1. Emergency Medical Services Emergency First Responders
“Infection Control”
for
Emergency First Responders
October 01, 2014

2. Objectives: Define Terminology & Concepts
Identify Means of Transmission
Identify Risk Factors
Demonstrate P.P.E.
Discuss Infection Control Policies and Procedures
Answer Questions

3. Introduction
Welcome!
Class Schedule
Breaks
Motivation
Outline

4. The Infection Control Plan
Brief Overview
What is it?
What does it do?
Introduction to Your Plan
Location
Obtaining a Copy

5. Applicable Laws and Standards
29 CFR
29 CFR
29 CFR
NFPA 1500
NFPA 1581
Ryan White Act
Connecticut DPH / OEMS
Center for Disease Control
– Bloodborne pathogens.
– Respiratory Protection.
– Hazard Communication.
NFPA 1500 – Fire Department Occupational Safety and Health Program
NFPA 1581 – Comprehensive Occupational Medical Program for Fire Departments
Ryan White Act – Federally Funded Program for people with HIV / Aids
Connecticut Department of Public Health / Office of Emergency Medical Services
Center for Disease Control

6. Communicable Diseases, Epidemiology
&
Symptoms

7. Principles & Modes of Transmission

8. Four Modes of Disease Transmission
Direct Contact
Indirect Contact
Airborne Transmission
Vector Transmission

9. Four Elements of Transmission
Pathogen
Communicability and Virulence
Quantity
Dosage, Duration, & Frequency
Susceptibility
Host Resistance

10. Four Elements of Transmission
Entry Site
Exposure type
Significant
Non-Significant
Other Factor(s):
Organism Hardiness
Environmental Survivability

11. Exposure Severity Significant: Non-Significant: Mucosal Percutaneous
Eyes & Mouth Membranes
Percutaneous
Puncture, Non-Intact Skin, Human Bite
Non-Significant:
Clothing, Intact Skin

12. Six Types of Pathogens Viruses* Bacteria* Fungi Protozoa Rickettsia
Parasitic Worms
*Most Common

13. For the Emergency Responder
Diseases of Concern
For the Emergency Responder

14. Some Diseases of Concern
Ebola
Enterovirus (EV-D68)
Hepatitis
Herpes
Herpes Zoster (Shingles)
HIV / Aids
Influenza
Meningitis
Tuberculosis

15. Ebola
Ebola hemorrhagic fever (EHF) or simply Ebola is a disease of humans and other primates caused by Ebola viruses.
The virus is acquired by contact with blood or other body fluids of an infected human or other animal.
May also occur by direct contact with a recently contaminated item
May be able to transmit the disease via semen for nearly two months.

16. Ebola Symptoms Fever (greater than 38.6°C or 101.4°F) Severe headache
Muscle pain
Weakness
Diarrhea
Vomiting
Abdominal (stomach) pain
Unexplained hemorrhage (bleeding or bruising)

17. Enterovirus (EV-D68)
Enteroviruses are a genus of positive-sense single-stranded RNA viruses associated with several human and mammalian diseases.
71 human Enterovirus serotypes on the basis of antibody neutralization tests.
Enteroviruses affect millions of people worldwide each year, and are often found in the respiratory secretions (e.g., saliva, sputum, or nasal mucus) and stool of an infected person.

18. Enterovirus (EV-D68)
Enterovirus: EV-D68 was first identified in California in 1962.
Most people who get infected are infants, children and teens.
Infections with Enteroviruses are usually common in the United States during summer and fall.
There is no specific treatment for EV-D68. Talk to your child's doctor about the best way to control his or her symptoms.

19. Enterovirus (EV-D68) Symptoms
Mild symptoms may include:
Fever
Runny nose
Sneezing
Cough
Body and Muscle aches
Severe symptoms may include:
Wheezing
Difficulty breathing

20. Hepatitis Family
Viral hepatitis is the most common cause of hepatitis worldwide.
Most common causes of viral hepatitis are the five unrelated hepatotropic viruses:
hepatitis A
hepatitis B
hepatitis C
hepatitis D (which requires hepatitis B to cause disease),
hepatitis E

21. Hepatitis Family Transmission: Symptoms:
Fecal / Oral, Body fluids, blood
Symptoms:
Fever
Loss of appetite/Nausea
Jaundice
Fatigue
Headache
Vaccine Available for Hep A Virus, Hep B Virus

22. Herpes Simplex Virus
Herpes simplex virus 1 and 2 (HSV-1 and HSV-2), also known as human herpes virus 1 and 2
Both HSV-1 (which produces most cold sores) and HSV-2 (which produces most genital herpes) are ubiquitous and contagious.
Herpes simplex can be spread through contact with saliva, such as sharing drinks.
A cure for herpes has not yet been developed. Once infected, the virus remains in the body for life.

23. HSV-1 (Cold Sores) & HSV-2 (Genital)
Transmission:
Transmitted by direct contact with a lesion or the body fluid of an infected individual
Fingers are at particular risk.
Symptoms:
Lesions around mouth, Malaise, Sore Throat
No vaccine available

24. Herpes Zoster (Shingles)
The initial infection with Varicella Zoster Virus (VZV) causes the acute, short-lived illness chickenpox which generally occurs in children and young adults.
Once an episode of chickenpox has resolved, the virus is not eliminated.

25. Herpes Zoster (Shingles)
Transmission:
As with chickenpox and / or other forms of herpes, direct contact with an active rash can spread VZV to a person who has no immunity to the virus. This newly infected individual may then develop chickenpox, but will not immediately develop shingles.

26. Herpes Zoster (Shingles)
Earliest symptoms of herpes zoster:
Headache
Fever
Malaise
Followed by sensations of:
burning pain
itching
hyperesthesia (oversensitivity) or
paresthesia (“pins and needles”)
tingling, pricking, or numbness

27. HIV / AIDS
The Human Immunodeficiency Virus (HIV) is a lentivirus (a subgroup of retrovirus) that causes the Acquired Immunodeficiency Syndrome (AIDS).
Infection with HIV occurs by the transfer of blood, semen, vaginal fluid, pre-ejaculate, or breast milk
lentivirus (a subgroup of retrovirus)

28. HIV / AIDS Transmission: Symptoms: No vaccine available Blood
Body fluids with blood
Symptoms:
Fever
Cough
Night sweats
Weight loss
No vaccine available

29. Influenza
Influenza, commonly known as "the flu", is an infectious disease of birds and mammals caused by RNA viruses of the family Orthomyxoviridae,
Typically, influenza is transmitted through the air by coughs or sneezes, creating an aerosol containing the virus.
Influenza can also be transmitted by direct contact with bird droppings or nasal secretions, or through contact with contaminated surfaces
prodrome is an early symptom (or set of symptoms) that might indicate the start of a disease before specific symptoms occur.

30. Influenza Most common symptoms are: chills fever runny nose
sore throat
muscle pains
headache (often severe)
coughing
weakness / fatigue
general discomfort
prodrome is an early symptom (or set of symptoms) that might indicate the start of a disease before specific symptoms occur.

31. Meningitis
An acute inflammation of the protective membranes covering the brain and spinal cord, known collectively as the meninges.
May be caused by infection with viruses, bacteria, or other microorganisms

32. Meningitis Bacterial (Rare) Vaccine available Transmission: Symptoms:
Direct Contact with Oral / Nasal Secretions
Intimate or Direct Exposure (i.e. Kissing)
Symptoms:
Fever >101 F, Sudden Severe Headache
Neck / Back Stiffness
Mental Changes
Rashes
Vaccine available

33. Meningitis Viral (Common) No vaccine available Transmission: Symptoms:
Fecal / Oral
Symptoms:
Same as Bacterial; Also possible:
Abdominal discomfort
Chest pain
Rash
No vaccine available

34. Tuberculosis
Tuberculosis typically attacks the lungs, but can also affect other parts of the body.
Spread through the air when people who have an active TB infection cough, sneeze, or otherwise transmit respiratory fluids through the air
The Mantoux tuberculin skin test is often used to screen people at high risk for TB

35. Tuberculosis Transmission: Symptoms: Vaccine available Airborne Fever
Night Sweats
Weight loss
Fatigue
Vaccine available

36. Other Diseases of Concern
Anthrax
Chickenpox
Smallpox
Lyme
MRSA
Pneumonia (Bacterial & Viral)
West Nile

37. Anthrax
Anthrax is an acute disease caused by the bacterium Bacillus anthracis.
Most forms of the disease are lethal
Anthrax can enter the human body through the intestines (ingestion), lungs (inhalation), or skin (cutaneous)
Anthrax does not usually spread from an infected human to a non-infected human.
Effective vaccines against anthrax are now available

38. Chickenpox
Chickenpox is a highly contagious disease caused by primary infection with Varicell Zoster Virus (VZV).
Chickenpox is an airborne disease which spreads easily through coughing or sneezing

39. Smallpox
Smallpox was an infectious disease caused by either of two virus variants, Variola major and Variola minor.
Transmission occurs through inhalation of airborne variola virus, usually droplets expressed from the oral, nasal, or pharyngeal mucosa of an infected person
Smallpox is highly contagious, but generally spreads more slowly and less widely than some other viral diseases
prodrome is an early symptom (or set of symptoms) that might indicate the start of a disease before specific symptoms occur.

40. Smallpox Incubation period is 12-14 days
Characteristic rash appears 2-3 days after nonspecific, flu-like prodrome (fever and headache)
Rash begins on face, hands, forearms and spreads to legs and centrally to trunk; Lesions are more predominant on the extremities than the trunk
prodrome is an early symptom (or set of symptoms) that might indicate the start of a disease before specific symptoms occur.

41. Smallpox Eczema Vaccinatum
Eczema vaccinatum is a rare severe adverse reaction to smallpox vaccination .

42. And… More Diseases… German Measles (Rubella) Lice Measles
Mononucleosis
Mumps
Scabies
Syphilis

43. Why is this important to know?
Incubation Period(s)
Anthrax
Ebola
Hep. Family
HIV/AIDS
Meningitis TB
Chickenpox
Pneumonia
1 to 7 days
21 Days
25 days or more
>3 Months
2 to 10 days
2 to 12 weeks
14 to 16 days
Several days
Why is this important to know?

44. Infection Control Plan
Health Maintenance System:
Concept & Components

45. Health Maintenance (HM) Concept
“A system to optimize the health
of employees, and to minimize
the risk of occupationally
acquired illness or injury”
A.K.A. “Risk Management!”

46. HM System Components Physical Exam Immunizations PPE
Post-exposure protocol
Member assistance programs

47. Physical Examination

48. Physical Examination Pre-entry health assessment On Going Assessment
Initial exam
Determination of baseline
Fitness for service
On Going Assessment
Repeat exams as determined by MD

49. Proactive Infection Control
Immunizations
Proactive Infection Control

50. Immunizations Proactive program offers protection to: Frequency:
Employee
Spouse / family members of employee
Emergency response organization
Patients
Frequency:
Initial
Annual

51. Common Vaccinations HBV or A/B combo
OSHA requirement to be offered (HBV)
(f)(1)(i)
Declination statement
App A
Three shot series
Titer recommended by CDC
As of 02/09/1990
Hepatitis B Virus

52. Common Vaccinations Diphtheria-Pertussis-Tetanus (DPT)
Measles-Mumps-Rubella (MMR)
Polio
Influenza
Pneumonia
Chickenpox
Smallpox

53. Personal Protective Equipment
Usage Concepts

54. Universal Precautions
“Precautions taken to prevent occupational risk exposure to blood and other bodily fluids.”
Universal Precautions now referred to as “Standard Precautions”
Often “Body Substance Isolation” used in its’ place by First Responders

55. Body Substance Isolation (BSI)
“An infection control strategy that considers all body substances as potentially infectious.”
Similar to Universal Precautions .. But goes further in
isolating workers from Pathogens

56. “Two” Levels of B.S.I. – P.P.E.
“Standard” Level of B.S.I.
Everyday calls, First Responder Protection
“Isolation” Level of B.S.I.(special circumstances)
Full Body Protection – No Skin Exposed

57. “Standard” Recommended P.P.E.
Gloves
Eye / Face splash protection
Splash Protection – Gowns
N95 or N-100 mask
Disposable resuscitation equipment

58. “Standard” P.P.E. – Gloves

59. “Standard P.P.E. – Eye Protection

60. “Standard” P.P.E. – Gowns
Gowns
Aprons

61. “Standard” P.P.E. – Respiratory
Respirators that filter out at least 95% of airborne particles during “worse case” testing using a “most-penetrating” sized particle are given a "95" rating. Those that filter out at least 99% receive a “99” rating. And those that filter at least 99.97% (essentially 100%) receive a “100” rating.

62. “Standard” P.P.E. – Kits

63. Disposable Respiratory Devices

64. “Isolation” P.P.E. Gloves – Double Glove
Eye / Face splash protection – NO GOGGLES
Gowns / Coveralls – Complete Body Coverage
Hood – if not part of Splash Protection or PAPR Ensemble
Respiratory Protection: PAPR or N95
(Powered Air Purifying Respirator)
Boot Covers – if not using a one piece suit
Disposable Resuscitation Equipment

65. “Isolation” P.P.E. – Gloves
Double Glove is highly recommended;
First Pair put on first under sleeve cuff
Second Glove over top on top of Sleeve Cuff

66. “Isolation” P.P.E. – Eye Protection
CDC is recommending full face shields or full hoods for eye protection.
Googles / Glasses tend to “Fog” – Responders then place hands near
the eyes to move goggles, thus potentially exposing to disease

67. “Isolation” P.P.E. – Gown / Coveralls

68. Hoods offer more body protection, usually require PAPR air supply
“Isolation” P.P.E. – Hood
Hoods offer more body protection, usually require PAPR air supply

69. “Isolation” P.P.E. – Respiratory
Powered Air Purifying Respirators (PAPR)
are recommended for long duration work capacity and reliability

70. “Isolation” P.P.E. – Boot Covers
Knee high boot covers are recommended
depending on the type of protective suit / coveralls being used

71. “Isolation” P.P.E. – Ventilation Equipment

72. Personal Protective Equipment
Proper usage
Storage location(s)
Proper removal
On scene self decontamination
Hand Washing
Disposal

73. Post Exposure Protocol
Critical Information for the Responder

74. What Do You Do?
You’re operating at the scene of a stressful emergency; You think you’ve just been exposed to blood or body fluids…
What do you do?
Who do you notify?
Should you go to the hospital?
Help!

75. Post Exposure System
A post exposure system establishes uniform procedures to protect the health of responders after a possible exposure to communicable diseases

76. Post Exposure System The “Players” Responders Supervisors
Infection Control Administrator (ICA)
Infection Control Practitioner (ICP)
Agency Physician (Fire / EMS / Law Enforcement)
Health Department

77. Treatment / Follow-up care
Post Exposure System
Components:
Notification
Verification
Treatment / Follow-up care
Documentation
Counseling

78. Post Exposure System Notification Phase Responder:
Exposure is perceived
Reports verbally to IC
Completes exposure report
Significant vs. non-significant exposure
Contacts workers’ comp. Hotline
Notifies Infection Control Administrator

79. Post Exposure System Notification Phase Supervisor (IC)
Visually verifies exposure when feasible
Ensures decon and treatment when needed
Endorses exposure report
Contacts Infection Control Administrator
Verifies workers’ comp. has been called

80. Post Exposure System Verification Phase Starts on scene
IC attempts to verify exposure
ICA schedules medical exam
Primarily for significant exposures
Recommended within 48 hours
ICA contacts receiving facility
Ryan White Care Act

81. Ryan White Care Act This act delineates specific notification
requirements that allow responders to find
out if they have been exposed to an
“infectious disease.”

82. Ryan White Care Act Routine Notification
The hospital notifies transporting responders
of a potential exposure
Within 48 hours
Does not apply to non-transporting responders
ICP contacts ICA
Confidential!

83. Ryan White Care Act Notification by Request Initiated by local ICA
ICA contacts receiving facility ICP
Reply within 48 hours
An exposure took place
An exposure did not take place
Insufficient information / undetermined
Confidential!

84. Confidentiality Issues
You’ve been exposed…
Privacy act limits information that can be given to ICA or CEO by ICP / MD
All information is confidential
You may give your consent
Reality check
How hard is it to keep a secret in your agency?

85. Post Exposure System Treatment Phase May start on scene
Medical Evaluation w/in 48 hours
Testing
Initial and follow-up
Incubation period
Treatment
May be long term
Prophylactics

86. Post Exposure System Documentation Phase Exposure record
Injury / illness report
Workers’ compensation
OSHA

87. Post Exposure System Documentation Phase ICA conducts follow up review
Within a reasonable period of time
Considerations?
Does responder need retraining?
Does Agency need to alter current procedures?
How can this be prevented from happening again?

88. Post Exposure System Counseling Phase Peer support / CISD
Stress management
Spousal or family counseling
Family protection
(e.g. Safe sex practices)
Retraining in infection control, if needed

89. Incident Operations & Recovery
The Infection Control Process

90. Incident Operations & Recovery
Four phases of response
Preparation for response
Response
Scene management
Post-response recovery

91. Preparation Phase IC Training SOP/SOG Enforcement
Storage of PPE (vehicles & station)
Regular inventory, maintenance
Personal Hygiene
In and out of the station

92. Response Phase Evaluation of dispatch information
A.K.A. “Size-up”
Don PPE en route when possible
Prepare mentally
Confidentiality and the radio

93. Scene Management Phase
Operations at scene
Use BSI / PPE
Limit patient contact
Use mechanical resuscitation devices
Do not recap needles
Handle sharps only when necessary

94. In health care workers, 80% of exposures are due to sharps injuries.
The greatest percentage of needle-stick accidents occur during recapping!

95. Scene Management Phase
Operations at scene
Use mechanical clean up methods
(e.g. Dust pan & brush)
Properly dispose of waste
Appropriate containers
Properly package contaminated gear
Transport to fire station safely

96. Scene Management Phase
Public relations at the scene
Explain universal precautions
If patient is uncomfortable with gloves, etc.
Reasonable BSI
(e.g. Coveralls for chest pains is overkill)

97. Scene Management Phase
Public information at the scene
Patient’s medical status confidential
Do not broadcast
Use care when discussing patient’s information at scene
Medical information is “need to know”

98. Post Response Phase Proper disposal of PPE Appropriate containers
Red “Bio” bags
Sharps containers
Designated decon area
Immediate decon (In house)
Storage for out-of-house decon

99. Post Response Phase Disinfection, Decon, & Cleaning
Four level’s of disinfection:
Low level – Routine ambulance cleaning
Intermediate – Typical post response
High level – (ie. Intubation equipment)
Sterilization – Destroys all micro-organisms

100. Disinfection Low level: Routine housekeeping Routine Cleaning
Removal of soil in absence of visible body fluids

101. Disinfection Intermediate level: Destroys mycobacterium TB
Vegetative Bacteria
Most viruses & Fungi
NOT Bacterial spores
Typical method for ambulances

102. Disinfection Intermediate level: Three types:
EPA registered Disinfectant
Commercially available hard surface germicides
Water-Chlorine Bleach (1:100)
2 cups bleach to 1 gal. water

103. Disinfection High level: Destroys all forms of micro-organisms
Except large numbers of bacterial spores
Required for reusable instruments
Contact with mucous membranes
(i.e. Laryngoscope blades)

104. Disinfection Sterilization: Destroys all micro-organisms
Usually not practical for EMS

105. Post Response Phase Equipment Decontamination
Conducted in designated area
Use appropriate PPE
Gross Decon
Mild soap & water
Use appropriate level disinfectant
Air dry in clean storage area

106. Post Response Phase Cleaning of PPE - Uniforms
Decon ASAP upon returning
Store appropriately until laundering
Launder in designated front loading washer or commercially
Follow manufacturers instructions
No chlorine bleach on turnout gear
Do not bring home!

107. Post Response Phase Wash Hands and Exposed Skin Often Wash Thoroughly
Wash with Anti-Bacterial Soap

108. Station / Home Issues Equipment Storage
Ensure proper storage equipment / supplies
Monitor usage levels for inventory Control
Monitor shelf life
Maintain SDS’s

109. Station / Home Issues Laundry Issues: Commercial front loading washer
Automatic pre-metered detergent
Computerized cycles
High temperature
Water completely drains out
Again… Do not bring home!

110. Station / Home Issues Designated decontamination area
Separate room, properly marked, secure
Proper ventilation
Adequate drainage, including floor
Non-porous sink with hot & cold water
Automatic water for hand washing
Rack/shelves for drying
Appropriate supplies

111. Program Evaluation On-going risk assessment Annual Re-Evaluation of:
Administrative controls
(Management Policy)
Engineering controls
(Physical changes to the workplace)
Work practice controls (Modified methods)
PPE
Vaccinations

112. Program Evaluation Annual record review Safety committee Sharps log
Injury log
Exposure reports
Safety Committee

113. Summary
Questions & Answers

114. Fire Service Instructor Connecticut Fire Academy Staff
Marc A. Scrivener
Fire Service Instructor
&
Connecticut Fire Academy Staff