10 Infectious Diseases and Sepsis.

10 Infectious Diseases and Sepsis

Multimedia Directory Slide 89 AIDS Video

Standard Medicine (Infectious Diseases)

Competency Integrates assessment findings with principles of epidemiology and pathophysiology to formulate a field impression and implement a comprehensive treatment/disposition plan for a patient with a medical complaint.

Introduction Infectious diseases: illnesses caused by infestation of body by biological organisms (bacteria, viruses, fungi, protozoans, helminths). Most infectious disease states not life threatening. Paramedics often first to encounter patients with communicable diseases. Teaching Tips Getting students to practice disease prevention and Standard Precautions is important. It should be practiced with every patient assessment and skill practice throughout the class.

Public Health Principles
Infectious agent: "hazardous material"; can affect large numbers of people. Epidemiologists: health professionals who study how infectious diseases affect populations. Characteristics of host, infectious agent, environment yield clues to how infectious agent transmitted.

Public Health Principles
Demographics: characteristics of certain population. Index case: individual who first introduced infectious agent to population. Paramedics must evaluate host (patient), infectious agent, environment.

Public Health Agencies
Local agencies first line of defense in disease surveillance and outbreak. At state level, an agency (health department or board of health) monitors infectious diseases. U.S. Department of Health and Human Services (DHHS) Centers for Disease Control and Prevention (CDC) most visible federal agency.

CDC monitors national disease data; disseminates information to all health care providers. CDC researches infectious diseases. National Institute for Occupational Safety and Health (NIOSH): standards and guidelines to prevent infectious diseases in workplace. Knowledge Application Many employers require yearly competencies that include bloodborne pathogens and OSHA requirements. Why do you think it is important to begin good practices now? How will this impact your career?

Federal Emergency Management Agency (FEMA) National Fire Protection Association (NFPA) U.S. Fire Protection Administration (USFPA) International Association of Firefighters (IAFF)

Microorganisms Majority of disease-causing organisms microscopic (visible only under microscope). Normal flora help keep us disease free by creating environmental conditions not conducive to disease-producing microorganisms (pathogens).

Microorganisms Opportunistic pathogens: nonharmful bacteria that cause disease only under unusual circumstances. Most opportunistic pathogens are normal flora. Patients with weakened immune system or unusual stress susceptible to diseases caused by opportunistic organisms.

Microorganisms Bacteria
Microscopic single-celled organisms; 1 to 20 micrometers; prokaryotes. Reproduce independently; require host to supply food and environment. Gram stain common method of differentiating bacteria.

Microorganisms Bacteria Cocci or spheres are round.
Rods are elongated. Spirals are coiled. Specific tissues and organs infected determine signs and symptoms. Heavy colonization may result in direct damage to tissues as bacteria feed.

Indirect damage by releasing toxic chemicals that have localized or systemic effects. Exotoxins: poisonous proteins shed by bacteria during bacterial growth. Endotoxins: proteins, polysaccharides and lipids; released when bacterial cell destroyed.

Most bacterial infections respond to antibiotics; bactericidal (kill bacteria) or bacteriostatic (inhibit bacterial growth or reproduction). Different antibiotics required to treat different bacteria. Overuse of antibiotics has made some ineffective against disease.

Microorganisms Viruses
Much smaller than bacteria; only seen with electron microscope. Cannot reproduce and carry on metabolism by themselves. Obligate intracellular parasites: grow and reproduce only within host cell. Resist antibiotic treatment.

Microorganisms Viruses
Enters host cell; becomes part of host cell, making eradication of virus impossible, as any treatment that kills virus will kill host cell as well. 400 types of viruses; most viral diseases mild and self-limiting.

Microorganisms Other Microorganisms
Prions: disease-producing agents referred to as "slow viruses." Cause progressive, untreatable dementia in Kuru, Creutzfeldt-Jakob disease, mad cow disease, fatal familial insomnia.

Fungi: plantlike microorganisms, most not pathogenic. Yeasts, molds, mushrooms are types of fungi. Become pathogenic in patients with compromised immune function.

Protozoa: single-celled parasitic organisms with flexible membranes and ability to move. Most live in soil; ingest decaying organic matter. Opportunistic pathogens in patients with compromised immune function. Enter body by fecal–oral route or through mosquito bite.

Parasites: common causes of disease where sanitation poor. Roundworms: live in intestinal mucosa; may reach 30–50 cm in length. Symptoms: abdominal cramping, fever, cough.

Pinworms: common in U.S. and civilized countries. Tiny worms (3–10 mm long) live in distal colon. Common cause of anal pruritus (itching) and infection.

Hookworms: found in warm, moist climates. Larvae passed in stool of infected animals; contracted when barefoot person walks in contaminated area. Epigastric pain and anemia.

Trichinosis: contracted by eating raw or inadequately cooked pork products. Gastrointestinal disturbances, edema, fever. If worms invade heart, lungs, brain in large numbers, death may result.

Contraction, Transmission, and Stages of Disease
Infectious agents exist in animals, humans, insects, environment. While inhabiting animal or insect reservoirs, they do not cause disease. When host and infectious agent come together at right time and conditions, disease transmission takes place.

Common direct transmission is from person to person through cough, sneeze, kiss, sexual contact. Indirect transmission spreads organisms in number of ways. Microorganisms transmitted via food products, water, soil.

Bloodborne diseases transmitted by contact with blood or body fluids of infected person. AIDS; hepatitis B, C, D; syphilis. Assume every patient has infectious bloodborne disease; take precautions. Teaching Tips Remind students of the immunology section and ask them to consider how the body responds to activation of the immune system.

Some infectious diseases transmitted through air on droplets expelled during productive cough or sneeze. Tuberculosis, meningitis, mumps, measles, rubella, chickenpox (varicella). Other diseases such as common cold, influenza, respiratory syncytial virus (RSV) transmitted by airborne route.

Some infectious diseases transmitted orally (eating) or by fecal–oral route. Risk of disease transmission rises if: Open wounds. Increased secretions. Active coughing. Ongoing invasive treatment.

Many EMS patient care activities occur in closed, poorly ventilated environment (back of ambulance). Use protective clothing; barrier devices. Regular cleaning and sanitization of ambulance and equipment will help reduce exposure. Knowledge Application How does the mode of transmission and entry affect the paramedic? How can we limit exposure when we are unsure if our patients are infectious? What additional measures can be taken in the closed environment of the ambulance?

Not all infectious agents and diseases communicable (transmitted to another host). Penetration of host: infection occurred, but never equated with disease.

Factors in becoming infected: Correct mode of entry. Virulence: organism's strength or ability to overcome body's defenses. Number of organisms transmitted (dose). Host resistance: host's ability to fight off infection. Other host factors.

Phases of the Infectious Process Latent period: once infected with infectious agent, host cannot transmit agent to someone else. Communicable period: host may exhibit signs of clinical disease; can transmit infectious agent to another host. Incubation period: time between exposure and presentation.

Viruses and bacteria have surface proteins (antigens); stimulate body to produce antibodies. Antibodies in blood indicates exposure to disease that they fight. Window phase: time between exposure to disease and seroconversion. Disease period: duration from onset of signs and symptoms until resolution.

The Body's Defenses Against Disease
The Immune System Fights disease by protecting body from foreign invaders. Must be able to differentiate "self" from "nonself." Inflammatory response involves selected leukocytes (white blood cells), functional units of blood in immune response. Teaching Tips Review the immune system and its components.

The Immune System Neutrophils and macrophages: attack infectious agent by combination of digestive enzymes and ingesting it (phagocytosis). Cell-mediated immunity does not result in formation of antibodies; humoral immunity does.

Phagocytosis occurs when cells engulf infectious agents.

The Immune System Cell-mediated immunity generates various T lymphocytes; react against specific antigens. Humoral immunity: immune system's properties of memory and specificity. Antibodies (immunoglobulins): protect against most infectious agents to which body repeatedly exposed. Class Activities Have students describe the different types of immunity and how the body prevents antigens from attacking the body.

The Immune System Five classes of human antibodies: IgG: remembers antigen and recognizes repeated invasions. IgM: formed early in most immune responses. IgA: main immunoglobulin in exocrine secretions.

The Immune System Five classes of human antibodies: IgD: present on surface of B lymphocytes; acts as antigen receptor. IgE: attaches to mast cells in respiratory and intestinal tracts.

The Complement System Provides alternate pathway to react more quickly to foreign bodies. At least 20 proteins; works with antibody formation and inflammatory reaction to combat infection. Starts cascade of biochemical events triggered by tissue injury.

The Lymphatic System Secondary circulatory system. Spleen, thymus, lymph nodes, lymphatic ducts. Set of small, thin-walled vessels; collects overflow fluid from tissue spaces and returns it to circulatory system. Fluid (lymph): same composition as normal interstitial fluid.

The Lymphatic System Important in disease prevention. Lymph nodes filter lymph before returning it to circulatory system. Spleen: generates antibodies and produces B and T lymphocytes; removes unwanted particulate matter.

Individual Host Immunity Passive immunity: received antibodies from maternal circulation via placenta or from inoculation. Active immunity: develops antibodies in response to inoculation by killed or modified form of infectious agent in attenuated vaccine.

Individual Host Immunity Serotype: determined by exposing microorganism to known antibody solutions. Immunizing against tetanus common practice in emergency medicine. Tetanus rare, but frequently fatal, disease; results from wound infected with bacterium.

Individual Host Immunity Generalized tetanus: pain and stiffness in jaw muscles ("lock jaw"); stiffness in trunk muscles. Progresses to reflex convulsive spasms and tonic contractions of muscle groups. Passive immunity provided by injection of tetanus immune globulin (TIG) (Hypertet).

Infection Control in Prehospital Care
EMS providers must protect themselves from infectious exposures. Four phases of infection control in prehospital care: Preparation for response Response Patient contact Recovery Knowledge Application What is your school's exposure plan and where is it located? Do you know what to do if you are exposed during your education? Is this adequate, or do students think changes be made to the plan?

Interruption of infectious disease transmission is a role of prehospital personnel.

Preparation for Response Establish and maintain written standard operating procedures (SOPs). Prepare infection control plan. Provide adequate original and ongoing infection control training. Ensure all employees provided with personal protective equipment (PPE).

Preparation for Response Ensure all EMS personnel treat and bandage all personal wounds before emergency response. Use disposable supplies and equipment when possible. Ensure all EMS personnel have access to facilities and supplies needed to maintain high level of personal hygiene.

Preparation for Response Do not allow EMS personnel to deliver patient care if signs or symptoms of infectious disease. Monitor EMS personnel for compliance with vaccinations and diagnostic tests. Appoint designated infectious disease control officer (IDCO).

Preparation for Response Identify specific job classifications and work processes in which possibility of exposure exists. Provide hazmat (hazardous materials) education for employees. Do not assume EMS agency can protect you from exposure to all infectious agents.

Response Obtain information from dispatch regarding nature of patient's illness or injury. Prepare for patient contact; put on gloves and don eye and face protection before patient contact. Prepare mentally for call; think infection control.

Patient Contact Isolate all body substances; avoid any contact with them. Take Standard Precautions. Allow only necessary personnel to make patient contact. Use airway adjuncts; disposable items preferable. Properly dispose of biohazardous waste.

Always use the personal protection recommended for the degree of exposure anticipated.

Patient Contact Use extreme caution with sharp instruments. Never smoke, eat, or drink in patient compartment of ambulance. Do not apply cosmetics or lip balm, or handle contact lenses.

Dispose of needles and other sharp objects properly.

Standard Precautions All health care workers should use appropriate barrier precautions to prevent exposure of skin and mucous membranes to any contact with blood, or body fluids, from any patient. Wash hands/skin surfaces with soap and warm water after removal of gloves.

Standard Precautions Prevent injuries caused by needles, scalpels, sharp instruments or devices when performing procedures and cleaning or disposing of instruments.

Standard Precautions Although saliva not directly implicated in HIV transmission, use mouthpieces with one-way valves or filters, bag-valve-mask devices, ventilation devices to avoid mouth-to-mouth contact.

Standard Precautions Do not put gloved hands close to your mouth; avoid wiping face with forearms or backs of gloved hands. If exudative or weeping skin lesions, refrain from direct patient care.

Standard Precautions Pregnant health care workers familiar with, and adhere to, precautions to minimize risk of HIV transmission. Disinfection of diagnostic or therapeutic equipment and supplies is mandatory.

Recovery Decontaminating ambulance and equipment is essential. Wash hands immediately after patient contact. If you sustain wound and are exposed to body fluids of others, wash wound with soap and warm water immediately, before contacting employer or IDCO.

Hand washing is one of the most effective methods of preventing disease transmission.

Recovery Dispose of biohazardous wastes. Place potentially infectious wastes in leakproof biohazard bags. Decontaminate all contaminated clothing and reusable equipment. Handle uniforms in accordance with agency's standard procedures.

Decontamination Methods/Procedures Decontaminate infected equipment according to local protocol and SOPs established by EMS agency. Low-level disinfection: destroys most bacteria and some viruses and fungi. Intermediate-level disinfection: destroys Mycobacterium tuberculosis and most viruses and fungi.

Decontamination Methods/Procedures High-level disinfection: destroys all forms of microorganisms except certain bacterial spores. Sterilization: destroys all microorganisms; required for all contaminated invasive instruments.

Infectious Disease Exposures Immediately report exposures of EMS personnel to designated IDCO, according to local protocol. Report all exposures to blood, blood products, potentially infectious material, regardless of perceived severity.

Infectious Disease Exposures The Ryan White Act: federal law, passed in 1990; outlines rights and responsibilities of agencies and health care workers when infectious disease exposure occurs. 2009, Congress passed Ryan White HIV/AIDS Treatment Extension Act.

Infectious Disease Exposures Employers required to provide medical evaluation and treatment for paramedic or EMS provider exposed to infectious disease. Treatment in line with U.S. Public Health Service recommendations. IDCO maintains records of all exposures; all are confidential.

Assessment of the Patient with Infectious Disease
Always maintain high index of suspicion that infectious agent may be involved. Dispatch information, evaluate environment, maintain Standard Precautions. Look for general indicators of infection.

Past Medical History Patients who have AIDS or are taking immunosuppressant medications such as steroids susceptible to infection. Chronic obstructive pulmonary disease (COPD); autoimmune diseases Transplant recipients; diabetes Alcoholism; malnutrition IV drug abuse; splenectomy Cancer; artificial heart valves or joints

The Physical Examination Determine level of consciousness and vital signs early on; increased temperature indicates infection. Hypotension with infectious disease may result from dehydration, vasodilation, or both. Dehydration common consequence of infectious diseases.

The Physical Examination Dehydration: tachycardia and hypotension; thirst, poor skin turgor, shrunken and furrowed tongue. Skin for temperature, hydration, color, or rash. Sclera (white of eye) for icterus (jaundice).

The Physical Examination Reaction to neck flexion. Lymph nodes for swelling or tenderness. Breath sounds. Hepatomegaly. Purulent (pus-filled) lesions.

Specific Infectious Diseases
Diseases of Immediate Concern to EMS Providers Human immunodeficiency virus (HIV) Collection of signs and symptoms; share anatomical, physiological, biochemical derangements in immune system. Like other viruses, HIV utilizes host cell's reproductive apparatus to copy itself.

Diseases of Immediate Concern to EMS Providers Human immunodeficiency virus (HIV) HIV is retrovirus. Action of reverse transcriptase enables genetic material from retrovirus to become permanently incorporated into DNA of infected cell. Two types: HIV-1 and HIV-2.

Diseases of Immediate Concern to EMS Providers Human immunodeficiency virus (HIV) Specifically targets T lymphocytes with CD4 marker. Correlation between disease progression and decrease in CD4 T lymphocyte count. Physicians can predict development of specific clinical events as CD4 count decreases.

Diseases of Immediate Concern to EMS Providers Human immunodeficiency virus (HIV) Measurement of viral load best indicator of response to therapy and long-term clinical outcome. AIDS can now be treated. Numerous medications (antiretroviral agents) have changed the face of AIDS. Decision Points Although many of these diseases are not immediately life threatening, they can cause long-term issues for patients and providers. How does this impact how you treat these patients? How should you approach not only these patients but also all patients?

Diseases of Immediate Concern to EMS Providers Human immunodeficiency virus (HIV) Transmitted through contact with blood, blood products, body fluids, semen, vaginal secretions, breast milk. Commonly contracted through sexual contact or sharing contaminated needles.

Diseases of Immediate Concern to EMS Providers Human immunodeficiency virus (HIV) Persons at high risk: Men who have sex with men African Americans Urban dwellers Infection of health care workers from HIV-positive patients exceedingly rare.

Diseases of Immediate Concern to EMS Providers Human immunodeficiency virus (HIV) Blood most dangerous; followed by fluids that may or may not contain blood. Other diseases: extrapulmonary and pulmonary tuberculosis, recurrent pneumonia, wasting syndrome, HIV dementia, sensory neuropathy.

Diseases of Immediate Concern to EMS Providers Human immunodeficiency virus (HIV) Kaposi's sarcoma: cancerous lesion quite rare until HIV appeared. As AIDS progresses, involves central nervous system (CNS); dementia, psychosis, encephalopathy, peripheral neurologic disorders.

Diseases of Immediate Concern to EMS Providers Human immunodeficiency virus (HIV) CD4 counts gives indication of how well immune system functioning. Viral load is number of copies of HIV virus in patient's blood. High viral load (>10,000 copies) indicates virus reproducing; disease progressing.

Diseases of Immediate Concern to EMS Providers Human immunodeficiency virus (HIV) No cure or vaccine for AIDS. Health care worker should immediately seek evaluation; initiation of treatment. Postexposure therapy: regimen of antiretroviral drugs.

Diseases of Immediate Concern to EMS Providers Human immunodeficiency virus (HIV) Counseling by ICDO or trained occupational infectious disease specialist. HIV-positive patients generally do not present in life-threatening situations to EMS.

Diseases of Immediate Concern to EMS Providers Human immunodeficiency virus (HIV) Important that care be compassionate, understanding, nonjudgmental. Take appropriate precautions to prevent disease transmission.

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Diseases of Immediate Concern to EMS Providers Hepatitis Inflammation of liver caused by viruses, bacteria, fungi, parasites, excessive alcohol consumption, medications. Headache, fever, weakness, joint pain, anorexia, nausea, vomiting, right upper quadrant abdominal pain.

Diseases of Immediate Concern to EMS Providers Hepatitis Patient may become jaundiced. Hepatitis A, B, C, D, E greatest potential for communicable disease. Hepatitis A (infectious or viral hepatitis): transmitted by fecal–oral route; hepatitis A virus.

Diseases of Immediate Concern to EMS Providers Hepatitis A Infections asymptomatic. Combination vaccine available for children for hepatitis A and B. Incubation period: 3 to 5 weeks.

Diseases of Immediate Concern to EMS Providers Hepatitis B Hepatitis B (serum) virus transmitted through direct contact with body fluids; substantial risk to EMS providers. Much more contagious than HIV. Health care workers infected by hepatitis B can develop acute hepatitis, cirrhosis, liver cancer.

Diseases of Immediate Concern to EMS Providers Hepatitis B Effectiveness of immunizations: 90%. Transmission: sexual, transfusion, dialysis, needle sharing, tattooing, acupuncture, communally used razors and toothbrushes.

Diseases of Immediate Concern to EMS Providers Hepatitis B Vaccination required before employment as health care provider; safe and effective. Incubation period: 8 to 24 weeks. Infections asymptomatic.

Diseases of Immediate Concern to EMS Providers Hepatitis C Transmitted by IV drug abuse; sexual contact. Chronic condition; 85% of infected people. Ineffectiveness of antibodies attributed to virus's high mutation rate.

Diseases of Immediate Concern to EMS Providers Hepatitis C Causes liver fibrosis; progresses over decades to cirrhosis. No effective vaccination. Treatment with alpha interferon has limited success.

Diseases of Immediate Concern to EMS Providers Hepatitis D Depends on surface antigen of hepatitis B virus (HBV) to produce structural protein shell. Hepatitis D virus (HDV) infection exists only with coexisting HBV infection. Immunization against HBV confers immunity to HDV; no vaccine exists.

Diseases of Immediate Concern to EMS Providers Hepatitis E Transmitted through fecal–oral route. Associated with contaminated drinking water. Does not lead to chronic infection.

Diseases of Immediate Concern to EMS Providers Tuberculosis (TB) Most common preventable adult infectious disease in world. Cause: bacteria known collectively as Mycobacterium tuberculosis complex. Affects respiratory system.

Diseases of Immediate Concern to EMS Providers Tuberculosis (TB) Multiple-drug-resistant tuberculosis (MDR-TB): drug-resistant bacteria outgrow drug-susceptible bacteria. Transmission: airborne respiratory droplets, through mucous membranes and broken skin, drinking contaminated milk.

Diseases of Immediate Concern to EMS Providers Tuberculosis (TB) Purified protein derivative (PPD) skin test identifies candidates for prophylactic drug therapy. Most EMS agencies skin test annually. Incubation period: 4–12 weeks.

Diseases of Immediate Concern to EMS Providers Tuberculosis (TB) Development of disease 6–12 months after infection. Reactivation in extrapulmonary sites (lymph nodes, pleura, pericardium) more common in HIV-infected persons. Known to lead to subacute meningitis and granulomas in brain.

Diseases of Immediate Concern to EMS Providers Tuberculosis (TB) Symptoms: chills, fever, fatigue, productive or nonproductive chronic cough, weight loss, night sweats. Hemoptysis (expectorating blood) very suggestive of active TB.

Diseases of Immediate Concern to EMS Providers Tuberculosis (TB) Protecting yourself from M. tuberculosis important step in preventing disease transmission. Risk of transmission increases if close and prolonged contact with patient.

Diseases of Immediate Concern to EMS Providers Tuberculosis (TB) Use appropriate respiratory precautions while performing cardiopulmonary respiration (CPR) and intubation.

Diseases of Immediate Concern to EMS Providers Tuberculosis (TB) Don protective respirator on contact with patient. N95 masks: designed to prevent contaminated air from reaching health care workers wearing them.

NIOSH/OSHA standards call for N95 masks when caring for patients with tuberculosis.

Diseases of Immediate Concern to EMS Providers Tuberculosis (TB) Ventilation systems in selected ambulances recycle and filter air to ensure expulsion of infected droplet. Early identification of exposure and drug prophylaxis keys to preventing active TB in health care workers.

Diseases of Immediate Concern to EMS Providers Pneumonia Acute lung inflammation; not single disease but family of diseases; result from respiratory infection by viruses, bacteria, fungi. Spread by droplet nuclei, direct contact, linens soiled with respiratory secretions.

Diseases of Immediate Concern to EMS Providers Pneumonia Always consider possibility of community-acquired pneumonia. Signs and symptoms: acute onset of chills, high-grade fever, dyspnea, pleuritic chest pain worsened by deep inspiration, productive cough with phlegm of various colors.

Diseases of Immediate Concern to EMS Providers Pneumonia In children, fever, tachypnea, retractions ominous signs; but not specific to pneumonia. Triad of signs indicates respiratory distress secondary to infectious process in pediatric patients.

Diseases of Immediate Concern to EMS Providers Pneumonia Support adequate ventilation and oxygenation. Supplemental oxygen administered to correct hypoxia. Consider TB possibility in patient with pneumonia; place mask on yourself or patient.

Diseases of Immediate Concern to EMS Providers Pneumonia Vaccination exists against most serotypes of S. pneumoniae. Highly recommended for children 2 years and younger, adults over 65, those without spleens; EMS workers not necessary.

Diseases of Immediate Concern to EMS Providers Severe acute respiratory syndrome (SARS) Viral respiratory illness; SARS-associated coronavirus (SARS-CoV). Spread by close person-to-person contact via respiratory droplets; touching contaminated object.

Diseases of Immediate Concern to EMS Providers Severe acute respiratory syndrome (SARS) Incubation period: 2 to 14 days. Considered contagious as long as he has symptoms. Quarantined to home for 10 days after fever abated and symptoms cleared.

Diseases of Immediate Concern to EMS Providers Severe acute respiratory syndrome (SARS) All personnel should use PPE on every call or as directed by local health authorities. Altered mental status, one- to two-word speech dyspnea, cough, cyanosis, hypoxia.

Severe acute respiratory syndrome (SARS) is a viral respiratory illness that first appeared in China in November 2002.

Diseases of Immediate Concern to EMS Providers Severe acute respiratory syndrome (SARS) Sore throat, rhinorrhea, chills, rigors, myalgias, headache, diarrhea, cough, sputum production, respiratory distress, respiratory failure. Administer oxygen to correct hypoxia.

Diseases of Immediate Concern to EMS Providers Severe acute respiratory syndrome (SARS) Provide ventilatory assistance. Establish IV access; administer fluids. If wheezing, consider administering nebulized bronchodilator. Notify hospital if you suspect SARS.

Diseases of Immediate Concern to EMS Providers Chickenpox (Varicella) Caused by varicella zoster virus (VZV); herpesvirus family. Much more lethal in adults. Infectious agent of shingles (herpes zoster): painful condition; skin lesions along course of peripheral nerves and dermatome bands.

Diseases of Immediate Concern to EMS Providers Chickenpox (Varicella) Respiratory symptoms, malaise, low-grade fever; rash on face and trunk and progresses to rest of body, including mucous membranes. Rupture, forming small ulcers; scab over within 1 week.

Diseases of Immediate Concern to EMS Providers Chickenpox (Varicella) Transmission: inhalation of airborne droplets; direct contact with weeping lesions and tainted linen. Incubation period: 10 to 21 days. In adults, common complication is varicella zoster virus (VZV) pneumonia.

Varicella (chickenpox). (Centers for Disease Control/Joe Miller)

Diseases of Immediate Concern to EMS Providers Chickenpox (Varicella) Important for unexposed or unvaccinated paramedics to be immunized. Most people develop immunity for life after recovery from childhood chickenpox infections. Chickenpox vaccine: Varivax.

Diseases of Immediate Concern to EMS Providers Chickenpox (Varicella) Observe Standard Precautions. If patient only has chickenpox, remain home until lesions crusted and dry. If susceptible paramedic exposed to chickenpox, postexposure vaccination may be warranted.

Diseases of Immediate Concern to EMS Providers Meningitis Inflammation of meninges and cerebrospinal fluid; caused by bacterial and viral infections. Meningococcal meningitis (spinal meningitis) disease variant of greatest concern to EMS responders.

Diseases of Immediate Concern to EMS Providers Meningitis Vaccines proven effective, especially in children. Enteroviruses: 90% of patients with viral (aseptic) meningitis. Transmitted by respiratory droplets; peaks in midwinter months with low temperature and humidity.

Diseases of Immediate Concern to EMS Providers Meningitis For EMS responder, contact with secretions during mouth-to-mask ventilation, intubation, suctioning increases probability of transmission. Incubation period: 2 to 10 days.

Diseases of Immediate Concern to EMS Providers Meningitis Fever, chills, headache, nuchal rigidity with flexion, arthralgia, lethargy, malaise, altered mental status, vomiting, seizures. Rash may appear; develop into hemorrhagic spots, or petechiae.

Diseases of Immediate Concern to EMS Providers Meningitis Fever in newborns evaluated with high index of suspicion for meningococcemia. Brudzinski's sign: flexion of hips or knees when neck flexed considered positive; finding suggestive of meningitis.

Diseases of Immediate Concern to EMS Providers Meningitis Kernig's sign: inability to fully extend knee due to meningeal irritation; positive sign. Effective vaccine developed against A, C, Y, W-135 serotypes.

Diseases of Immediate Concern to EMS Providers Meningitis Observe Standard Precautions. Use masks on yourself and/or patients; adequately protect yourself against all infectious agents of meningitis. Postexposure prophylaxis primary means of preventing meningococcal disease in patients with significant exposures.

Other Job-Related Airborne Diseases Influenza and colds, rubella, measles, mumps, respiratory syncytial virus (RSV): viral infections. Pertussis: highly contagious bacterial disease; poses risk. Transmitted by direct inhalation of infected droplets or exposed mucosal surfaces.

Other Job-Related Airborne Diseases Influenza Caused by viruses types A, B, C. Identified on basis of where they were isolated, culture number, year of isolation. Leading cause of respiratory disease worldwide; various strains cause epidemics.

Other Job-Related Airborne Diseases Influenza Easily transmittable in crowded spaces. High potential for transmission by autoinoculation. Sudden onset of fever, chills, malaise, muscle aches, nasal discharge, cough. More serious in very young, very old, and those with underlying disease.

Other Job-Related Airborne Diseases Influenza Incubation period:1 to 3 days. Fever: 3 to 5 days. Severe cases: pneumonia, hemorrhagic bronchitis, death. Determine hydration status early; begin fluid replacement if indicated. Everyone susceptible to influenza.

Other Job-Related Airborne Diseases Influenza Influenza viruses mutate so rapidly that protection effective only against particular strain or variant. CDC recommends vaccination for EMS personnel.

Other Job-Related Airborne Diseases Common cold (viral rhinitis) Caused by rhinoviruses; more than 100 serotypes. Transmission: direct contact, airborne droplets, hands and linen soiled with discharges from infected individuals. Course mild, often without fever and muscle aching.

Other Job-Related Airborne Diseases Avian influenza Some avian viruses mutate or merge with human influenza virus to form virus that can infect humans. Most human infections in those who worked with poultry or lived around domestic birds. H5N1 virus called "bird flu"; particularly pathogenic.

Other Job-Related Airborne Diseases Avian influenza Tends to affect younger people; high mortality rate. Vaccine available. Influenza-like symptoms, pneumonia, acute respiratory distress, viral pneumonia, severe and life-threatening complications.

Other Job-Related Airborne Diseases Measles (rubeola, hard measles) Systemic disease caused by measles virus; highly communicable. Immunity following disease is lifelong. Transmitted by inhalation of infective droplets and direct contact. Incubation period: 7 to 14 days.

Other Job-Related Airborne Diseases Measles (rubeola, hard measles) Fever, conjunctivitis, swelling of eyelids, photophobia, malaise, cough, nasopharyngeal congestion. Fever increases, rising to as high as 104◦–106◦F, when rash reaches its maximum.

Other Job-Related Airborne Diseases Measles (rubeola, hard measles) Before rash develops, Koplik's spots appear on oral mucosa. Everyone should be immunized. Immunization 99% effective in children; vaccination mandatory. Postexposure hand washing is critical. Life-threatening sequela: encephalitis.

Other Job-Related Airborne Diseases Mumps Virus; transmitted through respiratory droplets and direct contact with saliva of infected patients. Characterized by painful enlargement of salivary glands. Most cases occur in 5- to 15-year age group; 12- to 25-day incubation period.

Other Job-Related Airborne Diseases Mumps Occurs in epidemics; lifelong immunity conferred after infection. Generally benign and self-limiting. Mumps live-virus vaccine available; administered with measles and rubella vaccines to children over 1 year of age. Mumps easily transmitted.

Other Job-Related Airborne Diseases Rubella (German measles) Systemic viral disease caused by rubella virus transmitted by inhalation of infective droplets. Sore throat and low-grade fever, accompanied by fine pink rash on face, trunk, extremities; lasts about 3 days.

Other Job-Related Airborne Diseases Rubella (German measles) Incubation period: 12–19 days. Natural infection conferring lifelong immunity, as does immunization. No specific treatment. Devastating to developing fetus; mothers infected during first trimester at risk for abnormal fetal development.

Other Job-Related Airborne Diseases Rubella (German measles) All females should be immunized against rubella before becoming pregnant. Vaccines for measles, mumps, rubella (MMR vaccination); given safely with varicella vaccine.

Other Job-Related Airborne Diseases Rubella (German measles) Immunization 98–99% effective. Not recommended for pregnant women. EMS providers required to receive MMR vaccination before being allowed to work.

Other Job-Related Airborne Diseases Respiratory syncytial virus (RSV) Cause of pneumonia and bronchiolitis in infants and young children. In this age group, RSV may be fatal. Associated with outbreaks of lower respiratory infections. If patient with pneumonia or bronchitis simultaneously contracts virus, disease becomes more severe.

Other Job-Related Airborne Diseases Respiratory syncytial virus (RSV) Wheezing, tachypnea, respiratory distress. Diagnosed by rapid assay using nasal washings. High-risk children can be treated with antiviral agent ribavirin (Virazole). Treatment expensive; poses risk to unborn babies.

Other Job-Related Airborne Diseases Pertussis (whooping cough) Caused by bacterium; affects oropharynx in three phases; incubation 6 to 20 days. Develops mild cough; quickly becomes severe and violent. Rapid consecutive coughs followed by deep, high-pitched inspiration ("whoop").

Other Job-Related Airborne Diseases Pertussis (whooping cough) Large amounts of thick mucus; sustained coughing may lead to increased intracranial pressure and intracerebral hemorrhage. Vaccination of children; diphtheria-tetanus-pertussis (DTP).

Other Job-Related Airborne Diseases Pertussis (whooping cough) Disease likely to confer immunity. Previously immunized and exposed adolescents/adults may be at risk of infection. Anticipate intubation for patients with respiratory failure. Highly contagious.

Other Job-Related Airborne Diseases Pertussis (whooping cough) Transmission: respiratory secretions or aerosolized form. Mask patient; observe Standard Precautions; postexposure hand washing. Everyone susceptible to B. pertussis infection.

Viral Diseases Transmitted by Contact Mononucleosis Caused by Epstein-Barr virus (EBV). Affects oropharynx, tonsils, reticuloendothelial system. 4- to 6-week incubation period; begins with fatigue. Fever, severe sore throat, oral discharges, enlarged and tender lymph nodes, splenomegaly.

Viral Diseases Transmitted by Contact Mononucleosis Generally confers immunity for life. Transmission: oropharyngeal contact involving exchange of saliva. Common in 15 and 25 years of age. Full recuperation may take several months; no specific treatment. Immunization unavailable.

Viral Diseases Transmitted by Contact Herpes simplex virus type 1 Transmitted in saliva of carriers; infects oropharynx, face, lips, skin, fingers, toes. Everyone susceptible. Infections of health care workers' hands and fingers can result in herpetic whitlow, weeping inflammations at distal fingers and toes.

Viral Diseases Transmitted by Contact Herpes simplex virus type 1 Incubation period: 2 to 12 days. In oral cavity, fluid-filled vesicles develop into cold sores or fever blisters; deteriorate into small ulcers. Disappear in 2 to 3 weeks. May recur spontaneously, especially following periods of stress or illness.

Viral Diseases Transmitted by Contact Herpes simplex virus type 1 Can cause meningoencephalitis in newborns; aseptic meningitis in adults. Treatment with antiviral agents. Standard Precautions, primarily gloves, absolutely essential. Immunization not available.

Herpes virus. Causative agent of herpes infections
Herpes virus. Causative agent of herpes infections. (Centers for Disease Control/Dr. Fred Murphy; Sylvia Whitfield)

Other Infectious Conditions of the Respiratory System Epiglottitis Inflammation of epiglottis; may involve areas just above and below it. In children it is true emergency. Four "Ds": dysphonia, drooling, dysphagia, distress.

Other Infectious Conditions of the Respiratory System Croup (laryngotracheobronchitis) Cause of acute upper airway obstruction in children under 3. Viral illness; inspiratory and expiratory stridor; seal-bark-like cough. Generally not life threatening. Total airway obstruction rare.

Other Infectious Conditions of the Respiratory System Pharyngitis Infection of pharynx and tonsils. Caused by virus or bacteria; sudden onset of sore throat and fever. Most cases in 5- to 11-year-olds. Group A streptococcus (strep throat) causes particularly serious pharyngitis.

Other Infectious Conditions of the Respiratory System Pharyngitis Can progress to rheumatic fever or scarlet fever (scarletina). Strep throat very contagious; wear mask when assessing and managing these patients. Antibiotics effectively treat strep throat.

Other Infectious Conditions of the Respiratory System Sinusitis Inflammation of paranasal sinuses. Mucus and pus cannot drain; become trapped in sinus. Preceded by viral upper respiratory infection or exposure to allergens. Nasal congestion; blocked sinus passages.

Other Infectious Conditions of the Respiratory System Sinusitis If untreated, can cause abscess or spread into cranium and attack brain. Antibiotics, decongestants. Apply heat pack directly over affected sinus to help relieve pain and facilitate drainage.

Other Infectious Conditions of the Respiratory System Hantavirus Family of viruses carried by rodents such as deer mouse. Transmission: inhalation of aerosols stirring up dried urine, saliva, fecal droppings of rodents, contamination of food.

Other Infectious Conditions of the Respiratory System Hantavirus Causes hantavirus pulmonary syndrome (HPS); anyone susceptible. 4 to 10 days, symptoms of pulmonary edema occur. No immunization available. EMS responders should wear face masks.

GI System Infections Gastroenteritis Gastrointestinal disorder; nausea, vomiting, gastrointestinal cramping or discomfort, anorexia, diarrhea. Causative agents: viruses and parasites. Highly contagious via fecal–oral route, including ingestion of contaminated food and water.

GI System Infections Gastroenteritis In very young, very old, those with preexisting disease, can be serious and fatal. Prolonged vomiting and/or diarrhea may result in dehydration and electrolyte disturbances. Start IV with isotonic saline.

GI System Infections Gastroenteritis If shock, management objectives no different than for hemorrhagic shock. If prolonged vomiting or retching, administer antiemetic. Standard Precautions; postexposure hand washing critical to avoid infection.

GI System Infections Food poisoning Nonspecific term: gastroenteritis. Occurs suddenly; caused by eating, bacteria and their toxic products. Diarrhea, vomiting, gastrointestinal discomfort. Botulism or Escherichia coli O157:H7 can cause debilitating illness or death.

GI System Infections Food poisoning Other bacteria in food poisoning: Campylobacter, Salmonella, Shigella, Vibrio cholerae. Most transmitted by uncooked or undercooked meat, poultry, or fish. Stool cultures required to confirm bacterial cause of gastroenteritis.

GI System Infections Food poisoning Initiate standard advanced life support (ALS) protocols, assessment of airway and ventilatory status, oxygenation, initiation of IV, cardiac monitoring, fluid resuscitation with isotonic crystalloids. No immunization against these agents or their toxins exists.

Nervous System Infections Encephalitis Inflammation caused by infection of brain and its structures by viruses. Encephalitis similar to meningitis, as they often coexist. Neurologic signs: uncoordinated and involuntary movements; weakness of arms, legs, other portions of body; unusual sensitivity of skin to stimuli.

Nervous System Infections Rabies Transmitted by rabies virus. Urban: unimmunized domestic dogs and cats. Sylvatic: skunks, foxes, raccoons, mongooses, coyotes, wolves, bats. Humans susceptible when bitten by infected animals.

Nervous System Infections Rabies Creates encephalomyelitis; almost always fatal. Excessive motor activity, excitation, agitation, confusion, hallucinations, combativeness, bizarre aberrations of thought, muscle twitches and tetany, seizures, focal paralysis. Untreated: death 2 to 6 days.

Nervous System Infections Rabies Inspect wound for bite pattern; presence of saliva. Rinse with copious amounts of normal saline to remove saliva and blood. Do not bandage or dress wound; allow to drain freely during transport. Ensure suspect animal secured and contained.

Nervous System Infections If you believe you are rabid: Vigorously wash wound with soap and warm water. Debride and irrigate wound; allow it to drain freely. Discuss postexposure prophylaxis with physician. Consider need for tetanus and other antibiotic therapy.

Nervous System Infections Tetanus Acute bacterial infection of CNS. Musculoskeletal signs and symptoms. Shorter incubation period leads to more severe illness. General population susceptible. Pain and stiffness in jaw muscles; muscle spasm and rigidity of entire body.

Nervous System Infections Tetanus EMS responders will rarely encounter this disease. Use Standard Precautions. Postexposure prophylaxis with tetanus immune globulin (TIG), diphtheria-tetanus toxoid (Td), diphtheria-tetanus-pertussis (DTP).

Nervous System Infections Lyme disease Recurrent inflammatory disorder accompanied by skin lesions, polyarthritis, involvement of heart and nervous system. Caused by tick-borne spirochete Borrelia burgdorferi. Northeast, upper Midwest, Pacific Coast.

Nervous System Infections Lyme disease Most infections in spring and summer. Everyone susceptible; natural infection does not confer immunity. Incubation period: 3 to 21 days. Painless, flat, red lesion at bite site. Rash ("bull's eye") disappears in time.

Characteristic target rash of Lyme disease
Characteristic target rash of Lyme disease. (Centers for Disease Control/James Gathany)

Nervous System Infections Lyme disease CNS sequelae: meningitis, seventh-cranial-nerve Bell's palsy, peripheral neuropathy; cardiac abnormalities. Late stage (persistent infection) can occur months or years after initial exposure.

Sexually Transmitted Diseases (STDs) Gonorrhea Gram-negative bacterium; 1 million cases treated annually. Everyone susceptible to infection. Males in early 20s; painful urination and purulent urethral discharge. Women: no pain; minimal discharge.

Sexually Transmitted Diseases (STDs) Gonorrhea Affected females: increased risk for sterility, ectopic pregnancy, abscesses within reproductive structures, peritonitis. No immunization available.

Sexually Transmitted Diseases (STDs) Syphilis Disease caused by spirochete. Transmitted: direct contact with exudates from syphilitic lesions of skin and mucous membranes, semen, blood, saliva, vaginal discharges. Congenital syphilis: infants contract disease before birth from infected mother.

Sexually Transmitted Diseases (STDs) Syphilis Everyone susceptible to infection. Lesions (may involve virtually any organ or tissue); skin rash; loss of hair and/or eyebrows. Period when symptoms improve or disappear completely. Tertiary syphilis: justifies reputation as "great imitator."

Sexually Transmitted Diseases (STDs) Syphilis Avoid frequent contact with lesions. Hand washing after patient contact. Treatment: benzathine penicillin. No immunization available.

Sexually Transmitted Diseases (STDs) Genital warts (condyloma acuminatum) Caused by human papillomavirus (HPV), a DNA virus. 70 HPV types; some associated with cervical cancer. Contagious and easily spread. In males, cauliflower-like, fleshy growths on penis, anus, mucosa of anal canal.

Genital warts (condyloma) on female labial surfaces caused by human papillomavirus. (Centers for Disease Control/Joyce Ayers)

Sexually Transmitted Diseases (STDs) Genital warts (condyloma acuminatum) In females, appear on labial surfaces. Vaccine available for HPV; serves as cervical cancer prevention agent.

Sexually Transmitted Diseases (STDs) Herpes simplex virus type 2 (HSV-2) HSV-2 causes 70–90% of all genital herpes cases. Transmission by sexual contact. Everyone susceptible. Vesicular lesions on penis, anus, rectum, mouth of male.

Sexually Transmitted Diseases (STDs) Herpes simplex virus type 2 (HSV-2) Females: asymptomatic; can display lesions of vagina, vulva, perineum, rectum, mouth, cervix. Painful lesions may recur periodically during patient's lifetime. Immunization not available.

Sexually Transmitted Diseases (STDs) Chlamydia Genus of intracellular parasites most like gram-negative bacteria. Most clinically significant species; affects genital area, eyes, respiratory system. Everyone susceptible.

Sexually Transmitted Diseases (STDs) Chlamydia Transmitted by sexual activity; hand-to-hand transfer of eye secretions, causing conjunctivitis. Leading cause of preventable blindness. Symptoms similar to gonorrhea's, less severe. No immunization available.

Sexually Transmitted Diseases (STDs) Trichomoniasis Trichomonas vaginalis, protozoan parasite, common cause of vaginitis. In women, greenish-yellow vaginal discharge, irritation of perineum and thighs, dysuria. Frequently present with gonorrhea. Men asymptomatic carriers of disease.

Sexually Transmitted Diseases (STDs) Chancroid Highly contagious ulcer caused by gram-negative bacterium. Uncircumcised men at higher risk. Spread by direct contact, mostly sexual, with open lesions and pus. Painful, inflamed pustule or ulcer; appears on penis, anus, urethra, vulva.

Chancroid. (Centers for Disease Control/ Joe Miller)

Sexually Transmitted Diseases (STDs) Chancroid Linked with increased risk of HIV infection. Health care workers have contracted disease by contacting patients' ulcers. Immunization not available; infection does not appear to confer immunity.

Diseases of the Skin Impetigo Very contagious infection caused by staphylococci or streptococci. Single vesicle; ruptures and forms thick, honey-colored crust with yellowish-red center. Lesions occur on extremities and joints. Easily transmitted by direct skin-to-skin contact; use Standard Precautions.

Diseases of the Skin Lice (pediculosis) Parasitic infestation of scalp, trunk, pubic area. Infest hosts rather than infect them because they do not break skin. Head lice, body lice, pubic lice. Head lice diagnosed by presence of small, white, oval-shaped eggs (nits).

Diseases of the Skin Lice (pediculosis) Three-stage life cycle: eggs, nymphs, adults; anyone can be infested. Body lice: infest clothing close to skin surfaces; attach to skin only to feed. Pubic lice: infest through sexual contact by attaching to hair in genital and anal regions.

Diseases of the Skin Lice (pediculosis) Treated with one of several nonprescription agents. Isolating infested linen and clothing advisable. Clean and wipe all sprayed areas to remove insecticide residues.

Diseases of the Skin Scabies Caused by infestation of mite barely visible without magnification. Close personal contact, from hand holding to sexual relations. Female tunnels into skin; lays eggs in epidermis. Intense itching.

Diseases of the Skin Scabies Remains communicable until all mites and eggs destroyed. All household members and/or close contacts of infested EMS responders treated simultaneously.

Bed Bugs (Cimex lectularius) Small, flat, parasitic insects that feed solely on blood of people and animals while they sleep. Reddish-brown in color, wingless, range from 1 mm to 7 mm; can live several months without blood meal. Generally do not transmit disease.

Nosocomial Infections Hospital-acquired diseases. Bacteria that resist antibiotics of particular concern. These organisms cause severe host damage; difficult to treat. May also contract resistant strains of tuberculosis; spread easily from patient to patient.

Patient Education Prevention is without question the most effective intervention in preventing transmission of infectious diseases. Key to effective prevention: education. CPR and first-aid classes offer platform to introduce and discuss issues related to disease transmission.

Patient Education Taking active part in public disease-prevention education will be among your most important roles as paramedic. Infectious diseases' serious personal and public health implications require you to be knowledgeable in this area and take lead in educating others.

Preventing Disease Transmission
Do not go to work if you: Have diarrhea. Have draining wound or any type of wet lesions; allow them to dry and crust over. Are jaundiced. Have mononucleosis. Have been exposed to lice or scabies and have not yet been treated.

Do not go to work if you: Have strep throat; have not been taking antibiotics for at least 24 hours. Have a cold. Have not kept immunizations current.

Approach scene cautiously with high index of suspicion. Control scene to decrease body fluid exposure for everyone present. Use Standard Precautions. With experience, you will develop intuition and associate symptoms with infectious patients you have treated. Class Activities The class should be familiar with all personal protective equipment and how to don it appropriately. Have the class use the proper precautions for every practice and assessment.

After call, wash your hands first. Decontaminate and disinfect equipment and interior of ambulance. Spray gurney and interior of ambulance with appropriate insecticide; wipe or mop up any residue. Report any infectious exposure to IDCO, human resources director, appropriate designated official.

Topics mandated by OSHA/NIOSH for compliance with standards reflect paramedic's minimum needed knowledge of infectious diseases. Proactive EMS agencies offer continuing education. Always consider interaction of three major factors: infectious agent, host, environment.

Be a role model. Paramedics cannot allow their personal prejudices to interfere with providing optimum care for patients. Standard Precautions, which are EMS practice standards, are predicated on possibility that all body fluids, in any situation, are infectious.

Sepsis/Systemic Inflammatory Response Syndrome (SIRS)
Sepsis (septicemia): most common cause of death in debilitated patients in hospital intensive care units. Life-threatening medical condition caused by whole-body inflammatory state called systemic inflammatory response syndrome (SIRS). Knowledge Application Sepsis kills many patients after we have corrected the original problem. How can we diminish the incidence of sepsis? Are there things we can do to help prevent sepsis?

Original site of infection can be anywhere in body; infection spreads to vascular system or other sterile areas. Sepsis can result from medical interventions and devices.

At risk of developing sepsis: People with immunosuppression Patients who are hospitalized People with pre-existing infections or medical conditions People with severe trauma People with genetic tendency for sepsis The very old or very young

Sepsis Signs and Symptoms Heart rate > 90 beats per minute. Abnormal body temperature. Tachypnea. Abnormal white blood cell count on a complete blood count (CBC). Severe sepsis: presence of sepsis and evidence of hypoperfusion.

Septic Shock Mean systemic blood pressure below 60 mmHg. Maintenance of mean arterial pressure above 60 mmHg requires vasopressor therapy. Early recognition and aggressive treatment necessary for best outcome.

Early Goal-Directed Therapy (EGDT) Supplemental oxygen with or without intubation and mechanical ventilation. Central venous line placement. Fluid resuscitation. Maintenance of blood pressure > 90 mmHg with vasopressors. Administration of broad-spectrum antibiotics.

Summary In past 30 years, medical science has made tremendous progress in diagnosing and treating infectious diseases. New vaccines and antibiotics are continually being developed.

Summary Advances in laboratory technology, notably polymerase chain reaction (PCR), have made detection and identification of microorganisms easier, quicker, more accurate. Despite advances, many infectious diseases cannot be effectively treated.

Summary Specific treatments for most viral diseases remain elusive.
Each year countless people die from AIDS, hepatitis, pneumonia, sexually transmitted diseases, other infectious diseases.

Summary EMS can have significant impact on incidence of infectious disease if: Providers remain knowledgeable. Are leaders in public education. Are consistently alert in protecting themselves and their patients.

Summary Title of the International Association of Fire Fighters (IAFF) hepatitis B curriculum, The Silent War, provides metaphor for dilemma of infectious diseases in EMS.

Summary EMS personnel deal with few infectious disease emergencies; when we do respond to such emergencies, we often are unaware of disease's presence until after call. Constant vigilance and personal accountability are the keys to reducing risks.

10 Infectious Diseases and Sepsis.

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10 Infectious Diseases and Sepsis.

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