Faculty of Medicine Introduction to Community Medicine Course

Faculty of Medicine Introduction to Community Medicine Course (31505201) Unit 3 Public Health/Environmental Health Occupational Health By Hatim Jaber MD MPH JBCM PhD 25-10-2017

1 Introduction to Unit 3 Public Health and Environment 4 lectures 1. Introduction to Public Health and Environment-- 16-102017 2. Environment 1- Air pollution18-10-2017 3. Environment : introduction to Water Quality and water borne diseases Food Safety and food borne diseases Waste and health- Management 23-10-2017

4. Occupational Health -25-10-2017 6 Presentation outline Time Introduction; definition, rational, goal and objectives, OHS day, ergonomics 08:15 to 08:25 Hazards and risks; types and forms

08:25 to 08:40 Prevention and Control Principles 08:40 to 09:00 Occupational Health Programs 09:00 to 09:15 OH for Healthcare Workers (HCW) 09:15 to 09:30

7 Definition: Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity(WHO, 1948) Health is only possible where resources are available to meet human needs and where the living and working environment is protected from life-threatening and health threatening pollutants, pathogens and physical hazards(WHO, 1992)

Economical system Social justice National policies Work environment Education environment

Different cultures hosing environment Society support Social changes Congenital and psychological factors Health

services Life style Resources Facilities Health Entertainment Social policies Income services Media and communication Effect levels on health

9 RATIONALE A large sector of the population is in the labor force. Because health and well-being are greatly affected by the work people do, physicians must learn about work/occupational health hazards and play an active role in promoting the health of workers and preventing and controlling work-related health problems. FATHER of OCCUPATIONAL HEALTH

Ramazzini Italy 1700 De Morbis Artificum Diatribia 41 occupations and specific diseases to each occupation What is Occupational Health? Occupational Health is the

promotion and maintenance of the highest degree of physical, mental and social well-being of workers in all occupations by preventing departures from health, controlling risks and the adaptation of work to people, and people to their jobs. (ILO / WHO 1950) Objectives of occupational health: 1- Health promotion: Fulfilling requirements of physical, mental and social wellbeing. 2- Protection of the workers from workplace health hazards to which workers are exposed

3- Prevention and control of workplace health hazards. 4- Rehabilitation of the disabled. The main aim of occupational health is to eliminate the hazard if not possible is to minimize the risk. What is Occupational Health and Safety? Occupational health and safety (OHS) encompasses the social, mental and physical well-being of workers,

And for that matter the whole person. 18 Occupational Safety and Health Legislation in Jordan 1- The Constitution of Jordan, of 1952, Labour Law No. 8, of 1996 The provisional Public health law No. 54, of 2002 The Standards and Specifications Law No. 22, of 2000 Article (17) The Law of Organizing Professional Labour, No. 27, 1999:Article (4) 6- Nuclear and Radioactive Energy Law No. 29, 2001: 7- Hazardous Wastes Management and Handling Instructions of:2003Article (7)

8- The Social Security Law No. (19) of 2001: The other laws that are related, in a way or an other, to OSH are: 1- Civil defense law. 2- The environment Protection Law 3- The Agriculture law 4- Handicrafts and Industries Law Governmental Agencies working on OSH A: Ministry of Labour: B: The Ministry of Health C: The Social Security Corporation D: Occupational Safety and Health Institute (OSHI): The Directorate of Civil Defense: Social partners in Occupational Safety and Health A- The workers organizations:

B- Employers Organizations: Semi Governmental Agencies and the NGOs 1- The Royal Scientific Society (RSS): 2- The Universities: 3- The Media: 4- The insurance companies 5-The international agencies: 6- The private sector: Occupational Health components Work environment Occupational Hygiene

Hygienist Workers health Occupational Medicine Occupational Physician Primary function To reduce or eliminate worker diagnosis, management and Exposure to workplace hazards.

prevention of diseases due to or exacerbation by workplace factors. Occupational Safety Accidents: injuries, fire, explosion. Machines, installations, equipments Safety Engineer Occupational Diseases Work-related Diseases Occupational Diseases are cause-specific, occurring mainly among working population, exposure at workplace is essential,

notifiable and compensable. Work-related Diseases are multifactorial in origin (not only work), occurs commonly in the community, exposure at work-place may be a factor, may notifiable and compensable. Global estimates of occupational burden of disease Accidents Sudden unfavorable event following series of consequent and /or parallel human errors. Accidents are the end-products of unsafe acts and unsafe

conditions of work. Factors- technical equipment working environment worker Accidents have preventable causes What What is is Ergonomics? Ergonomics? The term ergonomics comes from the Greek words:

ergon (work) and nomos (law). study of the laws that govern the interaction between people, machines, and their environment. study of the relation between people and their work environment. fitting workplace conditions and job demands to the capabilities of workers Ergonomics: Ergonomics: ``Adjustment of Man & Machine``/ Application of human biological sciences with engineering science to achieve optimum mutual adjustment of man & his work, the

benefit being measured in terms of human efficiency and well being Tool / machine design to fit to work. Ergo tools/ ergofriendly tools : Tools which reduce the stresses or problems resulting in CTDs / MSDs.) The TheGoal Goalof ofErgonomics Ergonomics Is to make the work

fit the operator, not make the operator fit the work. Bad ergonomics Hazard is something with the potential to cause harm, such as a substance, a piece of equipment, a form of energy, a way of working or a feature of the environment. Harm includes death and major injury and any form of physical or mental ill health.

Risk it is a measure of the probability that the hazard (defined previously) will manifest some degree of harm. Hazards of workplace Physical Chemical 1-Noise 2-Radiation 3-Vibration 4-Heat and cold

1-Gases 5-Changes of pressure 2-Dust -- organic -- Inorganic 3-Metals:e.g. lead , Mercury Arsenic, Aluminum 4-Chemical compound

6-Electricity -Asphyxiants -simple - Toxic - Irritant -upper -lower -Toxic Mechanical Biological Sociopsychological 1-Accidents 1-Bacteria

1-Shift work 2-Lak of ergonomics 2-Virus 2-Work 3-Parasites hierarchy 3-Interpersonal 4-Fungus relation 33

Forms of Hazards Form Airborne Radiated emissions Examples -Chemical as dusts, gases, etc - Physical as radioactive particles -Biological as microbiological organisms ( all of which enter the body via the lungs) -_Noise, heat, light or ionizing and non-ionizing radiation

( affects body through the skin or other exposed organs) Liquid form Chemicals in liquid form can affect the skin or enter the body via that organ Solid form Chemicals in solid form can affect the skin or enter the body via that organ 34

Man and man (psychosocial hazards):- Human relationships amongst Rhythm of work. system of payment, Job security, workers participation, security, welfare conditions workers themselves on one

hand, and those in authority over them on the other hand. job satisfaction, Responsibility leadership style, Psychosocial hazards Psychosocial hazards like ; frustration, lack of job satisfaction, insecurity, poor human relationships, emotional tension may undermine both physical and mental health of the workers.

The health effects can be classified in two main categories: (a)Psychological and behavioral changes as: hostility, aggressiveness, anxiety, depression, fatigue, alcoholism, drug abuse, Sickness and absenteeism; (b) Psychosomatic ill health: including fatigue, headache; pain in the shoulders, neck and back; propensity to peptic ulcer, hypertension, heart disease and rapid ageing. DISEASES DUE TO PHYSICAL AGENTS Heat - Heat hyperpyrexia, Heat Exhaustion Heat Syncope, Heat Cramps, burns, Prickly heat Cold - Frost bite, Light Occupational Cataract,

Atmospheric-pressure-Caisson disease, air embolism, explosion. Noise - Occupational deafness,NIHL Radiation -Cancer, Leukemia, aplastic anemia, Pancytopenia Electricity - Burns, Shocks, Heat Illness Predisposing Factors

Physical activity Extremes of age, poor physical condition, fatigue Excessive clothing Dehydration Cardiovascular disease Skin disorders Obesity Drugs

Phenothiazines, anticholinergics, B and Ca channel blockers, diuretics, amphetamines, LSD, cocaine, MAOIs Heat Stroke SYMPTOMS True emergency Altered LOC Any neurological finding

And elevated temperature May still be sweating initially Syncope History is critical PREVENTION Awareness Adaptation of behavioral and physical activity Clothing Activity

Appropriate hydration Education Frost Bite TREATMENT SYMPTOMS Giving warm drinks, Caused by freezing and covering with conditions which cut off blankets. Warm the

circulation, usually in injured part with body extremities (hands, feet, heat only-put a hand ears, nose), which may be permanently affected. Frost- under an armpit, for bitten areas are cold, pale or example. Do not rub marbled-looking, solid to the the skin or apply direct touch, and painless (until heat to the injured circulation is restored). area. CHEMICAL HAZARDS

Routes of entry - Inhalation, Ingestion, skin absorption. (inhalation is the main route of entry) Chemical agents can be classified into 1) Metals - Lead, TEL, As, Hg, Cd, Ni , Co etc. 2) Aromatic Hydrocarbons - Benzene, Toluene,phenol etc. 3) Aliphatic Hydrocarbons - Methyl alcohol 4) Gases - *Simple asphyxiants : N2, CH4, CO2 * Chemical asphyxiants : CO, H2S, HCN

* Irritant gases : Ammonia, SO2, Cl2, * Systemic poison : CS2 Pneumoconiosis is a generic name covering the group of lung disorders which result from the inhalation of inorganic dust pneumon = lung konis = dust Pneumoconiosis = accumulation of inorganic dust in lungs, following nonneoplastic tissue reaction. Industrial dust Inorganic dust (consists of particles of minerals and metals)

Organic dust (contains particles of plant and animal origin, and also microorganisms that are on them, and their waste products) Mixed dust Inorganic dust Asbestos fibers under the electron microscope Talc - hydrated aluminum silicate oal dust of mining enterprises

Organic dust Dust generated during processing of raw cotton Moldy hay Pathogenesis Size of Dust 10- 5 Upper Respiratory tract 5-3 Mid respiratory tract

3-1 Alveoli DUSTS (Pneumoconiosis) Inorganic Dust Coal Dust -Anthracosis Silica -Silicosis Asbestos-Asbestosis Organic Dusts Cane Fiber -Bagassosis (Bronchi gets affected)

Cotton dust -Byssinosis (In Textile industries) Tobacco - Tobaccosis,Lung Cancer Grain Dust -Farmers Lungs Biological Hazards Bacteria- Tetanus, Tuberculosis, Anthrax, Brucellosis (Milkmen),Gonorrhea(Sexworkers-Genital organs get affected). Virus - Hepatitis, AIDS Protozoal & Parasitic- Malaria,Hydatid(Dog handlers),Hookworms, tapeworms (Agriworkers), etc.

Fungi- (Agri-workers) - Tinea-infections, Coccidiomycosis, Psittacoses, ornithosis, etc. MECHANICAL HAZARDS InjuriesFalls,cuts,abrasions,concussions,contusions,etc. Ergonomic DisordersMusculo-skeletal disorders(MSDs),Cumulative-traumaDisorders (CTDs) etc. PREVENTION OF OCCUPATIONAL DISEASES Prevention of occupational diseases may be grouped under three heads:I- Medical measures

III- legislations II- Engineering and environmental measures General Outlines of Prevention of Occupational Hazards Environmental 1-Substitution - of the process

- of the used substances Medical measures 1-Preplacement Medical examination - Selection of suitable workers - Base line for follow-up 2- Isolation- within the work-place 3- Segregation far from the work-place 4- Ventilation 5- Environmental Monitoring TLV 6- Assurance of Ergonomics in the

work-place 2- Periodic Medical examination - Early detection in the reversible stage - Indicator of the OH program 3-Personal protective devices 4-Health education H.Jaber2005 50 Hierarchy of Occupational Exposure

Controls 1. 2. 3. 4. 5. 6. Elimination or Substitution Process or equipment modification Isolation or Enclosure Local exhaust ventilation Personal Protective Equipment Work practices and housekeeping

Occupational Health Hierarchy of Controls Increase effectiveness and sustainability Elimination and/or substitution Engineering Controls Administrative Controls Workplace Practices PPE

Increase participation and supervision needed I. Medical measures 1. Pre-placement examination It is complete medical examination before the worker is employed. Significance: To put the right man in the right place. To detect diseases not previously know to the workers. A useful benchmark for future comparison It is done at the time employment and includes the worker's medical, family, occupational and social history;. a thorough physical examination and

a battery of biological and radiological examinations,( eg., chest x-ray, electro-cardiogram, vision testing, hearing testing, urine and blood examination, special tests for endemic disease. A fresh recruit may either be totally rejected or given a job suitable for his physical and mental abilities I. Medical measures 2. Periodical examination Aims at detecting as early as possible any deviation from normal health. The frequency and content of periodical medical examinations will depend upon the type of occupational exposure.

Ordinarily workers are examined once a year. But in certain occupational exposures (e.g., lead, toxic dyes, radium) monthly examinations are indicated. I. Medical measures 3. Medical and health care services: The medical care of occupational diseases first aid services which if properly applied will reduce suffering ,disability and will hasten recovery Immunization is another accepted function of an occupational health service. I. Medical measures

4. Notification: notification of cases and suspected cases of occupational disease. Aim of notification in industry: Initiate measures for prevention and protection and ensuring their effective application Investigate the working conditions and other circumstances which have caused or suspected to have caused occupational diseases. I. Medical measures 5. Supervision of working environment: Periodic inspection of working environment provides information of primary importance in

the prevention of occupational disabilities. The physician should pay frequent visits to the factory in order to inspect the various aspects of the working environment such as temperature, lighting, ventilation, humidity, noise, cubic space, air pollution and sanitation which have an important bearing on the health and welfare of the workers. I. Medical measures 6. Maintenance and analysis of records: The worker's health record and occupational disability record must be maintained. Review of records should enable the service to

a. watch over the health of the workers, b. to assess the hazards inherent in certain types of work and c. to devise or improve preventive measures. I. Medical measures 7. Health education and counseling Health education should start before the worker enters the factory and should be continuous. About: Personal hygiene. All the risks involved in the industry in which he is employed Use of personal protective equipments.

Safety and accident prevention. Special diet & food sanitation. II- Engineering and Environmental Measures 1. Design of building 2. Good housekeeping 3. General ventilation 4. Mechanization 5. Substitution 6. Dusts control 7. Enclosure 8. Isolation 9. Local exhaust ventilation 10. Protective devices

11- Environmental monitoring 12. Statistical monitoring II- Engineering and Environmental Measures 1. Design of building Start in the blue-print stage including the type of floor, walls, height, ceiling, roof, doors and windows, cubic which should receive attention in the original plan of the building .. II- Engineering and Environmental Measures 2. Good housekeeping general cleanliness, ventilation, lighting, washing, food arrangements and general maintenance.

It also contributes to efficiency and morale in industry. The walls, ceilings, and passages should be white-washed at least once a year. The dust which settles down on the floor, ledges, beams, machinery and other stationery objects should be promptly removed by vacuum cleaners or by wetting agents. Masks, gloves, aprons and other protective equipment should be kept clean and in a state of good repair. To prevent accidents, the right thing should be in the right place. Not only the inside, but the outside of the plant should also be kept clean and tidy. II- Engineering and Environmental Measures 4.General ventilation

Good general ventilation decreases. the air- borne hazards to the workers, especially hazards from dusts and gases. There should be good general ventilation in factories. It has been recommended that in every room of a factory, ventilating openings shall be provided in the proportion of 5 sq. feet for each worker employed in such room, and the openings shall be such as to admit of a continued supply of fresh air. In rooms where dust is generated there should be an efficient exhaust ventilation system. II- Engineering and Environmental Measures 4. Mechanization The plant should be mechanized specially for

hazardous processes e.g. dermatitis can be prevented if hand-mixing is replaced by mechanical devices. II- Engineering and Environmental Measures 5. Substitution By substitution is meant the replacement of harmful material by a harmless one, or one of lesser toxicity 6. Enclosure Enclosing the harmful materials and processes will prevent the escape of dust and fumes into 1he factory atmosphere. example, grinding machinery can be completely enclosed . Such enclosed units are generally combined with exhaust ventilation. 7. Isolation

Sometimes it may be necessary to isolate the hazardous process in a separate building so that workers not directly connected with the operation and are not exposed to hazard. Isolation may not be only in space, but also in the fourth dimension of time. Certain operations can be done at night in the absence of the usual staff II- Engineering and Environmental Measures 8.Dusts control Dusts can be controlled at the point of origin by sprays, e.g., wet drilling of rock. Inclusion of a little moisture in the materials will make the processes of grinding, mixing comparatively dust-free. 9. Local exhaust ventilation Local exhaust ventilation ,dusts, fumes and other injurious substances can be trapped and extracted "at source " before they

escape into the factory atmosphere and thus the breathing zone of workers may be kept free from dangerous dust and poisonous fumes Dusts, gases and fumes are drawn into suction and are conveyed through ducts into collecting units. II- Engineering and Environmental Measures 10.Protective devices Protective devices comprise respirators , gas masks, ear plugs, ear muffs, safety shoes, aprons, gloves, gum boots, barrier creams , screens and goggles. The worker should be instructed in the correct use of protective devices.

II- Engineering and Environmental Measures 11- Environmental monitoring Periodical environmental surveys sampling the factory atmosphere to determine whether the dusts and gases escaping into the atmosphere are within the limits of permissible concentration. The use of "permissible limits" has played an important part in reducing occupational exposure to toxic substances II- Engineering and Environmental Measures 12. Statistical monitoring

Statistical monitoring comprises the review at regular intervals of collected data at the health and environmental exposure of occupational groups. The main objective of these reviews is to evaluate the adequacy of preventive measures and occupational health criteria, including permissible exposure levels. 13. Research better understanding of the industrial health problems. III- Legislation Society has an obligation to protect the health of the worker engaged in diverse occupations. The worker is more important than the machine which he operates.

Factory laws, have been framed in every country to govern the conditions in industry and to safeguard the health and welfare of the worker. For effective implementation of national policies and programs, a good national OSH system is critical, including: laws and regulations, and collective agreements where appropriate, on occupational disease prevention; law compliance mechanisms, including effective workplace inspection systems; cooperation between management and workers and their representatives; occupational health services;

a mechanism for the collection and analysis of data on occupational diseases; provision of OSH training and information; collaboration with social security schemes covering occupational injuries and diseases. (ILO 2013 Hazard prevention and control programs require:

political will and decision-making; commitment from top management, with a clear and well circulated policy basis; commitment from workers; well defined goals and objectives; adequate human and financial resources; technical knowledge and experience; adequate implementation and competent management of programmes;

establishment of multidisciplinary teams; mechanisms for communication; monitoring mechanisms (indicators); continuous improvement of the programme WHOs work on occupational health is governed by the Plan of Action on Workers Health 2008-2017, endorsed by the World Health Assembly in 2007. Only a small proportion of the global workforce has access to occupational health services for primary prevention and control of diseases and injuries caused or aggravated by work.

In 2007, the 60th World Health Assembly endorsed a Global Plan of Action on Workers Health for 20082017 and urged WHO member states to devise national policies and plans for its implementation1 Risk factors for mental health problems

Drugs/alcohol Lack of education Poor nutrition Poverty Racial injustice Violence/delinquency War Work stress Unemployment

Sources of Stress at Work Work policies Interpersonal relations Work environment Workplace Population Mental health should not only be limited to children and adolescents, but to adults as well. Adults need good coping mechanisms as they gain more tasks and responsibilities. Just like students spending a huge portion of their time in school, adults spend a third of their day in their workplace. Work holds potential stressors for an individual, as

he needs to establish himself/herself at his/her work. Failure in work tends to devalue an individuals selfesteem. A healthy workplace considers the: importance of psychosocial well-being and mental health wellness of workers and provides policies, facilities, and environment that support programs to maintain overall health and work efficiency. Employers must see to it that enforcing efficiency does not jeopardize the workers health, including his/her mental wellness. There are some sources of stress in the workplace that

must be minimized not removed. Workplace health promotion - What is it? The European Network for Workplace Health Promotion has defined workplace health promotion as the combined efforts of employers, employees and society to improve the health and well-being of people at work. This vision of workplace health promotion places particular emphasis on: improving the work organization and working environment, increasing workers' participation in shaping the working environment, and encouraging personal skills and professional development .

Workplace health promotion focuses on a number of factors that may not be sufficiently covered in the legislation and practice of occupational health programmes, such as : - the organizational environment, the promotion of healthy lifestyles, - and non-occupational factors in the general environment. - Non-occupational factors include family welfare, home and commuting conditions, and community factors which affect workers' health. Aims of MHP in the workplace

Identification of workplace risks- ways to reduce them Development of a workplace culture to support wellbeing Flexible working/work- life balance Use of multicomponent wellbeing programms (eg including physical exercise programms in MHP programs/ Mental Heath Policies Training and awareness on mental health issues for managers as well as employees Early identification of stress and mental ill-health Access to counseling There is no health without mental health

Everyone is susceptible to mental health problems Blood borne Pathogens (BBPs) Microorganisms present in Blood, or Other Potentially Infectious Materials

Blood borne Pathogens (BBPs) Other Potentially Infectious Materials (OPIM) Blood Vaginal secretions Synovial fluid Peritoneal fluid Semen Cerebrospinal fluid Pleural fluid Amniotic fluid

Saliva (if contaminated with blood) Any body fluid that is visibly contaminated with blood Blood borne Pathogen Diseases Some examples of bloodborne pathogens: Malaria Syphilis Brucellosis

Leptospirosis Arboviral infections Relapsing fever Creutzfeld-Jakob Disease Viral Hemorrhagic Fever Main blood borne pathogens and diseases of concern

Hepatitis B Virus (HBV) Hepatitis C Virus (HCV) Human Immunodeficiency Virus (HIV) Hepatitis B Hepatitis C AIDS Health Care Workers and BBPs Occupational Transmission

Causes of percutaneous injuries with hollow-bore needles, by % total percutaneous injuries Manipulating needle in patients 27% 8% IV linerelated causes Source: CDC [1999] Handling/transferring

specimens Improperly disposed Other sharp 4% 5% 10% Disposalrelated causes 12% 10%

5% 11% Clean-up Handling or passing device Recapping during or after use 8%

Collision w/ health care worker or sharp Most common: Needle sticks Cuts from other contaminated sharps (scalpels, broken glass, etc.) Contact of mucous membranes (eye,

nose, mouth) or broken (cut or abraded) skin with contaminated blood Transmission of BBPs Occupational Exposure: Means reasonably anticipated skin, eye, mucous membrane, or parentral (piercing of the skin) contact with blood or OPIM that may result from the performance of an employee's duties Exposure Incident: is a broken skin, mucous

membrane or sharps injury exposure to blood or OPIM Transmission of BBPs Risk of infection depends on several factors: The pathogen involved The type/route of exposure The amount of virus in the infected blood at the time of exposure The amount of infected blood involved in the exposure Whether post-exposure

treatment was taken Specific immune response of the individual Courtesy of Owen Mumford, Inc. Health Care Workers and BBPs Occupational Transmission Risk of infection following needle stick or cut from a positive (infected) source: HCV: 3% HIV: 0.3%

HBV: 30% a Immunization of health care personnel Booster dose Not recommended Vaccine repeated annually Route/

Schedule Indication Vaccine doses i.m 3 All health care staff Hepatitis B month, 6 0,1 month 1 i.m dose of All health care staff Influenza inactivated injectable

vaccine annually doses of 2 HCP born 1975 or MMR MMR 4 weeks later without apart are serologic evidence given S.C of immunity or prior vaccination Booster dose

Route/ Schedule doses of 2 varicella vaccine 4 weeks apart are given S.C Td booster doses every 10 years If exposed to a dirty wound and last booster dose is > 5

.years Indication Vaccine HCP who have no serologic proof of immunity, prior vaccination or history of varicella disease Varicella

)Chickenpox( doses i.m 3 Persons without a ,months 1-2, 0 history or an unknown history months 6 ,Tdap (tetanus diphteria & pertusis) Single dose

Meningococcal Microbiologists who are routinely exposed to isolates of N. meningitis Exposure Controls - Following universal precautions - Equipment and Safer Medical Devices - Proper work practices - Personal protective equipment Exposure Incident

If you have an exposure incident to blood or OPIM, immediately do the following: Thoroughly clean the affected area Wash needle sticks, cuts, and skin with soap and water Flush with water splashes to the nose and mouth Irrigate eyes with clean water, saline, or sterile irrigants Report exposure to (supervisor, person or department responsible for managing exposures, etc.); fill out an Incident Report Form

Post-exposure evaluation -Documentation of the route(s) of exposure -A description of the circumstances under which the exposure occurred -Provide immediate post-exposure medical evaluation and follow-up to exposed employee: Confidential Testing for HBV, HCV, HIV Preventive treatment when indicated Occupational Health and Infection Control Measures

Health care workers require appropriate personal protective equipments and the necessary knowledge to realize their work in a safety way in hospitals and health care settings. Saying goes: Who lost something cannot give it :

Be sure to secure your own oxygen mask first before helping another.

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