Airborne Pathogens and Respirator Use

Objectives – The Illnesses Discuss Airborne Diseases and the healthcare provider How they spread Who is at risk Possible causes Symptoms SAINT BARNABAS HEALTH CARE SYSTEM

Objectives – EMS Transport What you should do to protect yourself General considerations Infection control Waste disposal Cleaning and Disinfection Follow-up of EMS personnel SAINT BARNABAS HEALTH CARE SYSTEM

Objectives - The N95 Respirator What is it? Why do I need it? How do I use it? Fit testing What are the limitations? SAINT BARNABAS HEALTH CARE SYSTEM

SAINT BARNABAS HEALTH CARE SYSTEM Airborne Pathogens Tuberculosis Influenza Avian Influenza Smallpox SARS SAINT BARNABAS HEALTH CARE SYSTEM

Tuberculosis Famous people who have had TB Fredric Chopin* Eleanor Roosevelt* Nelson Mandela Ringo Starr Tom Jones Tina Turner *Died of TB

What is tuberculosis (TB)? Disease caused by bacteria called Mycobacterium tuberculosis Chronic bacterial infection Was once the leading cause of death in US The number of cases declined in the 1940’s when drugs were developed to treat TB TB is still a problem worldwide (NIAID) 8 million people develop TB yearly 3 million die SAINT BARNABAS HEALTH CARE SYSTEM

SAINT BARNABAS HEALTH CARE SYSTEM How is TB spread? Through the air from person to person by coughing Usually attacks lungs Two stages Latent TB asymptomatic and not contagious can take medication to prevent development of disease Active TB Disease May spread to others May have abnormal chest x-ray Usually have positive skin test SAINT BARNABAS HEALTH CARE SYSTEM

SAINT BARNABAS HEALTH CARE SYSTEM Symptoms of TB Chills Fever Weakness or fatigue Sweating while sleeping, Night sweats Cough that lasts longer than 2 weeks Pain in chest Coughing up blood or sputum SAINT BARNABAS HEALTH CARE SYSTEM

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SAINT BARNABAS HEALTH CARE SYSTEM Risk Factors Close contact with someone who is infected with TB Traveling to a country where TB is common Immune compromised Foreign-born individuals and minorities have a higher incidence of developing TB 2002: 50% of US cases were in foreign-born individuals (CDC) 2002: 80% of all US TB cases were in ethnic and racial minorities (CDC) SAINT BARNABAS HEALTH CARE SYSTEM

Multi-drug resistant TB (MDR TB) Bacteria become resistant to antibiotics Arose from improper use of antibiotics in the treatment of TB Treatment of one case can cost up to $1.3 million (CDC) 45 states and Washington, DC have confirmed cases of MDR TB (CDC) SAINT BARNABAS HEALTH CARE SYSTEM

SAINT BARNABAS HEALTH CARE SYSTEM MDR TB continued Treatment is difficult and costly Can develop from not taking proper course of antibiotics for TB MDR TB can be spread by an infected person SAINT BARNABAS HEALTH CARE SYSTEM

How to protect yourself BCG vaccine for TB is given in many countries, but not the US Not recommended for healthcare workers unless a high percentage of patients are infected with MDR TB (CDC) PPD test if exposure is suspected USE proper PPE when in contact with patients who may have TB SAINT BARNABAS HEALTH CARE SYSTEM

SAINT BARNABAS HEALTH CARE SYSTEM Tuberculosis Summary Chronic bacterial infection spread through the air Fever, chills, sweating while sleeping, persistent cough, coughing up blood or sputum MDR TB Use proper PPE and get PPD test if exposed SAINT BARNABAS HEALTH CARE SYSTEM

Influenza “I had a little bird, His name was Enza, I opened the window and in flew Enza.” -Children’s nursery rhyme about the flu epidemic of 1918

What is influenza (“the flu”)? Disease caused by a virus Respiratory More severe than a cold 10%-20% of US residents will get the flu each year (CDC) Can lead to complications for some people 36,000 people die each year from complications (CDC) SAINT BARNABAS HEALTH CARE SYSTEM

Types of influenza virus Influenza A Most common and most serious Can lead to epidemics Influenza B Can also cause epidemics Symptoms are milder Influenza C Never connected with large epidemics SAINT BARNABAS HEALTH CARE SYSTEM

How is influenza spread? Flu season is from November to March Respiratory droplets Coughing Sneezing Droplets on objects Contagious from 1 day before symptoms start to 7 days after symptoms start (CDC) SAINT BARNABAS HEALTH CARE SYSTEM

SAINT BARNABAS HEALTH CARE SYSTEM Symptoms Cough and congestion Fever Headache Body Aches General malaise Sore throat SAINT BARNABAS HEALTH CARE SYSTEM

SAINT BARNABAS HEALTH CARE SYSTEM Vaccine- The Flu Shot Administered yearly Injection or nasal spray (FluMist) New vaccine made every year Can prevent types A and B SAINT BARNABAS HEALTH CARE SYSTEM

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Who should get a flu shot? (CDC) >50 years old Diabetic Live or work in a nursing home Compromised immune system Chronic heart, lung, or kidney disease Will be more than 3 months pregnant during flu season SAINT BARNABAS HEALTH CARE SYSTEM

SAINT BARNABAS HEALTH CARE SYSTEM Protecting yourself Get flu shot Use proper PPE around patients suspected of having the flu Disinfect surfaces regularly Keep yourself healthy during the flu season! Get enough rest Eat well SAINT BARNABAS HEALTH CARE SYSTEM

SAINT BARNABAS HEALTH CARE SYSTEM Influenza Summary Flu season is from November to March Use PPE Disinfect Get a flu shot SAINT BARNABAS HEALTH CARE SYSTEM

Avian Influenza February 2004: 72,000 chickens were slaughtered in Delaware after two cases of Avian Influenza were found at a poultry farm under contract for Perdue Farms, Inc.

What is Avian Influenza? Influenza virus that can infect birds and humans Type A influenza 3 Type A viruses and each have 9 subtypes H5: can be high or low pathogenic; can cause severe illness or death H7: can be high or low pathogenic; infections are rare and symptoms are mild H9: low pathogenic; very rare in humans SAINT BARNABAS HEALTH CARE SYSTEM

SAINT BARNABAS HEALTH CARE SYSTEM Transmission Contact with infected poultry or contaminated surfaces No documented cases of sustained human to human transmission Have been isolated incidents of human to human transmission Monitoring is important Influenza viruses have the ability to change May gain the ability to spread from person to person SAINT BARNABAS HEALTH CARE SYSTEM

SAINT BARNABAS HEALTH CARE SYSTEM Symptoms Same as typical flu-like symptoms Conjunctivitis Pneumonia Severe respiratory distress SAINT BARNABAS HEALTH CARE SYSTEM

Incidents of H5 Avian Influenza 1997: Hong Kong- First documented transmission of birds to humans 18 people hospitalized 6 died 1.5 million chickens slaughtered to prevent further spread of disease Person to person transmission was also documented SAINT BARNABAS HEALTH CARE SYSTEM

Incidents of H5 Avian Influenza 2003: China and Hong Kong 2 people infected after traveling to China 1 died Source of infection not identified 2004: Thailand and Vietnam WHO reported cases of H5 influenza among bird populations Ongoing since January 2003 Human cases found in Thailand and Vietnam (WHO) 37 reported cases 26 died Most recent cases were reported August 12, 2004 SAINT BARNABAS HEALTH CARE SYSTEM

Avian Influenza Summary Can be transmitted from birds to humans Typical flu-like symptoms plus Conjunctivitis Respiratory distress Pneumonia Use PPE SAINT BARNABAS HEALTH CARE SYSTEM

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Smallpox In 1972, a single case of small pox in Yugoslavia led to the infection of 150 people, 34 deaths, 10,000 people quarantined and 20 million vaccinated. -World Health Organization

SAINT BARNABAS HEALTH CARE SYSTEM What is Smallpox? Variola Virus Contagious infectious disease Eliminated in human populations Laboratory stockpiles exist Concern that it may be used as an agent of bioterrorism No treatment Only prevention is vaccine Two types Variola major Variola minor SAINT BARNABAS HEALTH CARE SYSTEM

SAINT BARNABAS HEALTH CARE SYSTEM Variola Major Most common Severe Very high fever Large rash 4 types Ordinary: most frequent Modified: occurs in people who have been vaccinated; mild Flat: rare and severe Hemmorhagic:rare and severe Fatality rate of 30% (CDC) SAINT BARNABAS HEALTH CARE SYSTEM

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SAINT BARNABAS HEALTH CARE SYSTEM Variola Minor Less common Less severe symptoms Fatality rate of <1% SAINT BARNABAS HEALTH CARE SYSTEM

SAINT BARNABAS HEALTH CARE SYSTEM From World Health Organization SAINT BARNABAS HEALTH CARE SYSTEM

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SAINT BARNABAS HEALTH CARE SYSTEM Transmission Person to person Prolonged contact with infected person Contact with infected body fluids or contaminated objects Can be spread through the air in enclosed settings, but this is rare SAINT BARNABAS HEALTH CARE SYSTEM

SAINT BARNABAS HEALTH CARE SYSTEM Vaccine Complete protection if given before exposure If given within 3 days after exposure, will prevent or greatly lessen severity 4-7 days after exposure: lessens severity of disease No protection if given after rash appears Not widely available to the public at this time Stockpiles are in place in case of an outbreak SAINT BARNABAS HEALTH CARE SYSTEM

Vaccine contraindications (CDC) Vaccinia virus can be spread to others from the injection site of an immunized person Eczema and other exfoliative skin conditions May develop eczema vaccinatum Inadvertent autoinnoculation of affected area Could develop vaccinia Immune compromised individuals Pregnancy Infants and children Not given to infants <12 months of age Only in emergency situations to children <18 years of age Breastfeeding mothers should not get the vaccine Heart disease SAINT BARNABAS HEALTH CARE SYSTEM

SAINT BARNABAS HEALTH CARE SYSTEM Protecting yourself Vaccine Use PPE when in contact with infected patient or contaminated fluids Watch for signs/symptoms of smallpox if you believe you were exposed Early vaccination after exposure can prevent or lessen the disease SAINT BARNABAS HEALTH CARE SYSTEM

SAINT BARNABAS HEALTH CARE SYSTEM Smallpox Summary Contagious infectious disease Transmitted through close contact with infected person Vaccine SAINT BARNABAS HEALTH CARE SYSTEM

SARS Severe Acute Respiratory Syndrome The 2003 global SARS outbreak led to over 8,000 people becoming ill, and 774 deaths. It is estimated the panic caused by the disease cost Canada $1 billion in lost tourism and all of Asia over $28 billion. (BBC News)

What is SARS? Center for Disease Control Definition SARS is a respiratory illness of unknown etiology. It was first identified in February 2003. SARS was first noticed in Southeast Asia. To date more than 100 cases have been reported in the United States Public health experts think that SARS is spread by close contact between people SAINT BARNABAS HEALTH CARE SYSTEM

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SAINT BARNABAS HEALTH CARE SYSTEM How SARS Spreads SARS is most likely spread when someone sick from the disease coughs droplets into the air and someone else breathes the virus in It is possible that SARS may spread more broadly through the air or from touching an object that is contaminated SAINT BARNABAS HEALTH CARE SYSTEM

SAINT BARNABAS HEALTH CARE SYSTEM Who Is at Risk for SARS? Individuals having close contact with someone sick from the disease Those sharing a household with someone sick from the disease Healthcare providers who do not use the proper infection control techniques when providing care for patients sick from the disease SAINT BARNABAS HEALTH CARE SYSTEM

Possible Causes of SARS Scientists at the CDC and other laboratories have detected a previously unrecognized coronavirus in patients with SARS. While the new coronavirus is still the leading hypothesis for the cause of SARS, other viruses are still under investigation as potential causes. SAINT BARNABAS HEALTH CARE SYSTEM

What are Coronaviruses These viruses are a common cause of mild to moderate upper-respiratory illness in humans and are associated with respiratory, gastrointestinal, liver and neurologic disease in animals. Coronaviruses can survive in the environment for as long as three hours. SAINT BARNABAS HEALTH CARE SYSTEM

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SAINT BARNABAS HEALTH CARE SYSTEM Symptoms of SARS Fever or hot to touch AND Cough Clinical findings of respiratory distress Travel within 10 days to an area with suspected community transmission OR Close contact within 10 days with a person with a respiratory illness or someone sick from SARS SAINT BARNABAS HEALTH CARE SYSTEM

How to protect yourself Wear proper respiratory protection Recognize signs and symptoms of SARS SAINT BARNABAS HEALTH CARE SYSTEM

SAINT BARNABAS HEALTH CARE SYSTEM SARS Summary Very little known about SARS Possibly spread through droplets in air Fever, chills, severe respiratory distress Wear respiratory protection SAINT BARNABAS HEALTH CARE SYSTEM

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Transport of Patients with Suspected Airborne Illness SAINT BARNABAS HEALTH CARE SYSTEM

General Considerations Patients should be transported using the minimum number of EMT personnel and without non-infectious patients or passengers in the vehicle. Sufficient infection control supplies should be on board. Receiving facilities must be notified prior to transport of infectious patients. SAINT BARNABAS HEALTH CARE SYSTEM

Infection Control - General PPE may not be removed during transport. Personal activities (including: eating, drinking, application of cosmetics, and handling of contact lenses) should not be performed during patient transport. These diseases may be transmitted if residual infectious particles on environmental surfaces are brought into direct contact with the eyes, nose or mouth. SAINT BARNABAS HEALTH CARE SYSTEM

Infection Control – PPE Disposable, non-sterile gloves must be worn for all patient contact. Disposable fluid-resistant gowns should be worn for all patient care activity. Goggles or face-shields must be worn in the patient-care compartment and when working within 6 feet of the patient. Corrective eyeglasses alone are not appropriate protection. N-95 respirators should be worn by personnel in the patient-care compartment at all times. SAINT BARNABAS HEALTH CARE SYSTEM

Infection Control - PPE Gloves are removed in the correct manner and discarded in biohazard bags after patient care is completed (e.g., between patients) or when soiled or damaged. Hands must be washed or disinfected with a waterless hand sanitizer immediately after removal of gloves. SAINT BARNABAS HEALTH CARE SYSTEM

Infection Control – Driver & Vehicle N-95 respirators should be worn by the driver if the driver's compartment is open to the patient-care compartment. Drivers that provide direct patient care must wear a disposable gown, face shield, and gloves during patient-care activities. Use vehicles with separate ventilation for driver and patient compartments if possible. Maximize air exchange Open dashboard vents Open rear vents to maximum level SAINT BARNABAS HEALTH CARE SYSTEM

SAINT BARNABAS HEALTH CARE SYSTEM Infection Control The patient may wear a paper surgical mask to reduce droplet production, if tolerated. Oxygen delivery with NRB masks may be used for patient oxygen support during transport. CPR should never be performed using mouth-to-mouth or mouth-to-mask. SAINT BARNABAS HEALTH CARE SYSTEM

Infection Control – Patient Care The BVM should be equipped with a HEPA filter for expired air. When using CPAP ensure that a HEPA filter is attached to the exhalation port. There is no documented additional risk when using aerosol nebulizers if all of the precautions just discussed are used by the health care provider. SAINT BARNABAS HEALTH CARE SYSTEM

Follow-up of EMS Personnel Record the following information Date and route of transport Duration of patient transport Names of personnel in contact with the patient EMT services should closely monitor personnel who have transported potentially infectious patients for evidence of fever, rash or respiratory illness. EMT personnel who transport SARS patients should be assessed at least daily for 10 days after transporting a SARS patient (directly or by telephone). If the EMT was exposed to Smallpox, it is important to be vaccinated as soon as possible. May be symptom-free for up to 17 days after contracting the disease. SAINT BARNABAS HEALTH CARE SYSTEM

Follow-up of EMS Personnel Personnel may continue working during the follow-up period if they have no symptoms of the disease. Personnel who have transported a SARS patient and become symptomatic within the 10 day follow-up period should be directed to seek medical evaluation and should be reported to the state health department and to the CDC. SAINT BARNABAS HEALTH CARE SYSTEM

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The N95 Respirator

SAINT BARNABAS HEALTH CARE SYSTEM The N95 Respirator The most common respirator used is the disposable particulate type N95. The “N” stands for respirator filters that can be used when no oil is present in the contaminants. The“95” means that the product has been tested and certified by NIOSH to have a filter efficiency level of 95% or greater against particulate aerosols. SAINT BARNABAS HEALTH CARE SYSTEM

Why a Respirator Is Necessary Healthcare providers work in an environment where there is a risk of disease transmission through airborne infectious particulates. Respirators, such as the N-95, provide protection from airborne infectious particulates when properly fitted and worn. SAINT BARNABAS HEALTH CARE SYSTEM

OSHA 1910.134 Standards for Respiratory Protection Medical screening to determine if the employee is physically able to wear a respirator. Fit-test to determine if the respirator fits properly on the employee’s face. Training on the selection, use, storage, and limitations of the respirator used. SAINT BARNABAS HEALTH CARE SYSTEM

SAINT BARNABAS HEALTH CARE SYSTEM The Medical Screening A licensed health care professional will perform the evaluation using a medical questionnaire. The contents of the medical questionnaire are mandated by OSHA. Administered to the HCW in a confidential manner and the HCW can request to discuss the results of the medical evaluation with the licensed health care professional. SAINT BARNABAS HEALTH CARE SYSTEM

Follow-up Medical Examination Is Performed If: 1- If HCW reports medical signs or symptoms that are related to ability to use the respirator. 2- If the supervisor informs employee health of the need for re-evaluation. 3- If information from the respirator program monitoring activities should indicate any need for re-evaluation. 4- If the workplace conditions significantly change. SAINT BARNABAS HEALTH CARE SYSTEM

FIT TEST Procedure is Done: 1- Before initial use of the respirator 2- Whenever a different size, style, model or make of respirator is used 3- If HCW has a change in facial structure such as: facial trauma, facial surgery, loss of body weight, or dental changes. 4- If the HCW worker notifies the employer that the respirator fit is unacceptable. 5- At least annually SAINT BARNABAS HEALTH CARE SYSTEM

SAINT BARNABAS HEALTH CARE SYSTEM Types of Fit Testing Qualitative Fit Test: Worker is assessed on a pass/fail basis to determine the adequacy of respirator fit. It relies on the individual’s response to the test agent. Quantitative Fit Test: Assessment of respirator adequacy by numerically measuring the amount of leakage into the respirator. SAINT BARNABAS HEALTH CARE SYSTEM

Fit Testing the Respirator Qualitative Testing HCW puts on the respirator. Hood is applied over the head. Sweet tasting aerosol mist is introduced into the hood. If the seal is tight the HCW should not experience any sweet taste. The test simulates activities such as turning the head, talking, and other possible activities that might occur during job tasks. SAINT BARNABAS HEALTH CARE SYSTEM

Fit Testing the Respirator Quantitative Testing HCW puts on respirator attached to PortaCount machine. HCW performs series of movements to test respirator fit. PortaCount machine measures amount of particles leaking into mask. SAINT BARNABAS HEALTH CARE SYSTEM

Donning of the N95 Respirator* Step #1 Cup the respirator in your hand with the nosepiece at your finger tips allowing the headbands to hang freely below hands. *Always refer to the instructions provided by manufacturer SAINT BARNABAS HEALTH CARE SYSTEM

Donning of the N95 Respirator Step #2 Position the respirator under your chin with the nosepiece up. SAINT BARNABAS HEALTH CARE SYSTEM

Donning of the N95 Respirator Step #3 Pull the top strap over your head so it rests high on the back of head. SAINT BARNABAS HEALTH CARE SYSTEM

Donning of the N95 Respirator Step #4 Pull the bottom strap over your head and position it around your neck below ears. SAINT BARNABAS HEALTH CARE SYSTEM

Donning of the N95 Respirator Step #5 Using two hands, mold the nosepiece to the shape of your nose by pushing inward while moving your fingertips down both sides of the nosepiece. Pinching the nosepiece using one hand may result in less effective respirator performance. SAINT BARNABAS HEALTH CARE SYSTEM

Fit Check of the N95 Respirator Face fit check - the respirator seal should be checked before each use. To check fit, place both hands completely over the respirator and exhale. If air leaks around your nose, adjust the nosepiece as described in step 5. If air leaks at respirator edges, adjust the straps back along the sides of your head. Recheck. Fit Check of the N95 Respirator SAINT BARNABAS HEALTH CARE SYSTEM

SAINT BARNABAS HEALTH CARE SYSTEM Facial Hair Facial hair will make the seal loose and will not provide protection from harmful airborne hazards. Even just one or two days beard growth can effect the seal. Males should be clean shaven. This is to ensure that the respirator is fully protective. SAINT BARNABAS HEALTH CARE SYSTEM

Removal of the N95 Respirator Step #1 Cup the respirator in your hand to maintain position on face. Pull bottom strap over head. SAINT BARNABAS HEALTH CARE SYSTEM

Removal of the N95 Respirator Step #2 Still holding respirator in position, pull top strap over head. SAINT BARNABAS HEALTH CARE SYSTEM

Removal of the N95 Respirator Step #3 Remove the respirator from your face Discard as a Biohazard (Red Bag) SAINT BARNABAS HEALTH CARE SYSTEM

Limitations of the N95 Respirator If this respirator becomes wet, it is no longer effective and must be replaced. The N-95 respirator has the ability to filter particles 1 micrometer with a filter efficiency of > 95%. The N-95 is not intended for protection from organic vapors, toxic gases, or toxic particulates. SAINT BARNABAS HEALTH CARE SYSTEM

SAINT BARNABAS HEALTH CARE SYSTEM Waste Disposal All solid waste, e.g., Used gloves, dressings, etc., Should be collected in a red biohazard bags for regulated medical waste disposal. Any suctioned fluids and secretions must be sealed to prevent any splashes. SAINT BARNABAS HEALTH CARE SYSTEM

Cleaning and Disinfection Non-patient-care areas of the vehicle should be cleaned and maintained according to vehicle manufacturer’s recommendations. Cleaning personnel should wear non-sterile gloves, disposable gowns and face shields while cleaning the patient-care compartment. Patient-care compartments (including stretchers, railings, medical equipment control panels, and adjacent flooring, walls and work surfaces likely to be directly contaminated during care) should be cleaned using the department approved disinfectant. SAINT BARNABAS HEALTH CARE SYSTEM

Cleaning and Disinfection Spills of body fluids during transport should be cleaned by placing absorbent material over the spill and collecting the used cleaning material in a biohazard bag. The area of the spill should be cleaned using an EPA-registered hospital disinfectant. Contaminated reusable patient care equipment should be placed in biohazard bags and labeled for cleaning and disinfection. Wear proper PPE when cleaning equipment. SAINT BARNABAS HEALTH CARE SYSTEM

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For Additional Information CDC Center for Disease Control www.cdc.gov WHO World Health Organization www.who.int SAINT BARNABAS HEALTH CARE SYSTEM