Occupational Health Nursing in a USPHS
Deployed Environment:
A Critical Role
CAPT Cynthia Bentley Rubio
PhD, RN
Rapid Deployment Force Team, PHS-2
United States Public Health Service

• The presenter has no financial relationships to disclose.
• This continuing education activity is managed and accredited by Professional
Education Services Group in cooperation with AMSUS.
• Neither PESG,AMSUS, nor any accrediting organization support or endorse any product or service mentioned in this activity.
• PESG and AMSUS staff has no financial interest to disclose.
• Commercial support was not received for this activity.

At the conclusion of this activity, the participant will be able to:
1.Understand the story of the Monrovia Medical Unit, Liberia through the lens of force health protection nursing.
2.Explore the emergence of Occupational Health Nursing embedded with the
Safety group as a means of promoting team health and maximizing the mission.
3.Discuss applications for similar roles in future USPHS endeavors .

Change of Command Ceremony for MMU Teams 1 & 2, December 2014

The USPHS response to the
Ebola crisis in West Africa, and the subsequent public health teams deployed to the
Monrovia Medical Unit
(MMU) in Liberia, presented unprecedented physical and psychological challenges for
Public Health Service officers deployed to Liberia.
Ebola Survivors of the Monrovia Medical Unit at the “Survivor Wall” in Liberia

These challenges, if unaddressed by prevention and aggressive health promotion, would have negatively impacted the Mission of the MMU of “Providing hope through care to healthcare workers in Liberia who may have the Ebola Virus Disease, and continue efforts with the
Liberian government and international partners to build capacity for additional care”.

It was imperative to the success of the mission that the MMU teams maintained aggressive force health protection strategies to prevent harm and improve wellbeing.
An Occupational Health Nurse, served in this role on Team 2 that staffed the MMU in Liberia.
Force Health Protection staff from MMU Teams 2 & 3

A novel approach by the
Monrovia Medical Unit (MMU)
Team 2 was to incorporate an occupational health nurse role within the Safety/Preventive
Medicine Section.
USPHS Officers Prepared for the Hot Zone in at the MMU

For the mission, the role of the occupational health nurse role included active monitoring of the team, conducting health assessments, responding to emergencies, and providing access to care for deployed officers.
These duties were conducted in a manner that seamlessly blended with active field operations.

Primary workload for the MMU Occupational Health Nurse included twice-daily mandatory temperature monitoring of all team members, sick calls, responses to emergencies and newly evolving requirements. Additional responsibilities included performing or assisting with:
• Camp sanitation
• Teaching (security staff temperature screening skills, team health/self care)
• Data collection (Case reporting in potential GI cluster, daily ill, injuries, occupational exposures)
• Documentation of NIOSH and other field health illnesses and injuries
• Syndromic surveillance
• Interacting with theatre partners, such as the US Army, USAID, site contractors, US CDC staff,
NGOs, and the public
• Safeguarding the health of MMU staff by screening visitors and non-PHS workers
• Developing dynamic standard operating procedures (SOPs)
• Producing and disseminating health education materials
• Creating action plans to mitigate harm
• Collaborating with team Behavioral Health and Operation sections to enhance team well-being
• Informing/advising Command staff

This newly defined Occupational
Health Nurse role offered the opportunity to develop dynamic policy SOPs affecting the mission operations internally, preparing future teams, and augmenting the operations of partnering agencies involved with the Ebola Crisis
Response Mission in West Africa.
Aerial View of the Monrovia Medical Unit Margibi County, Liberia, West
Africa

The table on the right represents total visit types
(workload) by/to the MMU Team 2
Force Health
Protection Nurse workload.
“Sick calls” (visits potentially engaging the
Operations section provider) are broken out in the pie chart below.
The pie chart represents all visits except medication and temperature checks
PURPOSE OF VISIT
TWICE DAILY TEMP CHECK
TWICE DAILY ANTIMALARIAL CHECK
RESPIRATORY TOTAL
INJURY TOTAL
GASTROINTESTINAL TOTAL
MINOR RASH
ATHLETES FOOT-FUNGAL
HEAT STRESS
Chlorine-related irritation
19
Minor Strains
Minor Laceration
Fracture
18
Acute Diarrhea* (meeting case def)**
Mouth ulcers
Constipation
12
5
5
8,500
8,500
44 n
EXACERBATION OF CHRONIC ILLNESS
BUG BITE
Other
Febrile Illnesses
*No clusters
**Acute diarrhea= 5 episodes of acute watery diarrhea within a 48 hour period
TOTAL VISITS
1
1
2
0
17,107
36
6
12
1
5
5
1

The Occupational Health Nurse worked with officers to mitigate health risks and challenges including:
• Disrupted sleep and sleep deprivation
• Full PPE wear daily in a hot and humid climate
• Heat stress and exhaustion
• Stress caused by new and unfamiliar environment
• Close quarters with other officers
• Nutrition, food-borne illnesses
• Hydration
• Risk of injury
• Foot issue
• Occupational exposures including chlorine
• Risk of Ebola virus disease transmission
• Exacerbation of chronic health conditions
• Prescription medication compliance in a stressful environment
(including anti-malarials)
• Risk of diseases other than Ebola (Lassa Fever, Malaria, Dengue, etc.)
MMU Team 2 being briefed after arrival at the airport in Monrovia, Liberia

1. Having the Occupational Health Nurse incorporated into the safety section provided a direct link to address force health issues. Occupational health surveillance practices assisted the safety team in determining extent of chlorine exposure and identified possible food-related gastrointestinal issues.
2. Chlorine exposure cases: close review between safety and the occupation health nurse identified an ongoing chlorine exposure cases and issues. These data were used to determine that corrective measure were effective.
3. Trends in GI symptoms were quickly identified with safety/prev med and actions were taken to ensure food safety.
4. A dishwashing station was constructed at the MMU, reducing the potential for GI issues.
5. An all-hands approach was employed for field sanitation.
6. Provided team with 24/7 health care services described as “wrap-around care”.
7. Development of Standard Operating Procedures on Occupational Health (Nursing) and visiting screening by Security Staff.
8. 74 officers in, 74 officers home healthy, safe and disease free. Finishing Strong!

1. Having an Occupation Health Nurse associated with safety allowed for a better connection to respond to trends as they were recognized.
2. The Occupation Health Nurse and the Safety/Pre Med managers worked closely in constantly reviewing the reported cases and were able to respond quickly as issues arose.
3. Having all the force protection components under a single command structure allowed for better communication and quicker response on all safety and security issues.

LCDR Julie Erb-Alvarez
LCDR Matthew Johns
LCDR Amy Peterson
LDCR Joanna Gaines
LT Andrew Hickey
LCDR Okumura, Kazuhiro
CDR Derrick Newcomer
CDR Mark Clayton
CAPT John Whitesides
CAPT Timothy Radtke
CAPT David de la Cruz
CAPT James Dickens
CAPT Richard Childs and the entire MMU Team 2

CAPT Cynthia Bentley Rubio, PhD, RN
Lead Public Health Advisor
US Department of Health and Human Services
Substance Abuse and Mental Health Services Administration
Cynthia.Rubio@samhsa.hhs.gov
For more information about USPHS access www.usphs.gov

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