the working environment. Working mothers will be role models for their young, not only during private discussions in the household environment, but also by their participation in community campaigns and efforts against communicable diseases aimed at more widely implemented measures for such diseases, such as during a pandemic. Well-informed and trained women may convey healthier lifestyles to their families regarding ways of handling exposure to communicable diseases and appropriate preventive and protective measures. They will also focus on maintaining a high level of health in their offspring by maintaining a complete vaccination schedule and scheduling regular health check-ups. Furthermore, instituting healthier nutritional habits, together with other activities targeting communicable diseases, may lead to an overall healthier lifestyle at home and will be of paramount importance in this regard.

The control of communicable diseases resulting from health care worker exposure to blood-borne pathogens and other potentially infectious material remains the best example. Preventive measures against Hepatitis B acquisition involve vaccination and other prophylactic measures-e.g., administration of the specific immunoglobulin-and have been proven safe and effective in large trials Prince et al. 1978; Prince et al. 1975; Szmuness, Stevens, Zang, Harley & Kellner 1981) .

Reduction in HIV transmissions after percutaneous exposure has been shown in small studies as a result of post-exposure prophylaxis with antivirals (Cardo et al. 1997) . Failures, however, have been described (Ippolito et al. 1998; Jochimsen 1997; Jochimsen et al. 1999; Pratt, Shapiro, McKinney, Kwok & Spector 1995) and the administration of prophylaxis and follow-up should be instituted by experienced staff according to national guidelines (Ippolito, Puro, Petrosillo & De Carli 1999) and recommendations from internationally acknowledged organizations (Puro et al. 2005 Administration, together with the occupational health department, should ensure the availability of policies and procedures relevant to occupational infections affecting specific job environments. These policies and procedures should adhere to legislative requirements and published literature and guidelines. Surveillance of exposures (even if only potential exposures) and analysis of collected data, together with the communication of the results, should be established in high-risk professions. Confidentiality and maintenance of a secure medical record in affected female workers is essential in following such infections. A referral process for exposed female workers and for further diagnostic and clinical evaluation and management is necessary in all environments.

Ongoing evaluation of strategies to minimize exposure to occupational infections is a continuous challenge in the workplace. The occupational health department should develop indicators that can assist in the evaluation of any preventive strategy instituted in the work environment. These could include, for example: a) rates of immunization for vaccine-preventable diseases, b) availability of engineering controls for sharp-related injuries, c) rates of percutaneous injuries for blood-borne pathogens, d) impact of training programs for use of newer preventive technologies for any relevant communicable diseases, e) product evaluation before and after implementation, and f) periodic screening of female workers for acquisition of infection, and so forth. To ensure consistency, collaboration with a more central authority such as the local public health authority may be preferable when assessing these indicators. The collection, analysis, interpretation, and finally the dissemination of such epidemiological information on occupational infections will enhance infection prevention and control at work.

Working women should be educated via training and information sessions provided by experts in occupational diseases and infectious diseases specialists to avoid exposure to risk factors associated with communicable diseases in the working environment. It is the primary responsibility of the health care department and occupational physician, however, to organize risk-reduction strategies to this effect and implement appropriate control measures, as well as institute appropriate educational activities. For example, a working woman could not have prevented transmission of legionellosis to herself from an infected water source in her work environment (Muraca, Stout, Yu & Yee 1988) ,and b) if engineering controls are not instituted, a female health care worker is at a much higher risk for a sharp-related injury.

Furthermore, the appropriate analysis of surveillance data collected at work will help in establishing safer work practices or identify groups at highest risk for contraction of an occupational infection.

Prevention of exposure and acquisition of an infectious disease contributes to the well-being of a woman and assists in developing and preserving an overall healthier lifestyle. Through such prevention efforts, healthier habits are also acquired and become a part of the woman's life and are sometimes passed along to her immediate environment (e.g., preventive measures for transmission of a sexually transmitted infection, Hepatitis B vaccinations, and others).

Women, and especially working women, should be aware of a large list of communicable pathogens that can be transmitted in the workplace (see Table 7 .1). They should also participate in preventive efforts concerning these entities in their environment under the close collaboration and expert guidance of an occupational physician supervising their health. Diseases they encounter may differ according to the type of occupation and the overall prevalence of the disease in the general population, thus preventive measures will vary from one working environment to the other and between different countries. Guidelines have been established for specific infection control measures for occupational infections in the health care setting. According to the working environment and relevant infections, similar guidelines should be established for other professions. For global threats such as an influenza pandemic, the world should stand united in its preventive efforts (Whitley & Monto 2006) , and special measures for the workplace should be incorporated in national pandemic plans. More education and training together with real-life exercises will be necessary for the successful implementation of preventive policies.

Useful web links about communicable diseases affecting women in their workplace include the following: 

Published and educational material can be found readily on the Web. Examples include the following:

• OSHA Guidance update on protecting employees from avian flu (avian influenza)

viruses. Available at: http://www.osha.gov • Hand hygiene quick card available at: http://www.osha.gov/pls/publications/ pubindex.list • Mold quick card available at: http://www.osha.gov/pls/publications/pubindex.list Table 7 .1 lists significant representative pathogens/diseases causing communicable diseases that may be occupationally acquired.

A seroepidemiological study of the risks of Q fever infection in Japanese veterinarians

Hepatitis C: an update for occupational health nurses

Management of an outbreak of tuberculosis in a small community

Seroprevalence of anti-H5 antibody among Thai health care workers after exposure to avian influenza (H5N1) in a tertiary care center

Past, imminent and future human medical countermeasures for anthrax

Risk of tuberculin conversion among health care workers and the adoption of preventive measures

Avian influenza A (H5N1) infection in humans

Occupational risk of human immunodeficiency virus infection in healthcare workers: an overview. The American journal of medicine

Tuberculosis outbreak in a Texas prison

Human hydatid disease: evaluation of an ELISA for diagnosis, population screening and monitoring of control programmes

Epidemiologic features of four successive annual outbreaks of bubonic plague in Mahajanga

Bichat guidelines for the clinical management of anthrax and bioterrorism-related anthrax

Bichat guidelines for the clinical management of plague and bioterrorism-related plague

Risk of influenza A (H5N1) infection among poultry workers

Occupational lyssavirus risks and post-vaccination monitoring

Surveillance of nosocomial infections: a preliminary study on hand hygiene compliance of healthcare workers

A case-control study of HIV seroconversion in health care workers after percutaneous exposure

Investigation of a slaughterhouse-related outbreak of Q fever in the French Alps

The dissemination of anthrax from imported wool: Kidderminster 1900-14. Occupational and environmental medicine

Case-control study of HIV seroconversion in health-care workers after percutaneous exposure to HIV-infected blood-France

Hantavirus pulmonary syndrome due to Andes virus in Temuco, Chile: clinical experience with 16 adults

Assessment of personto-person transmission of hantavirus pulmonary syndrome in a Chilean hospital setting

Infection control and SARS transmission among healthcare workers

Seroprevalence of tick-borne infections in forestry rangers from northeastern Italy

Risk of tick-borne bacterial diseases among workers of Roztocze National Park (south-eastern Poland)

Coccidioidomycosis in workers at an archeologic site-Dinosaur National Monument

An epidemiological and ecological study of human alveolar echinococcosis transmission in south Gansu

Parvovirus B19 infection in pregnancy

Fatal avian influenza A (H5N1) in a child presenting with diarrhea followed by coma

Healthcare workers with tuberculosis infected during work

Coccidioidomycosis in non-endemic areas: a case series

Hospital disinfection: efficacy and safety issues

Occupational risk of tuberculosis transmission in a low incidence area

Employment loss following HIV infection in the era of highly active antiretroviral therapies

Tuberculosis in prisons-forgotten plague

Hantavirus pulmonary syndrome: a clinical description of 17 patients with a newly recognized disease. The Hantavirus Study Group

Promoting Health for Working Women-Communicable Diseases 205

Severe acute respiratory syndrome: another challenge for critical care nurses

Giardia duodenalis infection and wastewater irrigation in Pakistan

Childhood Type 1 diabetes mellitus and parental occupations involving social mixing and infectious contacts: two population-based case-control studies

Brucella abortus infection acquired in microbiology laboratories

HIV/AIDS knowledge among female migrant farm workers in the midwest

Rickettsial Diseases Other Than Q Fever as Occupational Hazards. Industrial medicine & surgery

Rapid HIV testing: a review of the literature and implications for the clinician

Exposure to rodents and rodent-borne viruses among persons with elevated occupational risk

Nurses and occupational exposures to bloodborne viruses in Poland

Occupational risk of human immunodeficiency virus, hepatitis B virus, and hepatitis C virus infections among funeral service practitioners in Maryland

Measuring trends in prevalence and incidence of HIV infection in countries with generalised epidemics

Human cases of avian influenza in eastern Turkey: the weather factor

Parvovirus B19 infection and its significance in pregnancy

Abattoir-associated Q fever: a Q fever outbreak during a Q fever vaccination program

Efficiency of human immunodeficiency virus transmission through injections and other medical procedures: evidence, estimates, and unfinished business

Indoor women jobs and pulmonary risks in rural areas of Isfahan

Immunization to protect the US Armed Forces: heritage, current practice, and prospects

Hepatitis B immune globulin for accidental exposures among medical personnel: final report of a multicenter controlled trial

Epidemiologic investigations of bioterrorism-related anthrax

Brucellosis: an occupational hazard for medical laboratory personnel

High rubella seronegativity in daycare educators

Avian flu from an occupational health perspective

Serological study of selected disease antibodies in Arkansas-furbearer trappers, a high risk group

Isolated case of bioterrorism-related inhalational anthrax

Risk of giardiasis in Aucklanders: a case-control study

Two outbreaks of occupationally acquired histoplasmosis: more than workers at risk. Environmental health perspectives

Inhalation anthrax associated with dried animal hides-Pennsylvania

Surveillance of occupational exposure to bloodborne pathogens in health care workers: the Italian national programme

Simultaneous infection with HIV and hepatitis C virus following occupational conjunctival blood exposure

Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings

Bioterrorism-related inhalational anthrax: the first 10 cases reported in the United States

Failures of zidovudine postexposure prophylaxis. The American journal of medicine

Investigations of possible failures of postexposure prophylaxis following occupational exposures to human immunodeficiency virus

Safety issues in the exotic pet practice

Rocky Mountain spotted fever acquired in a laboratory

Transmission of tuberculosis in a jail

Acute pulmonary histoplasmosis in bridge workers: a persistent problem

Prevalence of antibody to Brucella species in butchers, slaughterers and others. Eastern Mediterranean health journal = La revue de sante de la Mediterranee orientale = al-Majallah al-sihhiyah li-sharq almutawassit

Endemic mycoses: blastomycosis, histoplasmosis, and sporotrichosis. Infectious disease clinics of North America

Tuberculosis infection among health care workers in Kampala, Uganda

Hepatitis C prevention with nurses

Use of HIV Postexposure Prophylaxis in healthcare workers after occupational exposure: a Thai university hospital setting

Occupational health response to SARS

Promoting Health for Working Women-Communicable Diseases 207

Early effects of climate change: do they include changes in vector-borne disease?

Skin disease among Latino farmworkers in North Carolina

Rocky Mountain spotted fever

Tuberculosis in correctional facilities : a nightmare without end in sight

New paradigm for protection: the emergency ambulance services in the time of severe acute respiratory syndrome

A loophole in international quarantine procedures disclosed during the SARS crisis. Travel medicine and infectious disease

Tick-borne encephalitis in Sweden and climate change

Impact of climatic change on the northern latitude limit and population density of the disease-transmitting European tick Ixodes ricinus

Climate change and malaria transmission

Malaria in the African highlands: past, present and future

Pulmonary histoplasmosis associated with exploration of a bat cave

Guidelines for preventing opportunistic infections among HIV-infected persons-2002. Recommendations of the U.S. Public Health Service and the Infectious Diseases Society of America

Occupational risk of the acquired immunodeficiency syndrome among health care workers

Extensive transmission of Mycobacterium tuberculosis among congregated, HIV-infected prison inmates in South Carolina, United States. The international journal of tuberculosis and lung disease

Brucellosis in laboratory workers at a Saudi Arabian hospital

Hantavirus pulmonary syndrome-United States: updated recommendations for risk reduction

Risk of tuberculosis in correctional healthcare workers

Tuberculosis outbreak in a housing unit for human immunodeficiency virus-infected patients in a correctional facility: transmission risk factors and effective outbreak control. Clinical infectious diseases

Professional ice hockey players: a high-risk group for fungal infection of the foot?

An outbreak of multidrug-resistant tuberculosis involving HIV-infected patients of two hospitals in Milan, Italy. Italian Multidrug-Resistant Tuberculosis Outbreak Study Group

Distribution of hydatidosis and cysticercosis in different Peruvian populations as demonstrated by an enzymelinked immunoelectrotransfer blot (EITB) assay. The Cysticercosis Working Group in Peru (CWG). The American journal of tropical medicine and hygiene

Legionnaires' disease in the work environment: implications for environmental health

Work-related accidents and occupational diseases in veterinarians and their staff

Q fever with clinical features resembling systemic lupus erythematosus

Unexpected high prevalence of IgGantibodies to hepatitis E virus in Swedish pig farmers and controls

Anthrax-an overview

Tuberculosis in healthcare workers: a molecular epidemiologic study in San Francisco

Outbreak of histoplasmosis among industrial plant workers-Nebraska

Epidemiology of coccidioidomycosis. Current topics in medical mycology

Future trends in human brucellosis treatment

Bell AM (2006) Q fever

Outbreak of multiple drug-resistant tuberculosis in Lisbon: detection by restriction fragment length polymorphism analysis. The international journal of tuberculosis and lung disease

Virologic characterization of primary human immunodeficiency virus type 1 infection in a health care worker following needlestick injury

Hepatitis B immune globulin: final report of a controlled, multicenter trial of efficacy in prevention of dialysis-associated hepatitis

Hepatitis B "immune" globulin: effectiveness in prevention of dialysis-associated hepatitis

Epidemiological study of Q fever in humans, ruminant animals, and ticks in Cyprus using a geographical information system

European recommendations for the management of healthcare workers occupationally exposed to hepatitis B virus and hepatitis C virus

Occupational HIV infection among health care workers exposed to blood and body fluids in Brazil

Brucellosis-a persistent occupational hazard in Ireland

Seroprevalence of Borrelia infection in occupational tick-exposed people in Bavaria (Germany)

Decline in sexually transmitted infection prevalence and HIV incidence in female barworkers attending prevention and care services in Mbeya Region

Risk assessment and control of waterborne giardiasis

Outbreak of isoniazid resistant tuberculosis in north London

Infection of cattle and livestock handlers with Coxiella burnetti and Chlamydiae in the farm of Bernolakovo (West Slovakia)

Practice of universal precautions among healthcare workers

Dermatophytoses in forestry workers and farmers

Multicentric study of seroprevalence of Borrelia burgdorferi and Anaplasma phagocytophila in high-risk groups in regions of central and southern Italy

American journal of public health and the nation's health

Anthrax vaccines: Pasteur to the present. Cellular and molecular life sciences

Occupational risks in sewage work

Nutritional status and productivity of Sri Lankan tea pluckers

Occupational deaths among healthcare workers

Letter: Possible needle-associated Rocky Mountain spotted fever

Rocky mountain spotted fever

Genetic characterisation of a Hantavirus isolated from a laboratory-acquired infection

Lethal avian influenza A (H5N1) infection in a pregnant woman in Anhui Province, China

Analysis of occupational exposures associated with emergency department thoracotomy

Q fever: hazard from sheep used in research

Transmission of infections during commercial air travel

Correction facility TB rates soar; some jails bring back chest roentgenograms

Cutaneous manifestations of anthrax in rural Haiti

Skin disease among staff in a large Korean nursing home

A multivariate analysis of risk factors for hepatitis B virus infection among hospital employees screened for vaccination

How soon after infection with HIV does the risk of tuberculosis start to increase? A retrospective cohort study in South African gold miners

Bat-associated histoplasmosis in Maryland bridge workers. The American journal of medicine

Hydatidosis-echinococcosis in Greece

Health effects of wastewater reuse for agriculture in the suburbs of Asmara city

Evaluation of tickborne encephalitis case classification in Poland

Outbreak of histoplasmosis among employees in a paper factory-Michigan

Nurses' working conditions: implications for infectious disease

Avian influenza. Combating the bird flu menace, down on the farm

Reducing urinary tract infections among female clean room workers

Occupational and consumer risks from avian influenza viruses

A controlled clinical trial of the efficacy of the hepatitis B vaccine (Heptavax B): a final report

Rabies in man handling infected calf

Epidemiologic Investigation of a Cluster of Workplace HIV Infections in the Adult Film Industry

Avian influenza A (H5N1) in 10 patients in Vietnam

Tuberculosis outbreaks in prison housing units for HIV-infected inmates-California

Promoting a safer practice environment as related to occupational tuberculosis: a nursing care quality issue in Taiwan

HIV and hepatitis B seroprevalence in trauma patients in North Central Nigeria

Probable person-to-person transmission of avian influenza A (H5N1)

Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis

Multidrug-resistant tuberculosis in the New York State prison system

Outbreak of multi-drug-resistant tuberculosis in a New York State prison

Effectiveness of protocols for preventing occupational exposure to blood and body fluids in Dutch hospitals

Differences between hospital-and community-acquired blood exposure incidents revealed by a regional expert counseling center

Puumala virus infections in Finland: increased occupational risk for farmers

Streptococcus suis infection in Thailand

Risk of severe acute respiratory syndrome-associated coronavirus transmission aboard commercial aircraft

Bubonic plague from exposure to a rabbit: a documented case, and a review of rabbit-associated plague cases in the United States

What happens to women who sell sex? Report of a unique occupational cohort

Rabies and other lyssavirus diseases

Occupational health and safety in small animal veterinary practice: Part I-nonparasitic zoonotic diseases. The Canadian veterinary journal

Accidental hepatitis-B-surface-antigen-positive inoculations

Borrelia burgdorferi antibodies in outdoor and indoor workers in south-west Sweden

An epidemic of coccidioidomycosis among archeology students in northern California

Histoplasmosis: a review for clinicians from non-endemic areas

Seasonal and pandemic influenza preparedness: a global threat

Laboratory exposures to brucellae and implications for bioterrorism

Exposure of hospital personnel to Brucella melitensis and occurrence of laboratory-acquired disease in an endemic area

Workplace and HIV-related sexual behaviours and perceptions among female migrant workers

The first confirmed human case of avian influenza A (H5N1) in Mainland China

The impact of the HIV/AIDS epidemic on hospital nurses in KwaZulu Natal, South Africa: nurses' perspectives and implications for health policy