Workplace Safety and Insurance Board (WSIB)
Appeals Resolution Officer Decision
Decision Number: 20100163
Objection By: Worker
Employer: Not Participating
Participants: Worker, Worker’s Representative, Employer, Employer’s Representative
Hearing Location: N/A
Issue
The worker is requesting entitlement to Methicillin Resistant Staphylococcus Aureus (MRSA).
How the Issue Arises
The worker, a now 47 year old resident care worker employed with the employer since October 2007, reported feeling unwell on approximately January 17, 2009. He called in sick to his employer on January 18, 2009 and went for treatment at a local Emergency Department on January 20, 2009 where they diagnosed pneumonia. His condition persisted and he was eventually admitted to another hospital on January 27, 2009. When his condition did not improve and tests showed he had MRSA empyema, he was transferred to another hospital where he was admitted on February 7, 2009.
The worker relates his MRSA to exposure in his workplace and the claims adjudicator denied entitlement on the basis the evidence did not support it was more probable than not that he contracted the illness in the workplace. She informed the workplace parties of this decision in a letter dated April 24, 2009.
The worker is objecting to this decision.
Authority
WSIB Operational Policy
11-01-02 – Decision-Making
Workplace Safety and Insurance Act (the Act)
Section 15(1) and (2).
Resolution Method and Process
I discussed and confirmed the issue with the worker’s representative and agreed a decision could be made with the evidence on file after receiving written submissions from the employer. The employer participated in the process.
Assessment of the Evidence
I have reviewed the record and considered the evidence.
The claim was established when the worker submitted a Worker’s Report of Injury/Disease dated February 23, 2009. In his addendum to the form, he wrote he started having fevers and chills on January 17, 2009 and called in sick for his shift on January 18, 2009. He then went to an Emergency Department on January 20, 2009 where they did a chest x‑ray and informed him that he had a severe case of pneumonia. They treated him with oral medication but when the condition did not improve, he went to another Emergency Department on January 23, 2009 where he was given intravenous fluid, Gravol and Toradol.
By Monday, January 26, 2009, the worker returned to the original Emergency Department where he was admitted because of his worsening condition. The worker reported they did blood cultures which showed he had MRSA in his blood. He was then placed on intravenous antibiotics and did not improve so on February 3, 2009, they did an ultrasound guided thoracentesis which showed he had MRSA in his lungs as well. A CT Scan of the chest done on February 5, 2009 showed empyema. He was then transferred to the London Health Science Centre and on February7, 2009 where they inserted a chest tube. He remained in the hospital until February 12, 2009 and continued to receive intravenous antibiotics until February 16, 2009.
The claims adjudicator obtained a statement from the worker documented in memo 3 dated April 30, 2009. The worker informed her he feels his condition resulted from his employment because he is routinely exposed to people with infectious diseases due to the nature of his employment. He informed the claims adjudicator he learned of other co-workers who were also similarly diagnosed although he did not have specifics as to when the co-workers contracted the illness. The claims adjudicator documented in her memo, the worker would not identify a specific client who had the illness but strongly felt he contracted the illness either directly or indirectly from his employment. He confirmed he has not been out of the country for a few years and denied visiting any other shelter or working anywhere else. He was unaware of any other family member or friends who had the illness and he denied having any prior history of MRSA.
The employer reported the worker worked during the week of January 11, 2009 and had cold/flu like symptoms. He worked Friday, January 16, 2009 and was scheduled to return on Saturday, January 17, 2009 but called in sick and remained off work at that point. Apparently the worker reported he had community acquired MRSA pneumonia and was relating it to exposure in his workplace. The employer reported they have no known cases of MRSA in their facility. The employer reported the worker’s job requires him to be in contact with the clients in the residence as he frequents their living quarters and the common areas. The employer outlined their procedures for taking precautions with sanitation and reported the worker is very diligent about this. The employer also pointed out the worker’s spouse is a nurse and understands that the general public has a significant increase in incidents of MRSA when sharing a home with a health care worker.
The worker reported he was treated initially at an Emergency Department on January 20, 2009 but that report is not in the file. The initial Emergency Report in the file is dated January 23, 2009 and states the worker presented was recently diagnosed with pneumonia-pleurisy and was currently retching and vomiting. The worker had a fever and was very anxious and the discharge diagnosis was a flu like illness.
The worker’s condition worsened and he was admitted to the hospital on January 27, 2009 with a working diagnosis of pneumonia. They documented his history as having been diagnosed with pneumonia on January 20 and put on Biaxin. The worker went to Alexandra Hospital on January 23, 2009 and was diagnosed with dehydration and vomiting and was given fluids. Apparently he also had some confusion at the time. When he presented to the hospital, he was not improving and a chest x‑ray showed the pneumonia was actually worsening. It was noted he works at a Men’s mission and they wondered if he could have contracted an atypical bacteria or tuberculosis so they decided to put him on respiratory isolation.
The final consultation report dated February 6, 2009 noted the worker had developed a further consolidation in his left base. Blood cultures show gram positive cocci and he was put on Rocphin and Levaquin. The doctor felt a thoracentesis under ultrasound guidance would be helpful to rule out empyema.
On February 7, 2009, the worker was transferred from Woodstock Hospital to London Health Science Centre for a MRSA empyema. The hospital did a pulsed field gel electrophoresis (PFGE) of staphylococcus aureus and reported they arbitrarily designated the strain for this MRSA PFGE report only and indicated it was community acquired. While at the hospital, the worker had a chest tube placement and they felt he had done well from the MRSA empyema and they continued him with four days of vancomycin IV after discharge on February 12, 2009.
The worker attended the clinic at the London Health Sciences Centre on March 23, 2009 for a follow up evaluation and they indicated he had the following identified problems:
MRSA pneumonia;
A left MRSA empyema treated with vancomycin, chest tube drainage and TPA.
The doctor felt given the worker’s history, it was probable he had contracted the MRSA in the workplace. At the time of the follow up appointment, worker had resolved MRSA pneumonia and empyema clinically and radiographically.
A WSIB occupational medical consultant reviewed the evidence in the file and offered an opinion documented in memo 7 on April 9, 2009. She noted there was no specific incident in the workplace identified which could serve as a portal of entry for MRSA. She acknowledged the worker was well with no skin lesions or work-related skin abrasion. She also noted he was employed in clerical activities such as data entry, assistant at the front desk handing out supplies and inspection of the facilities and was not likely to be in contact with any client’s contaminated personal articles. She opined the worker’s illness would not be attributed to the employment as the risk for community acquired MRSA would be no greater than the general population. She further opined that MRSA septicemia was an unanticipated consequence of treatment for fever and systemic symptoms with Biaxin and furthermore, the original flu like symptoms or pneumonia would not be attributed to the employment.
The claims adjudicator accepted the WSIB occupational medical consultant’s opinion and denied entitlement on the basis that the evidence did not support it was more probable than not the worker contracted MRSA from exposure in the workplace.
The worker’s representative completed the Objection Form and offered the position that the worker was exposed to MRSA in the workplace and the medical opinion in the report dated March 23, 2009 supports entitlement. The doctor reported it is probable the worker has acquired MRSA pneumonia at work and given the worker’s history, there is no evidence of any other exposure other than in the workplace.
The employer’s representative submitted a letter in response to my letter dated December 23, 2009 requesting details of the worker’s exposure. The employer representative acknowledged a client, who they later learned had MRSA stayed in the employer’s shelter on August 26, 27, 28, 29 and December 28, 29, 30, 31, 2008. He returned again on February 13, 2009 and stayed until February 28, 2009 before returning again in April 2009. The employer indicated the worker likely had contact with the client in August 2008 but not in December 2008. He acknowledged that during the time period in December when the client was in the employer’s shelter, the worker was away from the workplace and he attached timesheets from December 15, 2008 to January 11, 2009 in support of his position. The employer learned on March 6, 2009 that the client in question had MRSA after receiving confirmation from an area hospital. The employer is unaware of when the client contracted MRSA and was unable to confirm that he had it when he stayed with them in August or December 2008. The employer’s representative later confirmed no other employee contracted MRSA and felt it is likely the statement indicating that another employee had MRSA was in reference to an employee from another shelter. The employer was unable to recall which shelter or which employee or client contracted MRSA.
Dr. Licskai, a Respirologist who treated the worker wrote on December 29, 2009 the worker works in a homeless shelter where there is a high probability of clients with community acquired MRSA colonization. He felt the fact that individuals were identified in the shelter as having MRSA suggests to him that the organism was in the workplace and there may well be other individuals similarly colonized but unknown to the staff. He agreed that the portal of entry is likely nasal or oropharyngeal colonization and secondary aspiration of bacteria since micro aspiration is a common mechanism for pneumonia. He felt that nasopharyngeal colonization would be very uncommon in an otherwise healthy 45 year old man without any identified exposures in Canada and further given that he works in an institution where MRSA is known to circulate, it seems probable that he acquired the colonization in the workplace. He concluded that it is a work-related illness.
The worker in response to the employer’s submission indicated he worked the day shift on January 1, 2009 and the client who was infected registered on December 31, 2008 and remained in the shelter until 12:00 Noon of the following day so he would have had opportunity for direct contact with the client.
I carefully considered the evidence presented and I acknowledge the WSIB occupational medical consultant’s opinion that no portal of entry was identified in the employment however I accept the treating respirologist’s opinion that this illness could be acquired through micro aspiration which would not exclude exposure in the workplace if there was an infectious source.
Communicable diseases are diseases that can spread from one infected person to another person either directly or indirectly. Multiple potential sources of infection may exist in the workplace and in the community which creates challenges in establishing work-relatedness when adjudicating claims. In determining whether the worker’s MRSA exposure in the workplace significantly contributed to the development of his MRSA, I considered:
Was there a contact source of MRSA in the workplace?
Was there an outbreak of the illness in the workplace?
Did the worker have opportunity for exposure to the contact source in the workplace?
Is the illness prevalent in the community or restricted to the facilities similar to the one in which the worker worked?
The employer confirmed they learned on March 6, 2009 a client who was at their shelter sometime during the months of August and December 2008 did have MRSA. However it is unknown when the client was infected when he was at the shelter in either August or December 2008. The Public Health Agency of Canada Fact Sheet on MRSA recognizes that MRSA infections occur most commonly among people in hospitals and other health care facilities and this has been recognized as a problem for the past 20 years. Outbreaks are more common in health care settings because some patients already have a compromised immune system. People with weakened immune systems and chronic conditions are most susceptible to the infection. The fact sheet further states; “At any given time, between 20 and 30 per cent of the general population carries staph bacteria on their hands or in their noses but are not ill. Some of these bacteria may be MRSA while others are not antibiotic resistant. You may have MRSA and not be sick however you can still spread it to others and they can become ill.”
The worker works in a facility which I acknowledge is at risk for the spread of communicable diseases and there is evidence a client who was at the facility was diagnosed with MRSA. However there is no indication of when this client had the MRSA and no evidence that anyone else in the workplace whether client or other employee contracted this illness.
While I acknowledge the worker works in a facility where there is great potential for the spread of communicable diseases, and there was a client who was diagnosed with MRSA who was in that facility in August and December 2008, I do not find the evidence supports it is more probable than not that the worker contracted the MRSA due to exposure in the workplace. I have no evidence to support when the client who had MRSA contracted the illness although the employer confirmed the worker likely had contact with the client in August 2008 but not in December 2008. The employer reported the worker did not work on the days the client was in the shelter but I accept his explanation that he likely would have had some contact with the client on January 1, 2009, a day on which he worked and when the client was likely in the shelter overnight starting December 31, 2008.
I appreciate Dr Licskai’s opinion but MRSA is not an illness that is isolated in health care facilities or the type of facilities in which the worker worked. The Public Health Agency of Canada acknowledged this disease is prevalent in the community at large and a person may not be able to account for the source of their illness because of the nature of how it is spread. As I am unable to find on the balance of probabilities the worker’s exposure in the workplace significantly contributed to the development of his MRSA, I am denying his request for entitlement.
Conclusion
I conclude the evidence does not support on the balance of probabilities the worker contracted MRSA in the workplace.
The worker’s objection is denied.
Dated: June 29, 2010.
D. Hart
Appeals Resolution Officer
Appeals Branch