1. Emerging Infectious Diseases What EMS Needs to Know
Katherine West, RN,BSN, MSEd
Infection Control Consultant

2. Some appear to be old diseases that have returned
Emerging Diseases
Some appear to be old diseases that have returned

3. Content
Measles
Chickenpox
Pertussis
CRE
C- diff
MERS
Ebola
Zika

4. Reminder - Ryan White Notification- 2009
New list of diseases
This means that medical facilities have expanded notification responsibilities
This means that departments have extended vaccine/immunization responsibilities
Read

5. -The List Bloodborne HCV HBV HIV Vaccinia virus Cutaneous Anthrax
Rabies
Viral hemorrhagic fevers(Ebola, Lassa Fever, Marlberg
Federal Register, 11/2/11

6. The List
Airborne
Tuberculosis
Chickenpox
Measles (rubeola)

7. List Droplet N. Meningitis Diphtheria Mumps Pertussis Plague Rubella
SARS-CoV
Novel Influenza A viruses
Note that meningitis is NOT airborne –
Medical facilities must notify the DICO if the department has transported any persons suspect for or diagnosed with any of the these diseases.
Federal Register, 11/2/11

8. Other Diseases - 2014 Measles Mumps Rubella Chickenpox
Pertussis (whooping cough)
667
1,223 6
10,172
32,971
Large increase in cases of measles and mumps
Decrease in chickenpox
Pertussis is extremely high even in 2013 – no new numbers issued
Final numbers 2014, CDC, Sept. 2015

9. Pertussis
Whooping Cough

10. Bacteria
Bordetella Pertussis

11. Pertussis Cases in creasing over the past 3 decades Highest cases
Infants
Adolescents
Adults

12. Incubation Period 7 – 10 days (as long as 6 weeks)
Considered “highly contagious”
Incubation period -
CDC, January 2005/2011

13. Pertussis Transmission – Direct contact with respiratory discharges
3 foot rule

14. Pertussis Signs/symptoms Fever Coryza Non-productive cough

15. Pertussis Signs/symptoms Paroxysmal spasms of severe coughing
Black eyes
Whooping (inspiration)
Posttussive vomiting

16. Exposure Face-to-face contact within 3 feet of a symptomatic patient
Direct contact –respiratory, oral, nasal secretions -

17. Pertussis Outbreaks - 2014 Ohio California Michigan Wisconsin Texas
Colorado

18. Prevention Tdap - Adacel-
Boosters for all healthcare personnel involved in the care of children
Child care providers
Parents
Grandparents over age 64*
2005, 2011

19. Prevention Place a surgical mask on the patient Get vaccinated
Get your booster!

20. Primary Choice Z- Pack for 14 days
Erythromycin 4 dived daily doses x 14 days

21. Recent Outbreaks
Measles

22. Disneyland

23. Illinois

24. Measles Outbreak – 2016 AZ ICE Immigration Detention Center
Decline vaccine
On work restriction
Wear surgical masks
Vaccine for detainees
July 7, 2016

25. Rubeola
Red Measles
Hard Measles
Nine Day Measles

26. Rubeola Fever Rash Coryza Cough Koplik Spots (buccal Mucosa)
Conjunctivitis

27. Rubeola Incubation Period 7 – 18 days
Infectious 4 days before onset of rash – 4 days after rash onset
CDC, 2008, 2011

28. Exposure
Non-immune healthcare worker with >5 mins. In same room or face-to-face contact
Dec., 2011

29. Rubeola Post Exposure Management I.G. Given within 96 hours
Vaccine – within 72 hours of exposure
CDC, 2011

30. Work Restriction From 5th day to the 21st day of the exposure
Replacement costs

31. Measles Outbreak- Arizona
Required rapid review of measles documentation
12, 844 HCP at 7 hospitals
Cost over $800,000.00
CDC, 2011

32. Prevention
MMR Vaccine = $30.00

33. MMR Vaccine If received between 1963 – 1967
Revaccinate with 2 doses one month apart

34. MMR & Titers
“Serologic screening need not be done before vaccinating against MMR unless the healthcare facility considers it cost-effective”
Page 16
CDC, Rec. Vaccines/immunizations for Healthcare Workers

35. Chickenpox
Varicella Zoster
Herpes Zoster (shingles)

36. Chickenpox
Lesions on covered areas of the body
Fever
Photosensitivity

37. Chickenpox Incubation Period 10 days - 21 days
Contagious 1-2 days before rash appears
CDC, Dec., 2011

38. Exposure Chickenpox
Face to face contact while indoors for > 5 mins. – to up to 1 hour
Direct contact with drainage from lesions
CDC, 2009, 2011

39. Chickenpox Vaccine
Varivax
2 doses
1 month apart

40. Chickenpox Vaccine Varivax Do Not give to pregnant women
Avoid pregnancy for 4 weeks after each dose
Use consent form

41. Chickenpox Vaccine Unable to document immunity Just vaccinate
CDC, Nov. 25, 2011

42. Chickenpox Post Exposure Medical Treatment Offer vaccine
for pregnant or immune compromised persons offer VariZig
CDC, 2011

43. Work Restriction
If 2nd dose of vaccine in 3-5 days of exposure – no restriction
Otherwise day 8 following the exposure to the 21st day
CDC, 2011

44. VariZig - Update May now be administered up to 10 days post exposure
To obtain call : – (24/7)
Delivery in 24 hours
CDC, March 30, 2012

45. VariZig Post Exposure Extend furlough an additional 7 days
Total work restriction = 18 days
CDC, 2009

46. New Vaccine - Shingles Zostavax FDA approved March 24, 2011
Recommended for all persons 50 and older including those who have had a previous episode of shingles*
Employer does not need to offer**
March 24/Dec. 2011

47. Costs
Work restriction = sick time or work comp
Replacement costs

48. Check your vaccine records
Get your records from:
Previous employer
High school
College
Training program

49. New Hires Review for protection
Not protected – offer prevention up front
At least 90% less costly than one exposure

50. Current Staff Collect data on childhood diseases or vaccine
Offer vaccine to unprotected staff

51. C- diff Anaerobic spore-forming bacillus
Clostridium difficile-associated disease (CDAD)
Hospital-acquired
Related to antibiotic treatment

52. Transmission Fecal – oral Contaminated hands
Contamination of environment
Mayo Clinic, 2006, HIC, 2008

53. Signs/Symptoms Diarrhea (watery) Fever Loss of appetite Nausea
Abdominal pain/tenderness

54. New Information – C-diff
Soap and water for handwashing when caring for a patient with C-diff is more effective than using alcohol hand sanitizers
Infect. Control Hosp. Epidemiology. 2010, June 31 (6):571-3

55. Cleaning
Chlorine based product is needed

56. Treatment Most cost effective

57. Fecal Transplant
The fecal microbiota transplantation (FMT) movement is catching the attention of scientists, researchers and the media nationwide. Currently, fecal transplantation delivers pre-screened, healthy human donor stool to a patient via colonoscopy or by nasogastric tube. It’s prescribed as an effective alternative to long-term antibiotic use in treating debilitating infectious diseases such as Clostridium difficile, also known as C-diff.
new research published in Journal of the American Medical Association says there is a third, less invasive, less expensive option to treat C-diff: poop in a pill.

58. Carbapenem-Resistant Enterobacteriaceae (CRE)
New Delhi/Verona
Majority of cases in persons hospitalized outside the U.S. overnight within 6 month time frame
Occurs in patient receiving antibiotics and other significant medical treatments

59. Travel History
Have you ben hospitalized overnight outside the United States in the past 6months

60. Exposure No follow up needed or recommended
Healthy people usually do not get CRE infections
CDC, 2013

61. CRE
Have developed high levels of resistance to antibiotics including “last resort” antibiotics – carbapenems
S/S: fever, fatigue, UTI, sepsis

62. Prevention Prudent use of antibiotics Remove unnecessary devices
Good handwashing
Contact Precautions
Cleaning equipment

63. Current Outbreak in US UCLA Medical Center – (2015)
Hospital NorthWesten Illinois – 39 cases (2014)
Source – duodenoscopes
Currently – not a reportable infection

64. Efforts – Antibiotic Resistance
FY 16 budget, CDC has requested funding to support State Antibiotic Resistance Prevention Programs in all 50 states
September,2015 expanded to long-term care facilities

65. Middle Eastern Respiratory Syndrome - MERS

66. MERS Coronavirus – usually mild illness
History of travel to Arabian Peninsula in the past 10 days
Cleaning – B/W 1:100 post transport
CDC Home Care Guidelines

67. Transmission
Close contact – caring for or living with an infected person
MERS has been found in camels – contact with camels
Urine
Nasal secretions

68. Persons at Risk
Person with pre-existing medical conditions

69. MERS – Signs & Symptoms
Fever
Cough
Shortness of breath

70. Incubation Period
5 – 6 day ( can be days)

71. Prevention
Place surgical mask on the patient
Good handwashing

72. Post Exposure MERS No treatment available
Take Temperature twice daily x 14 days
Symptoms – seek medical care

73. MERS in U.S. May 2014 2 cases- very low risk to general population
1 in Indiana
1 in Florida
Believed to have been infected in Saudi Arabia
Both are healthcare workers in Saudi Arabia
Both recovered –

74. Ebola Outbreak

75. Travel History
Travel history to Africa or contact with a know or suspect Ebola patient
Symptoms – temp 101.5
Part of Patient assessment
Standard Precautions
Contact Precautions
Droplet Precautions
Mask patient

76. Medical Facility
Africa
United States

77. Transmission Human – to – Human Transmission
Direct contact through (broken skin or mucous membranes) with blood, secretions, organs of infected persons
Contact with contaminated environments
WHO/CDC

78. Incubation Period
2 – 21 days following an exposure event

79. Test for Ebola
2 min. fingerstick test

80. We are fortunate!
Fatu
Garbage Bag technique

81. Current CDC Recommendations
PPE EMS – pts. Without Vomiting/diarrhea
Surgical mask/face shield
Double gloves
Cover gown
CDC Dec. 2, 2014/ 2015

82. Current Approach All persons coming to US from West Africa will enter
the US through 4 airports
Ill persons transport (by air) to one of 35 medical facilities

83. Ebola Vaccine Ebola vaccine trial in Guinea shows 100% Merck – ZEBOV
Effective in 10 days after administration
World Health Organization reports that a human vaccine trial has ben successful in Guinea. The vaccine is manufactured by Merck. Future vaccine trials are questionable as the Ebola case numbers are so low. That is good news
WHO, August 3, 2015

84. Why CDC Guidelines Change

85. Steps in Outbreak Investigation
Establish an outbreak exists
Verify diagnosis
Define and identify cases
Collect data – time, place and person
Implement control measures
Evaluate hypotheses and conduct studies
Evaluate data and revise control measures if needed
Communicate findings

86. What We Have Learned We are not ready
Education/training basics are not in place
Travel history needs to be routine
Fear prevails over science

87. What We Have NOT Learned
Quarantine is broken if –
No access to food
No access to medications
No access to income

88. ZikA Virus Infection
The newest vector borne illness that may be heading north to the US

89. Travel History Key information
This should always now be a routine question on patient assessment

90. Mode of Transmission Mosquito bite Blood Sexual Contact (rare)
Infected mother to her child
How this is transmitted – you are NOT at risk for contracting this illness as a result of patient care activities
Zika virus can be transmitted from a pregnant mother to her fetus during pregnancy or around the time of birth.
Regarding sexual transmission - In all three cases, the men developed symptomatic illness. 
CDC/WHO

91. Symptoms
  About 1 in 5 people infected with Zika virus become symptomatic.
acute onset of fever with maculopapular rash
arthralgia,
conjunctivitis
myalgia
headache.
Clinical illness is usually mild with symptoms lasting for several days to a week.
Symptoms that have been noted -
CDC

92. Prevention - Women Women who are pregnant –
Updated guidelines include a new recommendation to offer serologic testing to asymptomatic pregnant women (women who do not report clinical illness consistent with Zika virus disease) who have traveled to areas with ongoing transmission of Zika virus
Testing should be offered between 2 and 12 weeks after pregnant women return from travel to areas with ongoing Zika virus transmission.
CDC recently updated its guidelines and more changes may be forthcoming
CDC/WHO

93. Women – Childbearing age
The advisory applies to women of child-bearing age, including Olympic athletes, traveling to Latin America and Caribbean countries.
Pregnant women who can't postpone their travel should talk to their doctor first and take precautions to avoid mosquito bites
These precautions also apply to women trying to become pregnant or who are thinking about becoming pregnant, because the virus lingers in the body for as long as two weeks after infection.
CDC advice to women of childbearing age and those trying to become pregnant
(James Gathany/Centers for Disease Control and Prevention 1/15/16))

94. Prevention - Men
If there has been travel to an are with active Zika virus transmission –
consider using a condom or abstinence if your partner is pregnant
the duration of persistence of Zika virus in semen remains unknown.
CDC, 2016

95. Mosquito control Use of repellant Air conditioning Clothing
Focus
Mosquito control Use of repellant Air conditioning Clothing

96. Treatment
Antiviral treatment is not currently available for Zika virus disease; treatment is supportive and includes rest, fluids, and analgesic and antipyretic medications.
Aspirin and other nonsteroidal anti-inflammatory medications should be avoided
Pregnant women with fever should be treated with acetaminophen.
Basic supportive treatment
CDC

97. Purpose- Training Conan Doyle, Author Hounds of the Baskervilles
“ That which is clearly known hath less terror than that which is but hinted at and guessed”
Conan Doyle, Author
Hounds of the Baskervilles

98. Questions & Answers
703 –