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Emerging Infectious Diseases What EMS Needs to Know
Katherine West, RN,BSN, MSEd Infection Control Consultant
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Some appear to be old diseases that have returned
Emerging Diseases Some appear to be old diseases that have returned
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Content Measles Chickenpox Pertussis CRE C- diff MERS Ebola Zika
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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
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-The List Bloodborne HCV HBV HIV Vaccinia virus Cutaneous Anthrax
Rabies Viral hemorrhagic fevers(Ebola, Lassa Fever, Marlberg Federal Register, 11/2/11
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The List Airborne Tuberculosis Chickenpox Measles (rubeola)
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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
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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
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Pertussis Whooping Cough
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Bacteria Bordetella Pertussis
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Pertussis Cases in creasing over the past 3 decades Highest cases
Infants Adolescents Adults
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Incubation Period 7 – 10 days (as long as 6 weeks)
Considered “highly contagious” Incubation period - CDC, January 2005/2011
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Pertussis Transmission – Direct contact with respiratory discharges
3 foot rule
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Pertussis Signs/symptoms Fever Coryza Non-productive cough
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Pertussis Signs/symptoms Paroxysmal spasms of severe coughing
Black eyes Whooping (inspiration) Posttussive vomiting
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Exposure Face-to-face contact within 3 feet of a symptomatic patient
Direct contact –respiratory, oral, nasal secretions -
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Pertussis Outbreaks - 2014 Ohio California Michigan Wisconsin Texas
Colorado
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Prevention Tdap - Adacel-
Boosters for all healthcare personnel involved in the care of children Child care providers Parents Grandparents over age 64* 2005, 2011
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Prevention Place a surgical mask on the patient Get vaccinated
Get your booster!
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Primary Choice Z- Pack for 14 days
Erythromycin 4 dived daily doses x 14 days
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Recent Outbreaks Measles
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Disneyland
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Illinois
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Measles Outbreak – 2016 AZ ICE Immigration Detention Center
Decline vaccine On work restriction Wear surgical masks Vaccine for detainees July 7, 2016
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Rubeola Red Measles Hard Measles Nine Day Measles
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Rubeola Fever Rash Coryza Cough Koplik Spots (buccal Mucosa)
Conjunctivitis
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Rubeola Incubation Period 7 – 18 days
Infectious 4 days before onset of rash – 4 days after rash onset CDC, 2008, 2011
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Exposure Non-immune healthcare worker with >5 mins. In same room or face-to-face contact Dec., 2011
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Rubeola Post Exposure Management I.G. Given within 96 hours
Vaccine – within 72 hours of exposure CDC, 2011
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Work Restriction From 5th day to the 21st day of the exposure
Replacement costs
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Measles Outbreak- Arizona
Required rapid review of measles documentation 12, 844 HCP at 7 hospitals Cost over $800,000.00 CDC, 2011
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Prevention MMR Vaccine = $30.00
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MMR Vaccine If received between 1963 – 1967
Revaccinate with 2 doses one month apart
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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
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Chickenpox Varicella Zoster Herpes Zoster (shingles)
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Chickenpox Lesions on covered areas of the body Fever Photosensitivity
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Chickenpox Incubation Period 10 days - 21 days
Contagious 1-2 days before rash appears CDC, Dec., 2011
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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
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Chickenpox Vaccine Varivax 2 doses 1 month apart
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Chickenpox Vaccine Varivax Do Not give to pregnant women
Avoid pregnancy for 4 weeks after each dose Use consent form
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Chickenpox Vaccine Unable to document immunity Just vaccinate
CDC, Nov. 25, 2011
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Chickenpox Post Exposure Medical Treatment Offer vaccine
for pregnant or immune compromised persons offer VariZig CDC, 2011
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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
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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
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VariZig Post Exposure Extend furlough an additional 7 days
Total work restriction = 18 days CDC, 2009
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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
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Costs Work restriction = sick time or work comp Replacement costs
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Check your vaccine records
Get your records from: Previous employer High school College Training program
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New Hires Review for protection
Not protected – offer prevention up front At least 90% less costly than one exposure
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Current Staff Collect data on childhood diseases or vaccine
Offer vaccine to unprotected staff
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C- diff Anaerobic spore-forming bacillus
Clostridium difficile-associated disease (CDAD) Hospital-acquired Related to antibiotic treatment
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Transmission Fecal – oral Contaminated hands
Contamination of environment Mayo Clinic, 2006, HIC, 2008
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Signs/Symptoms Diarrhea (watery) Fever Loss of appetite Nausea
Abdominal pain/tenderness
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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
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Cleaning Chlorine based product is needed
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Treatment Most cost effective
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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.
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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
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Travel History Have you ben hospitalized overnight outside the United States in the past 6months
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Exposure No follow up needed or recommended
Healthy people usually do not get CRE infections CDC, 2013
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CRE Have developed high levels of resistance to antibiotics including “last resort” antibiotics – carbapenems S/S: fever, fatigue, UTI, sepsis
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Prevention Prudent use of antibiotics Remove unnecessary devices
Good handwashing Contact Precautions Cleaning equipment
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Current Outbreak in US UCLA Medical Center – (2015)
Hospital NorthWesten Illinois – 39 cases (2014) Source – duodenoscopes Currently – not a reportable infection
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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
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Middle Eastern Respiratory Syndrome - MERS
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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
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Transmission Close contact – caring for or living with an infected person MERS has been found in camels – contact with camels Urine Nasal secretions
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Persons at Risk Person with pre-existing medical conditions
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MERS – Signs & Symptoms Fever Cough Shortness of breath
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Incubation Period 5 – 6 day ( can be days)
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Prevention Place surgical mask on the patient Good handwashing
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Post Exposure MERS No treatment available
Take Temperature twice daily x 14 days Symptoms – seek medical care
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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 –
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Ebola Outbreak
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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
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Medical Facility Africa United States
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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
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Incubation Period 2 – 21 days following an exposure event
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Test for Ebola 2 min. fingerstick test
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We are fortunate! Fatu Garbage Bag technique
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Current CDC Recommendations
PPE EMS – pts. Without Vomiting/diarrhea Surgical mask/face shield Double gloves Cover gown CDC Dec. 2, 2014/ 2015
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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
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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
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Why CDC Guidelines Change
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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
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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
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What We Have NOT Learned
Quarantine is broken if – No access to food No access to medications No access to income
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ZikA Virus Infection The newest vector borne illness that may be heading north to the US
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Travel History Key information
This should always now be a routine question on patient assessment
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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
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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
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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
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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))
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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
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Mosquito control Use of repellant Air conditioning Clothing
Focus Mosquito control Use of repellant Air conditioning Clothing
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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
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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
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Questions & Answers 703 –
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