Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Tularemia


Related Terms

  • Bacterium Tularense
  • Deer Fly Fever
  • Pasteurella Tularensis
  • Rabbit Fever

Differential Diagnosis

Specialists

  • Cardiovascular Internist
  • Dermatologist
  • Gastroenterologist
  • Hematologist
  • Nephrologist
  • Neurologist
  • Ophthalmologist
  • Otolaryngologist
  • Preventive Medicine Specialist
  • Pulmonologist
  • Rheumatologist

Comorbid Conditions

  • Immune system disorders

Factors Influencing Duration

Length of disability will be influenced by the severity of the symptoms, response to treatment, and the development of secondary infections. Immunosuppressed and elderly individuals are at greater risk for severe disease and may require a longer recovery period.

Medical Codes

ICD-9-CM:
021.0 - Tularemia, Ulceroglandular
021.1 - Tularemia, Enteric; Tularemia Cryptogenic, Intestinal, Typhoidal
021.2 - Tularemia, Pulmonary; Bronchopneumonic Tularemia
021.3 - Tularemia, Oculoglandular
021.8 - Tularemia, Other Specified; Generalized or Disseminated Tularemia, Glandular
021.9 - Tularemia, Unspecified

Overview

Tularemia is a zoonotic infection (i.e., a disease of animals that can be transmitted to humans) caused by the bacterium Francisella tularensis. It is transmitted from wild animals (in the US, wild cottontail rabbits are the main source of the disease) to humans by direct contact with infected animal tissues or through an insect bite, such as that from a tick or deer fly. Airborne bacteria can be inhaled into the lungs. Tularemia may also be transmitted when eating inadequately cooked meat or drinking contaminated water, although such transmissions are rare. Most cases of tularemia are characterized by fever, chills, fatigue, and a generalized feeling of illness (malaise), but severe cases can result in a widespread, life-threatening disease. Tularemia is a reportable disease in the US.

There are several forms of tularemia: ulceroglandular, glandular, typhoidal, pneumonic, oropharyngeal, and oculoglandular (see History).

Tularemia is of concern to the US government as a possible weapon of biological warfare. When inhaled, fewer than 100 organisms can infect an individual and cause severe respiratory infection within a few days. In the past a vaccine was used to protect laboratory workers. It is no longer available, but a new vaccine is in clinical trials as of 2004.

Incidence and Prevalence: In the US, a few hundred cases are seen per year (Cleveland).Outside the US, the incidence of tularemia is highest in northern regions, such as Russia and the Scandinavian countries ("Tularemia"). Tularemia is not found in Africa or South America (Cleveland). As of 2012, one case had been reported in Tasmania, Australia, which may indicate that the disease has found its way to the Southern Hemisphere ("Tularemia").

Source: Medical Disability Advisor



Causation and Known Risk Factors

Risk factors include geographic location (in the US, more than half of reported cases occur in Arkansas, Missouri, Oklahoma, Tennessee, and Texas), outdoor work, residence in a rural area, handling wild game, gardening and landscaping, veterinary practice, and laboratory work. Hunters and trappers, butchers, fur handlers, and laboratory workers are the individuals most commonly infected. In the Midwest, tularemia occurs most frequently in the summer when ticks and deer flies are common. East of the Mississippi River, most cases are seen in the winter when cottontail rabbits are hunted. Elderly individuals and individuals with a compromised immune system are at a higher risk for more severe disease. Although all races and both sexes are equally susceptible to tularemia, more men become infected, because they are more likely to participate in activities that bring them into contact with animals that carry the disease.

Source: Medical Disability Advisor



Diagnosis

History: Individuals will report a history of exposure to wild animals (particularly rabbits, hares, and rodents), ticks, or deer flies in areas where the disease is known to exist. Individuals who work in a laboratory will report working with animals or bacterial isolates.

Symptoms develop within 10 days (usually 2 to 4 days) of exposure to the bacteria (incubation period). They may include rapid onset of a high fever, headache, nausea, and weakness. Some individuals will report vomiting and extreme fatigue and/or chills associated with profuse sweating. In most cases, a red, itchy blister develops at the site of infection, usually on the finger, arm, eye, or roof of the mouth. The blister, which fills with pus, quickly ulcerates. Swollen and painful lymph nodes (lymphadenopathy) may be reported.

Ulceroglandular tularemia, the most common form, accounts for 70-80% of all cases and is characterized by skin ulcer(s) at the site of infection and swollen lymph nodes (regional lymphadenopathy) (Cleveland).

Glandular tularemia is also characterized by lymphadenopathy but lacks skin ulcers, indicating the bacteria were probably ingested.

Typhoidal tularemia is particularly severe, and is characterized by a high fever, abdominal pain, extreme exhaustion, enlarged liver (hepatomegaly) and spleen (splenomegaly), and pneumonia.

Tularemia involving the lungs is called pneumonic tularemia, and produces difficulty breathing (dyspnea), unproductive or dry cough, and a burning sensation or pain in the chest.

Oropharyngeal tularemia involves a sore throat, mouth ulcers, lymphadenopathy, abdominal pain, vomiting, and diarrhea.

The most rare form of tularemia, accounting for only about 1% of cases, is oculoglandular tularemia. Probably caused by touching the eye with an infected finger, oculoglandular tularemia causes redness, swelling, sensitivity to light (photophobia), tearing, discharge, and pain in the infected eye along with lymphadenopathy; typically only one eye is affected.

Physical exam: The exam may reveal a nonspecific rash (macular or maculopapular, and finally pustular) on the trunk or extremities (20% of individuals) (Cleveland), fever of 104° F to 106° F (40° C to 41.5° C), and hepatomegaly and/or splenomegaly. Listening to the chest (auscultation) may reveal signs of pneumonia. There may be signs of other organs being affected, including the heart, brain, and bones. Delirium may be noted in some cases of pneumonic tularemia. Bacterial infection of the blood (septicemia) and a toxic reaction (toxemia) are characteristics of typhoidal tularemia. Cases of oculoglandular tularemia are associated with inflammation of the mucous membrane of the eye (conjunctivitis) and multiple ulcers. If the individual is a laboratory worker, the infection might only affect the lungs and the lymph nodes, making diagnosis difficult.

Tests: Routine blood counts are not particularly helpful in diagnosing this disease. Diagnosis is usually based on serology. Although difficult, the bacterium can be cultured from an ulcer, sputum, or an infected lymph node, confirming the diagnosis; appropriate media and safety precautions should be used. Blood or suppurative material tests will also reveal antibodies to the bacteria (indirect fluorescent antibody testing); the level of antibodies will rise steadily, peaking 4 to 8 weeks after infection. If pneumonic tularemia is suspected, a chest x-ray may be performed to assess lung involvement.

Source: Medical Disability Advisor



Treatment

The goals of treatment are to eliminate the bacteria with antibiotics, treat symptoms, and provide supportive care if complications arise. Depending on the severity of the infection, treatment may require inpatient care. Antibiotics are given by injection or orally for 1 to 2 weeks; aminoglycosides (streptomycin or gentamicin), tetracyclines (doxycycline), chloramphenicol, or rifampin are the drugs of choice; fluoroquinolones (levofloxacin or ciprofloxacin) may also be used. Fever-reducing drugs (antipyretics) are given until the fever subsides. Pain medication (analgesics) may be prescribed. Skin ulcers are wrapped in moist bandages, which are changed frequently to prevent the spread of infection. Ulcers in the eye are treated with eyedrop antibiotics and possibly eyedrop anti-inflammatory medications. If the individual is dehydrated, fluids are given. Treatment of pneumonia is supportive in nature. In severe cases, corticosteroids may be used to reduce inflammation. Abscesses may be drained to relieve some of the discomfort (incision and drainage).

Source: Medical Disability Advisor



Prognosis

When diagnosed early and treated promptly, the prognosis for tularemia is good. Most individuals achieve a full recovery. With treatment, the overall mortality rate is 1-3%; in the absence of treatment the mortality rate is 5-15%. The mortality rate is 2-3 times higher for typhoidal-type infections (Cleveland). Severe, complicated, or untreated cases, or individuals with compromised immunity can experience delayed recovery and have a higher incidence of mortality (up to 15%). Individuals who recover from tularemia may have immunity to further infection.

Source: Medical Disability Advisor



Complications

The infection can result in pneumonia, lung abscess, respiratory failure, liver dysfunction, rhabdomyolysis, kidney failure, pericarditis, endocarditis, peritonitis, meningitis, mediastinitis, or osteomyelitis. If another medical condition is present that involves depressed immunity, tularemia will present as a more serious disease.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Work restrictions may not be required for uncomplicated cases. Complicated cases, severe infections, or infections involving the lungs, heart, or brain may include restrictions as symptoms dictate. Dyspnea and rapid exhaustion may necessitate restriction from heavy or strenuous work. Frequent breaks to change bandages may be required until skin ulcers heal. If the eye is involved, tasks requiring keen eyesight, bright lights, or dusty environments should be avoided. Safety glasses and/or sunglasses may be required.

Risk: Human to human transmission of tularemia has not been reported. Individuals engaging in at-risk occupations (wild game handlers, gardeners, veterinarians, laboratory workers) should use safety practices to protect the eyes and hands when handling animal tissues. Use of insect repellents and fully protective clothing is indicated to prevent recurrence in individuals working outdoors in geographically sensitive areas.

Capacity: Capacity may be temporarily affected at the onset of infection, although rapid treatment with antibiotics may resolve the infection quickly. During recovery from uncomplicated infection, individuals may need to keep skin or eye ulcers protected while at work. More severe infection may necessitate hospitalization and therefore a temporary leave of absence.

Tolerance: Individuals with tularemia may experience reduced tolerance for heavy or very heavy work if high fever, vomiting, and dense fatigue results from the infection. Once the individual has recovered from an uncomplicated tularemia infection, there is no expected impact on tolerance.

Accommodations: Temporary job reassignment may be necessary to allow individuals normally performing strenuous work to transfer to more sedentary job duties. Employers willing to accommodate activities as needed can have employees return to work earlier.

Source: Medical Disability Advisor



Maximum Medical Improvement

30 days.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Has individual had a history of exposure to wild animals or to ticks?
  • Has the diagnosis of tularemia been confirmed with a blood test or culture of the bacteria from an ulcer, sputum, or an infected lymph node?
  • What form of tularemia did individual have?
  • What organ or body system was affected?
  • If the diagnosis was uncertain, were other conditions with similar symptoms ruled out (pyoderma, staphylococcal infections, streptococcal infections, cat-scratch disease, Pasteurella infections, sporotrichosis, plague, toxoplasmosis, legionellosis, Rocky Mountain spotted fever, ehrlichiosis, Lyme disease, brucellosis, Q fever, psittacosis, tick-borne typhus)?

Regarding treatment:

  • Was prompt treatment with antibiotics received?
  • Is individual following instructions regarding medication use and dosage, rest, hydration, and/or bandage changing?
  • If incapable of following treatment regimen, would individual qualify for outside help such as a visiting nurse?
  • Have inpatient treatment and/or intravenous antibiotic therapy been considered? If not, why not?
  • Have other associated symptoms such as pneumonia or abscesses been addressed in the treatment plan?

Regarding prognosis:

  • Did individual receive prompt diagnosis and treatment?
  • Based on the severity of the disease and the general health of individual, what was the expected prognosis?
  • Has individual experienced any associated conditions or complications (pneumonia, lung abscess, respiratory distress syndrome, liver dysfunction, rhabdomyolysis, kidney failure, pericarditis, endocarditis, peritonitis, meningitis, mediastinitis, or osteomyelitis) that could affect recovery and prognosis? Are these conditions being addressed in the treatment plan?
  • Are there any underlying circumstances, such as advanced age or immune system disorders, that could affect ability to recover?

Source: Medical Disability Advisor



References

Cited

"Tularemia." Center for Infectious Disease Research and Policy. 6 Sep. 2013. 23 Jul. 2015 <http://www.cidrap.umn.edu/infectious-disease-topics/tularemia>.

Cleveland, Kerry O., et al. "Tularemia." eMedicine. 16 Jul. 2014. Medscape. 23 Jul. 2015 <http://emedicine.medscape.com/article/230923-overview>.

Source: Medical Disability Advisor






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