1. BLS 2014: Infectious Disease

2. Given the worldwide concern about infectious diseases—as an EMS provider and a citizen—you are responsible to help recognize infectious disease, treat your patients properly, and keep yourself safe.  Infectious disease has many potentially sources  Bloodborne pathogens  Airborne pathogens  Bio-terrorism Introduction

3. Objectives 1.Identify the types of PPE and how and when they should be applied. 2.Identify the characteristic infectious diseases that are a threat to EMS providers (HIV, HepC, HBV). 3.Identify appropriate measures for protecting yourself against infectious diseases. 4.Identify the appropriate actions to take for exposure to an infectious disease.

4. Terms  Antibodies — Proteins made by the immune system that have a memory for an invading virus and help recognize and destroy future invasions by that virus.  Antibiotic — Medicine or drug that is effective in killing bacteria or inhibiting their growth.  Bacteria — A single-celled, microscopic organism that can cause damage to the body's cells. They multiply very quickly by dividing.

5. Terms, continued  Epidemic — An outbreak of a contagious disease that spreads among many individuals in an area or a population at the same time.  Pandemic — An outbreak of a contagious disease that affects an entire population over a wide geographical area. A pandemic affects a far higher number of people and a much larger region than an epidemic.  Parasite — An organism that grows, feeds, and is sheltered on or in a different organism while contributing nothing to the survival of its host.

6. Terms, continued  Pathogen — An agent that causes disease such as a bacterium, virus or fungus.  Vaccine — A preparation of a weakened or disabled virus that stimulates antibody production and provides immunity when injected into the body.  Virus — A very small agent made of genetic information (RNA or DNA) surrounded by a protein coat. It cannot reproduce on its own but must take over a living cell to multiply.

7. Terms, continued  Body Substance Isolation (BSI) — An infection control practice that assumes all body substances including blood, urine, saliva, feces, tears, etc., are potentially infectious.  MRSA — Methicillin-resistant Staphylococcus Aureus (MRSA) are a type of staphylococcus or "staph" bacteria that are resistant to many antibiotics.  Personal Protective Equipment (PPE) - Specialized clothing or equipment worn for protection against health and safety hazards.  Universal Precautions - Universal precautions should be should be observed on every incident. Universal precautions include personal protective equipment (PPE) and body substance isolation (BSI).

8. Infectious Diseases

9. MRSA Methicillin-resistant Staphylococcus Aureus  Type of staph bacteria resistant to common antibiotics  Traditionally associated with hospitals but now is epidemic of community- acquired MRSA  Multiplies rapidly causing many types of infection ranging from skin infections to septicemia and toxic shock syndrome Cutaneous abscess caused by MRSA

10. MRSA, continued  Transmission  Found commonly on human skin, in nose & throat and, less commonly, in colon & in urine  Can infect other tissues when skin or mucosal lining have been breached  Occupational Exposure  Can be spread through contact with pus from infected wound, skin-to-skin contact with infected person, & contact with objects such as towels, sheets, or clothing used by infected person.

11. MRSA, continued Pre-hospital Presentation  Staph infections, including MRSA, generally start as small red bumps that resemble pimples, boils, or spider bites  Can quickly turn into deep, painful abscesses  Rarely, may also burrow deep into body, causing potentially life-threatening infections in bones, joints, surgical wounds, the bloodstream, heart valves, & lungs.

12. MRSA, continued Prevention  Best defense against MRSA – wash hands often, especially after contact with other people  Thorough washing with soap & water or alcohol hand disinfecting gels is effective against MRSA  Wear a gown when caring for patients with a known or suspected MRSA infection of the skin  In some cases MRSA is a respiratory infection  Patient has known or suspected MRSA skin infection & has a cough, or has MRSA respiratory infection, wear fitted mask  Put surgical or procedure mask on the patient if they can tolerate it.

13. HIV  AIDS caused by Human Immunodeficiency Virus (HIV)  HIV attacks cells of immune system  Immune system fails & patient becomes susceptible to "opportunistic" diseases & infections Chest x-ray of HIV-infected man with pulmonary Kaposi sarcoma Kaposi's sarcoma on the skin of an AIDS patient

14. HIV, continued  Transmission:  Unprotected sex with an infected partner  Sharing of needles by IV drug users  Infected mother to her baby  Infected blood given during a transfusion (extremely rare)  Occupational transmission usually by a needle stick of infected blood (also extremely rare)

15. HIV, continued  Pre-hospital Presentation:  Depends on which opportunistic disease or infection the person develops:  Dehydration & hypotension secondary to diarrheal diseases  Seizures or altered mental status secondary to nervous system infection  Dyspnea secondary to respiratory infection  Medication reactions  End of life issues

16. HIV, continued  Occupational Risk:  The occupational risk of acquiring AIDS is VERY LOW (less than 2% after a needlestick with infected blood; much lower after exposure to mucus membranes)  Prevention:  Prevention should focus on preventing significant blood exposures (needlesticks).  Post-exposure prophylaxis (PEP) if available if there is a significant exposure.

17. Hepatitis C  Four million persons infected with Hepatitis C in United States  Caused by hepatitis C virus (HCV) found in blood of persons who have disease  Spread by contact with blood of infected person  Most common chronic bloodborne viral infection in United States  Can cause cirrhosis of liver & liver cancer. Cirrhosis of the liver and liver cancer

18. Hepatitis C  Transmission  Blood & other bodily fluids  Sharing needles with infected person  Sex with infected person  From a woman to her baby during birth Pre-hospital Presentation  Hepatitis C infection generally produces no signs or symptoms during its early stages; may produce none for years  If encountered, symptoms may include:  Fatigue  Nausea  Vomiting  Poor appetite  Muscle & joint pain  Low-grade fever

19. Hepatitis C  Occupational Risk  After needle stick or sharps exposure to HCV positive blood, about 2 healthcare workers out of 100 become infected with HCV  Approximately 20% of patients with Hepatitis C recover completely following treatment with interferon and ribavirin  Prevention  No effective vaccine for hepatitis C  Only way to protect yourself – avoid exposure to infected blood

20. Hepatitis B  Caused by hepatitis B virus (HBV), which damages liver  Vaccination against HBV has been available since 1982  Spread by contact with blood of person infected with the disease or by sexual transmission Hepatitis B Virus

21. Hepatitis B, continued  Transmission:  Sex with infected person  Blood & other bodily fluids  Sharing needles with infected person  From a woman to her baby during birth

22. Hepatitis B, continued  Pre-hospital Presentation:  Most signs & symptoms of Hep B mild  Unlikely you will be called to respond to acute illness caused by this virus  However you may on occasion see a patient with end stage liver cancer or other complications from the disease

23. Hepatitis B, continued  Occupational Risk:  Occupational risk for acquiring HBV from unvaccinated person is significant. The risk for a vaccinated person is VERY LOW.  Prevention:  Best way to prevent occupational exposure to HBV, in addition to taking care to protect yourself from blood exposure, is to be vaccinated against the disease

24. Tuberculosis (TB)  Caused by small bacteria that travels from small airways to cells of lungs  Less than 10% of people infected with TB develop active disease  In the others, bacteria hides, causing no disease until host (patient) becomes immuno-compromised or otherwise debilitated

25. Tuberculosis, continued  Transmission:  Via small airborne particles expelled by cough, sneezing, or speaking  Particles are inhaled into small airways  Prolonged exposure in confined space confers highest risk

26. Tuberculosis, continued  Pre-hospital Presentation:  Cough, often productive of blood-tinged sputum  Fatigue & weakness  Night sweats  Low-grade fever  Loss of appetite & weight loss

27. Tuberculosis, continued  Occupational Risk:  Occupational risk low but difficult to quantify  Prevention:  Maintain high index of suspicion among patients who are at risk of having TB  Take precautions if patients present with suspicious signs & symptoms

28. Influenza (flu)  Caused by the influenza virus which attacks the respiratory system.  Occurs seasonally from November to April in the northern hemisphere.  The structure of the virus changes slightly but frequently over time; this accounts for the appearance of different strains each year.

29. Influenza (flu), continued  Transmission:  Coughed droplets  Touching contaminated surfaces (less common)

30. Influenza (flu), continued  Pre-hospital Presentation  Sudden onset of:  High fever  Malaise  Headache  Dry cough  Body aches

31. Influenza (flu), continued  Occupational Risk: Varies depending on the strain.  Prevention:  Hand washing, clean surfaces  Place mask on patient or ask patient to cover mouth when coughing  Best prevention is the flu vaccine, which must be taken yearly Best flu prevention is the flu vaccine

32. Pandemic Flu  Outbreak of contagious disease that affects entire population over a wide geographical area  Caused by influenza virus to which humans have little or no natural resistance  Such an outbreak has potential to cause many deaths & illnesses  Past pandemic flu viruses known for virulence causing rapid death, especially in young people  It is difficult to accurately predict which strain of influenza may give rise to next pandemic

33. Pandemic vs. Seasonal  Pandemic outbreaks different from seasonal outbreaks of influenza  Seasonal outbreaks caused by subtypes of influenza viruses that already circulate among humans  Pandemic outbreaks caused by new subtypes  Subtypes never circulated among people or subtypes not circulated among people for a long time Microbiologist examining reconstructed 1918 Pandemic Influenza Virus

34. Norovirus  Highly contagious virus responsible for outbreaks of gastrointestinal disease on cruise ships, nursing homes, etc.  Norovirus is the general name given to viruses of this type.  Responsible for many cases of severe but short-lived illnesses causing vomiting, diarrhea, and stomach cramps.  "Stomach flu" and "food poisoning" are typical infections of a Norovirus.

35. Norovirus, continued  Transmission  Occurs via fecal-oral route  For example, food handler does not wash his hands after using bathroom; a person then ingests food that has been contaminated with small amounts of fecal matter

36. Norovirus, continued  Pre-hospital Presentation  Nausea, vomiting & diarrhea  Stomach cramps  Low-grade, transient fever  General feeling of malaise, headache, body aches Symptoms begin suddenly, may last one to three days, and usually resolve on their own. Because the disease is caused by a virus, antibiotics are useless.

37. Norovirus, continued  Occupational Risk:  Community-acquired, usually situations where large numbers share same food or living space (cruise ships, college dorms)  Several outbreaks of noroviruses among staff at hospitals & nursing homes

38. Norovirus, continued  Prevention:  Wear gloves  Wash your hands thoroughly  Consider use of protective eyewear & mask  Surfaces contacted by the patient must be thoroughly disinfected If you become sick, wait two days after the last of your symptoms before returning to work.

39. Personal Safety and PPE

40. Personal Protective Equipment  Consider possible infectious disease for every patient that you see.  Avoid infection from fluids and airborne particles by using PPE  Wash your hands frequently  Decontaminate equipment and surfaces after use.

41. Types of PPE  Fit-tested masks (such as N95 and N100 masks)  Eye protection (such as glasses, face shields and goggles)  Gowns (or suits)  Gloves

42. Donning PPE  Put on PPE before entering the patient area. Base the PPE you use on your assessment of risk.  The sequence for donning PPE is MEGG: Mask Eye protection Gown Gloves

43. Doffing PPE  Remove PPE once call is complete or crew has left patient area  Be careful not to contaminate yourself taking it off  To remove PPE, reverse the order that you put it on: Gloves Gown—hand washing min 20 sec. Eye protection Mask—hand washing min 20 sec. Gloves Gown—hand washing min 20 sec. Eye protection Mask—hand washing min 20 sec.

44. Hand Washing is Vital  Single most effective way to prevent spread of disease  Soap & water for at least 20 seconds or with waterless alcohol  After all patient contact, even if you wore gloves

45. Equipment Decontamination After completing a response to an infectious patient, must decontaminate everything touched including:  All equipment that was exposed or cross- contaminated  Outside of kits  Stethoscopes  Radios  AEDs, etc. Wear new gloves while decontaminating equipment. Wear clean eye protection and mask if there is splash risk or vapors.

46. Masks  Don a fit-tested mask before entering the scene.  Place a mask on the patient, if tolerated.  Fitted masks provide the highest level of protection.  Remove and dispose of the mask without self contamination.

47. Eye Protection  Wear eye protection on all calls. You must prepare for unanticipated splashes such as:  Vomiting  Blood flicked from bloody hand  Violent spit  Glucometer strips  Splashing fluids  Respiratory infection  Violent cough or sneeze

48. Gloves  Wear medical gloves on all calls  Most bodily fluids, such as vomit or urine, do not typically carry blood borne viruses  While working in rescue or extrication environment where risk of both cut & body substance exposure present, wear latex or nitrile inner gloves & other protective outer gloves Glove Up!

49. Limits of Gloves  Gloves are for use during patient contact.  Wash your hands after all patient contact, even if you wore gloves.  Gloves will not protect you from sharp objects such as needles.

50. Sharps  Needlesticks represent greatest risk of occupational blood borne transmission  Many "exposures" involve cases where EMS providers inadvertently stuck themselves with used needles!  Keep eye on paramedics & needles  Watch where you put your hands

51. Needlestick  For needlestick exposures:  Wash area well with soap & water  Do NOT use bleach or other harsh chemicals  These may damage the skin, making it more likely for the virus to enter the body  Report exposure immediately to your officer for testing and possible post-exposure prophylaxis

52. Skin/Mucus  For exposures to non-intact skin:  Wash with soap and water.  Report the exposure immediately to your officer for testing and possible post-exposure prophylaxis. Blood on intact skin is not considered a significant exposure. Non-intact skin includes abrasions and cuts.

53. Skin/Mucus, continued  For exposures to mucus membranes (eyes, mouth):  Flush liberally with water  Report exposure immediately to your officer for testing & possible post-exposure prophylaxis

54. Airborne  Report possible exposure to your company officer  The hospital may notify exposed responders if patient is diagnosed with airborne disease (e.g., TB or bacterial meningitis)  Some diseases may require automatic & immediate post-exposure prophylaxis  Others may require post-exposure testing & then treatment only if you become positive

55. PEP for HIV  Any possible exposure to a blood borne disease must be reported immediately to your company officer  Post-exposure prophylaxis reduces the already very low risk of acquiring the disease  Medications taken for PEP are TOXIC  If patient is determined to be HIV- negative, PEP medications can be stopped

56. Summary

57.  Hand washing is the most effective method of preventing infectious disease  Clean visible contamination first, then disinfect surface  Wear gloves when disinfecting equipment  Occupational risk of acquiring AIDS is VERY LOW

58. Summary, continued  Best way to prevent occupational exposure to HBV, in addition to taking care to protect yourself from blood exposure, is to be vaccinated  Remove gloves when you are done with patient contact, before getting into your rig, talking on the radio, or driving

59. Summary, continued  If you suspect TB, put a mask on patient (if tolerated), & wear a mask yourself  Needlesticks represent the greatest risk of occupational blood borne transmission  If PEP is to be started, it should be started IMMEDIATELY after exposure, if at all possible within two hours

60. Resources  The recertification exam for this module is based on a variety of resources. We recommend that you review the following: Chapter 2 – Wellbeing of the EMT in Emergency Care and Transportation of the Sick and Injured, 9th edition (AAOS).

61. Questions Dr. Mickey Eisenberg Medical Director http://www.emsonline.net/doc.asp http://www.emsonline.net/doc.asp Ask the Doc: http://www.emsonline.net/doc.asphttp://www.emsonline.net/doc.asp EMS Online Guidelines and Standing Orders http://www.emsonline.net/downloads.asp Susan Kolwitz Program Manager help@emsonline.net help@emsonline.net Email support: help@emsonline.nethelp@emsonline.net