Sources: Pat Futterer, JFD; CDC; Mosby’s Paramedic Textbook 3 rd Ed

1. Infectious Diseases and Blood-Borne Pathogens Silver Cross EMS system CME2nd Trimester, June 2012 Sources: Pat Futterer, JFD; CDC; Mosby’s Paramedic Textbook 3rd Ed

2. Our Agenda Today • Discuss infectious diseases and their impact on EMS providers • History • The Laws • Types/Transmission/Treatment • Nosocomial infections (MRSA, C-Diff, etc) • The new Silver Cross EMS exposure reporting form • Strip O’ the Month – Atrial Fibrillation

3. INTRODUCTION • 1992 - Federal Occupational Health and Safety Administration (OSHA) regulation 29 CFR 1910.1030: • Requires employers to create exposure plan for at-risk workers • Requires free Hep B vaccines for at-risk workers • Requires free post-exposure follow-up for employees • Requires training on infectious disease risk and control. • Illinois not an OSHA state, but IDOL adopted and followed OSHA regs

4. WHO IS PROTECTED UNDER THE LAW? • Physicians • Medical staff (nurses, employees of clinical offices) • Firefighters, Paramedics • Police Officers • Home Health Care Workers

5. Ryan White Comprehensive AIDS Resources Emergency (CARE) Act • Requires notification of emergency responders if exposed to infectious disease. • Requires employers name a designated officer (DO) to communicate with hospital in case of exposure. • Extended in 2009 by congress.

6. CDC Classifications • The Centers for Disease Control classifies infectious disease into two types: • Airborne • Blood-borne. • Primary blood-borne are hep B, hep C and HIV. • Primary airborne is tuberculosis.

7. Transmission of Diseases • Direct Contact • Spread by the direct contact with infected blood or bodily fluids from one person to another. • Indirect Contact • Spread from one person to an object, and then to another person (doorknob, tissue, etc)

8. Risk for transmission depends on…. • Organism (type) • Dose of Organism (how large of dose/exposure) • Virulence (strength of the organism) • Host Resistance (how healthy are you)

9. Virulence • Organisms such as HIV and TB die quickly when exposed to light and air. • The hep-B virus however can survive up to 7 days in dried blood.

10. Body’s natural defenses • Skin is the first line of defense • Conjunctiva- cilia, moist mucous membranes, cough mechanism • GI Tract- acid of gastric juices, bile secretions • Immune System – resistance to the infection or disease.

11. Hep-B Virus • Hepatitis B virus (HBV) • 6 months before s/s appear • Flu-like symptoms • Fatigue, abdominal pain, nausea, vomiting • Late stage – Jaundice (yellowing)

12. Hep-B virus • Liver Infection • Severe, even fatal • Medications available to treat • Not effective with everyone • Prevention IMPORTANT • Hep B vaccine available • Safe – no evidence causes illness

13. Hep-B vaccine • Hep B vaccine • Must be made available to all employees who have occupational exposure. • Within 10 days of initial assignment • A three-shot series given over several months • Employees can refuse • Signed refusal • Can change mind any time

14. Hep-C virus • Also a liver disease • Caused by hepatitis C virus (HCV) • MOST common, chronic blood-borne infection in the US • Fatigue, abdominal pain, nausea, loss of appetite, late stage – jaundice

15. No vaccine for hep-C. • Can be years or decades before symptoms appear • Leading cause of liver transplants • Leading cause of cirrhosis of the liver in non-alcoholic patients. • Hepatitis C considered more serious than Hepatitis B

16. Tuberculosis • TB spread by droplets in the air, expelled by infected individual. • Most people infected with TB have no symptoms. • Only a 10% chance that latent infection will ever become full TB.

17. Groups at risk for exposure to TB • HIV-infected people • Nursing home residents and care workers • Immigrants • People in prisons, including employees

18. Risk is dependent on: • Amount of time spent with infected individual • Ventilation present at the time of exposure • Prevention measures used by the individual • Previous vaccination for TB (not available in US)

19. TB testing • Two-step testing required for anyone who has not been tested in the past twelve months • Health-care workers can not read their own test results.

20. Symptoms of TB • Weight loss • Night sweats • Swollen lymph glands • Cough, productive or nonproductive, that persists for more than a few weeks.

21. HIV • Human Immunodeficiency Virus • A virus that attacks the immune system and destroys its ability to fight off infection. • Later stages progress to what is termed AIDS (Acquired Immune Deficiency Syndrome)

22. Transmission of HIV • Primary ways to transmit HIV • Sexual contact • Male to Male • Male to Female • Few cases of Female to Male • Sharing IV drug needles and syringes • Mother to infant via breast milk or in utero • Infected blood transfusions

23. Risk for healthcare workers • The risk is higher if: • Stuck by needle with visible blood on the device or that has been in the patients vein or artery • Patient has HIV with high viral load • Large gauge hollow-bore needle

24. Signs and symptoms of HIV infection • Initially: • Fever • General malaise • Flu-like symptoms • Swollen Lymph glands (neck, groin, under arms) • Later: • Continued fatigue • Chronic diarrhea • Fever with night sweats • Opportunistic infections

25. Progression into AIDS-opportunistic infections • Pneumocystis Carinii Pneumonia- caused by a fungus • Kaposi’s Sarcoma- skin malignancy • CMV Infection - herpes virus that usually affects eyes. • Dementia- CNS complication of HIV infection

26. Infectious Disease • Tetanus • CNS disease caused by infection of a wound with spores of the bacterium • Bacteria is clostridium tetani • Symptom: trismus (lockjaw), which makes it difficult to open mouth, painful contractions

27. Infectious Disease • Tetanus • Incubation period: 3-21 days • Transmission: not directly transmitted • Burns, wounds introducing infected soil, street dust and animal/human feces • Recovery does not ensure immunity • Tetanus immune globulin administered for passive immunity post-exposure

28. Infectious Disease • Tetanus • Immunization • Generally begun early childhood • Booster before entry into elementary school • Booster every ten years thereafter • Usually administered as DPT, TDaP or DTaP • Includes diphtheria and pertussis

29. Infectious Disease • Rubella • Invades the lymph system, then into blood • Produces an immune response causing a rash which spreads from forehead to torso and extremities. • Rash lasts 3 days

30. Infectious Disease • Rubella • Communicable 5-7 days after rash • Immunization for pregnant women not recommended, may cause developmental defects

31. Infectious Disease • Rubella • Management • BSI, masks • Handwashing • Screening for immunity • Immunized during first trimester are at risk for abnormal fetal development • No specific treatment

32. Infectious Disease • Rubeola • Measles virus • Fever, conjunctivitis, cough • Bronchitis, blotchy red rash • Found in blood, urine and pharyngeal secretions

33. Infectious Disease • Rubeola • Koplik’s spots – white spots on inside cheek two days before rash • Lasts about 6 days • Can cause respiratory infections • Immunity is lifelong

34. Measles Koplik’s Spots

35. Infectious Disease • Chickenpox • Varicella-zoster virus • Transmitted direct/indirect contact with airborne droplets • Sudden onset of low-grade fever, mild malaise, skin eruption • Skin eruption last 3-4 days leaving scab

36. Infectious Disease • Chickenpox • Crops of vesicles appear in different stages • Differs from smallpox in that vesicles appear the same at the same time • May develop secondary bacterial infection, mononucleosis and Reye syndrome

37. Infectious Disease • Chickenpox • After recovery, virus is latent in dorsal root ganglia • May reactivate during stress or immunosuppression • Antiviral drugs may shorten duration • Vaccine available

38. Infectious Disease • Chickenpox

39. Chicken Pox Pneumonia

40. Infectious Disease • Pertussis (whooping cough) • Direct contact by discharges from mucous membranes in airborne droplets • Affects young children’s oropharynx • Inflammation of entire respiratory tract • Cough lasts 1-2 months • Cough has high-pitched inspiratory “whoop” • Greatest communicability is before onset of cough

41. Infectious Disease • Pertussis • Infection generally results in immunity • Incubation period 6-20 days • Immunization given with DTP • Immunization does not last a life-time, in recent years a booster is recommended. • Erythromycin decreases period of communicability, but only reduces symptoms if given in incubation period before cough

42. Infectious Disease • Influenza • Respiratory infection by influenza viruses A,B or C (and various sub-varieties with names like Swine, Bird, etc) • Known as the “flu” • Spread by droplets coughed/sneezed into air • Incubation period-1-3 days

43. Infectious Disease • Influenza • Signs and symptoms • Chills, fever, headache, muscular aches, loss of appetite and fatigue • Upper respiratory infection and cough • Lasts 2-7 days • Pneumonia may develop in elderly

44. Infectious Disease • Influenza • Vaccines may prevent infection, but they don’t always work against the right strain • Vaccines must be repeated each year • Vaccines must be given before “flu” season (November - March in US) • Healthcare workers should be immunized

45. Infectious Disease • Mononucleosis • Epstein-Barr virus (EBV) • Transmitted person to person via oral route • “kissing” disease • Fever, soar throat, splenomegaly with abdominal pain

46. Infectious Disease • Mononucleosis • May develop rash in mouth • Few weeks for recovery • Months to regain former level of energy • Pharyngeal excretion may persist for years

47. Antibiotic resistant infections • Also called Nosocomial infections • CDC defined – bacteria, other microorganisms, have developed resistance to antimicrobial drugs. • MRSA - methicillin/oxacillin-resistant Staphylococcus aureus. Often seen in wounds and bedsores. • VRE - vancomycin-resistant enterococci. Lives in digestive and urinary tract. • C-Diff – caused by recent antibiotic use, results in diarrhea • PRSP - penicillin-resistant Streptococcus pneumoniae

48. Where are these germs hiding? • MRSA /VRE most common multidrug-resistant organisms in patients residing in nursing homes and other long-term care facilities. • PRSP more common in patients in outpatient settings such as physicians' offices and clinics, especially in pediatric settings.

49. Danger to prehospital providers • Sometimes nursing home staff will forget to mention that patient has drug-resistant infection. • Prehospital providers only find out after reading paperwork, or when the ER staff tells them. • Most healthcare workers already colonized with MRSA or other drug-resistant bugs. • If you stay healthy and clean, and treat cuts and skin openings promptly, MRSA will have nowhere to go.

50. PPE