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© 2013 Seattle / King County EMS
BLS 2014: Infectious Disease
© 2013 Seattle / King County EMS
Given the worldwide concern about infectious diseases—as an EMS provider and a citizen—you are responsible to help recognize
infectious disease, treat your patients properly, and keep yourself safe.
Infectious disease has many potentially sources Bloodborne pathogens Airborne pathogens Bio-terrorism
Introduction
© 2013 Seattle / King County EMS
Objectives
1. Identify the types of PPE and how and when they should be applied.
2. Identify the characteristic infectious diseases that are a threat to EMS providers (HIV, HepC, HBV).
3. Identify appropriate measures for protecting yourself against infectious diseases.
4. Identify the appropriate actions to take for exposure to an infectious disease.
© 2013 Seattle / King County EMS
Terms Antibodies — Proteins made by the immune system that have a memory for an invading virus and help recognize and destroy future invasions by that virus.
Antibiotic — Medicine or drug that is effective in killing bacteria or inhibiting their growth.
Bacteria — A single-celled, microscopic organism that can cause damage to the body's cells. They multiply very quickly by dividing.
© 2013 Seattle / King County EMS
Terms, continued Epidemic — An outbreak of a contagious
disease that spreads among many individuals in an area or a population at the same time.
Pandemic — An outbreak of a contagious disease that affects an entire population over a wide geographical area. A pandemic affects a far higher number of people and a much larger region than an epidemic.
Parasite — An organism that grows, feeds, and is sheltered on or in a different organism while contributing nothing to the survival of its host.
© 2013 Seattle / King County EMS
Terms, continued Pathogen — An agent that causes disease such as a bacterium, virus or fungus.
Vaccine — A preparation of a weakened or disabled virus that stimulates antibody production and provides immunity when injected into the body.
Virus — A very small agent made of genetic information (RNA or DNA) surrounded by a protein coat. It cannot reproduce on its own but must take over a living cell to multiply.
© 2013 Seattle / King County EMS
Terms, continued Body Substance Isolation (BSI) — An infection
control practice that assumes all body substances including blood, urine, saliva, feces, tears, etc., are potentially infectious.
MRSA — Methicillin-resistant Staphylococcus Aureus (MRSA) are a type of staphylococcus or "staph" bacteria that are resistant to many antibiotics.
Personal Protective Equipment (PPE) - Specialized clothing or equipment worn for protection against health and safety hazards.
Universal Precautions - Universal precautions should be should be observed on every incident. Universal precautions include personal protective equipment (PPE) and body substance isolation (BSI).
© 2013 Seattle / King County EMS
Infectious Diseases
© 2013 Seattle / King County EMS
MRSA
Methicillin-resistant Staphylococcus Aureus Type of staph bacteria
resistant to common antibiotics
Traditionally associated with hospitals but now is epidemic of community-acquired MRSA
Multiplies rapidly causing many types of infection ranging from skin infections to septicemia and toxic shock syndrome
Cutaneous abscess caused by MRSA
© 2013 Seattle / King County EMS
MRSA, continued Transmission
Found commonly on human skin, in nose & throat and, less commonly, in colon & in urine
Can infect other tissues when skin or mucosal lining have been breached
Occupational Exposure Can be spread through contact with pus
from infected wound, skin-to-skin contact with infected person, & contact with objects such as towels, sheets, or clothing used by infected person.
© 2013 Seattle / King County EMS
MRSA, continued
Pre-hospital Presentation Staph infections, including MRSA,
generally start as small red bumps that resemble pimples, boils, or spider bites
Can quickly turn into deep, painful abscesses
Rarely, may also burrow deep into body, causing potentially life-threatening infections in bones, joints, surgical wounds, the bloodstream, heart valves, & lungs.
© 2013 Seattle / King County EMS
MRSA, continued
Prevention Best defense against MRSA – wash
hands often, especially after contact with other people Thorough washing with soap & water or alcohol hand
disinfecting gels is effective against MRSA
Wear a gown when caring for patients with a known or suspected MRSA infection of the skin
In some cases MRSA is a respiratory infection Patient has known or suspected MRSA skin infection
& has a cough, or has MRSA respiratory infection, wear fitted mask
Put surgical or procedure mask on the patient if they can tolerate it.
© 2013 Seattle / King County EMS
HIV AIDS caused by Human Immunodeficiency
Virus (HIV) HIV attacks cells of immune system Immune system fails & patient becomes
susceptible to "opportunistic" diseases & infections
Chest x-ray of HIV-infected man with pulmonary Kaposi sarcoma
Kaposi's sarcoma on the skin of an AIDS patient
© 2013 Seattle / King County EMS
HIV, continued
Transmission: Unprotected sex with an infected
partner Sharing of needles by IV drug users Infected mother to her baby Infected blood given during a
transfusion (extremely rare) Occupational transmission usually by
a needle stick of infected blood (also extremely rare)
© 2013 Seattle / King County EMS
HIV, continued
Pre-hospital Presentation: Depends on which opportunistic
disease or infection the person develops: Dehydration & hypotension secondary
to diarrheal diseases Seizures or altered mental status
secondary to nervous system infection Dyspnea secondary to respiratory
infection Medication reactions End of life issues
© 2013 Seattle / King County EMS
HIV, continued
Occupational Risk: The occupational risk of acquiring
AIDS is VERY LOW (less than 2% after a needlestick with infected blood; much lower after exposure to mucus membranes)
Prevention: Prevention should focus on
preventing significant blood exposures (needlesticks).
Post-exposure prophylaxis (PEP) if available if there is a significant exposure.
© 2013 Seattle / King County EMS
Hepatitis C Four million persons infected
with Hepatitis C in United States
Caused by hepatitis C virus (HCV) found in blood of persons who have disease
Spread by contact with blood of infected person
Most common chronic bloodborne viral infection in United States
Can cause cirrhosis of liver & liver cancer.
Cirrhosis of the liver and liver cancer
© 2013 Seattle / King County EMS
Hepatitis C Transmission
Blood & other bodily fluids Sharing needles with infected person Sex with infected person From a woman to her baby during birth
Pre-hospital Presentation Hepatitis C infection generally produces no
signs or symptoms during its early stages; may produce none for years
If encountered, symptoms may include: Fatigue Nausea Vomiting
Poor appetite Muscle & joint pain Low-grade fever
© 2013 Seattle / King County EMS
Hepatitis C
Occupational Risk After needle stick or sharps exposure
to HCV positive blood, about 2 healthcare workers out of 100 become infected with HCV
Approximately 20% of patients with Hepatitis C recover completely following treatment with interferon and ribavirin
Prevention No effective vaccine for hepatitis C Only way to protect yourself – avoid
exposure to infected blood
© 2013 Seattle / King County EMS
Hepatitis B Caused by hepatitis B virus (HBV), which
damages liver Vaccination against HBV has been available
since 1982 Spread by contact with blood of person
infected with the disease or by sexual transmission
Hepatitis B Virus
© 2013 Seattle / King County EMS
Hepatitis B, continued
Transmission: Sex with infected person Blood & other bodily fluids Sharing needles with infected person From a woman to her baby during
birth
© 2013 Seattle / King County EMS
Hepatitis B, continued Pre-hospital Presentation:
Most signs & symptoms of Hep B mild Unlikely you will be called to respond
to acute illness caused by this virus However you may on occasion see a
patient with end stage liver cancer or other complications from the disease
© 2013 Seattle / King County EMS
Hepatitis B, continued
Occupational Risk: Occupational risk for acquiring HBV
from unvaccinated person is significant. The risk for a vaccinated person is VERY LOW.
Prevention: Best way to prevent occupational
exposure to HBV, in addition to taking care to protect yourself from blood exposure, is to be vaccinated against the disease
© 2013 Seattle / King County EMS
Tuberculosis (TB)
Caused by small bacteria that travels from small airways to cells of lungs
Less than 10% of people infected with TB develop active disease
In the others, bacteria hides, causing no disease until host (patient) becomes immuno-compromised or otherwise debilitated
© 2013 Seattle / King County EMS
Tuberculosis, continued
Transmission: Via small airborne particles expelled
by cough, sneezing, or speaking Particles are inhaled into small
airways Prolonged exposure in confined space
confers highest risk
© 2013 Seattle / King County EMS
Tuberculosis, continued
Pre-hospital Presentation: Cough, often productive of blood-
tinged sputum Fatigue & weakness Night sweats Low-grade fever Loss of appetite & weight loss
© 2013 Seattle / King County EMS
Tuberculosis, continued
Occupational Risk: Occupational risk low but difficult to
quantify Prevention:
Maintain high index of suspicion among patients who are at risk of having TB
Take precautions if patients present with suspicious signs & symptoms
© 2013 Seattle / King County EMS
Influenza (flu) Caused by the influenza virus which attacks the respiratory system. Occurs seasonally from November to April in the northern hemisphere. The structure of the virus changes slightly but frequently over time; this accounts for the appearance of different strains each year.
© 2013 Seattle / King County EMS
Influenza (flu), continued
Transmission: Coughed droplets Touching contaminated surfaces (less
common)
© 2013 Seattle / King County EMS
Influenza (flu), continued
Pre-hospital Presentation Sudden onset of:
High fever Malaise Headache Dry cough Body aches
© 2013 Seattle / King County EMS
Influenza (flu), continuedOccupational Risk: Varies depending on the strain.
Prevention: Hand washing, clean surfaces Place mask on patient or ask
patient to cover mouth when coughing
Best prevention is the flu vaccine, which must be taken yearly
Best flu prevention is the
flu vaccine
© 2013 Seattle / King County EMS
Pandemic Flu Outbreak of contagious disease that affects
entire population over a wide geographical area
Caused by influenza virus to which humans have little or no natural resistance
Such an outbreak has potential to cause many deaths & illnesses
Past pandemic flu viruses known for virulence causing rapid death, especially in young people
It is difficult to accurately predict which strain of influenza may give rise to next pandemic
© 2013 Seattle / King County EMS
Pandemic vs. Seasonal Pandemic outbreaks different from
seasonal outbreaks of influenza Seasonal outbreaks caused by subtypes of
influenza viruses that already circulate among humans
Pandemic outbreaks caused by new subtypes Subtypes never circulated
among people or subtypes not circulated among people for a long time
Microbiologist examining reconstructed 1918 Pandemic Influenza Virus
© 2013 Seattle / King County EMS
Norovirus Highly contagious virus responsible for outbreaks of gastrointestinal disease on cruise ships, nursing homes, etc. Norovirus is the general name given to viruses of this type. Responsible for many cases of severe but short-lived illnesses causing vomiting, diarrhea, and stomach cramps. "Stomach flu" and "food poisoning" are typical infections of a Norovirus.
© 2013 Seattle / King County EMS
Norovirus, continued
Transmission Occurs via fecal-oral route
For example, food handler does not wash his hands after using bathroom; a person then ingests food that has been contaminated with small amounts of fecal matter
© 2013 Seattle / King County EMS
Norovirus, continued
Pre-hospital Presentation Nausea, vomiting & diarrhea Stomach cramps Low-grade, transient fever General feeling of malaise, headache,
body aches
Symptoms begin suddenly, may last one to three days, and usually resolve on their own.
Because the disease is caused by a virus, antibiotics are useless.
© 2013 Seattle / King County EMS
Norovirus, continued
Occupational Risk: Community-acquired, usually
situations where large numbers share same food or living space (cruise ships, college dorms)
Several outbreaks of noroviruses among staff at hospitals & nursing homes
© 2013 Seattle / King County EMS
Norovirus, continued
Prevention: Wear gloves Wash your hands thoroughly Consider use of protective eyewear &
mask Surfaces contacted by the patient
must be thoroughly disinfected
If you become sick, wait two days after the last of your symptoms before returning to
work.
© 2013 Seattle / King County EMS
Personal Safety and PPE
© 2013 Seattle / King County EMS
Personal Protective Equipment Consider possible infectious
disease for every patient that you see.
Avoid infection from fluids and airborne particles by using PPE
Wash your hands frequently Decontaminate equipment and
surfaces after use.
© 2013 Seattle / King County EMS
Types of PPE
Fit-tested masks (such as N95 and N100 masks)
Eye protection (such as glasses, face shields and goggles)
Gowns (or suits) Gloves
© 2013 Seattle / King County EMS
Donning PPE
Put on PPE before entering the patient area. Base the PPE you use on your assessment of risk.
The sequence for donning PPE is MEGG:
MaskEye protectionGownGloves
© 2013 Seattle / King County EMS
Doffing PPE Remove PPE once call is complete or
crew has left patient area Be careful not to contaminate yourself
taking it off To remove PPE, reverse the order that
you put it on:
GlovesGown—hand washing min 20 sec.Eye protectionMask—hand washing min 20 sec.
© 2013 Seattle / King County EMS
Hand Washing is Vital
Single most effective way to prevent spread of disease
Soap & water for at least 20 seconds or with waterless alcohol
After all patient contact, even if you wore gloves
© 2013 Seattle / King County EMS
Equipment DecontaminationAfter completing a response to an infectious patient, must decontaminate everything touched including:
All equipment that was exposed or cross-contaminated
Outside of kits Stethoscopes Radios AEDs, etc.
Wear new gloves while decontaminating equipment.
Wear clean eye protection and mask if there is splash risk or vapors.
© 2013 Seattle / King County EMS
Masks
Don a fit-tested mask before entering the scene.
Place a mask on the patient, if tolerated.
Fitted masks provide the highest level of protection.
Remove and dispose of the mask without self contamination.
© 2013 Seattle / King County EMS
Eye Protection Wear eye protection on all calls. You
must prepare for unanticipated splashes such as: Vomiting Blood flicked from bloody hand Violent spit Glucometer strips Splashing fluids Respiratory infection Violent cough or sneeze
© 2013 Seattle / King County EMS
Gloves Wear medical gloves on all calls Most bodily fluids, such as vomit or
urine, do not typically carry blood borne viruses
While working in rescue or extrication environment where risk of both cut & body substance exposure present, wear latex or nitrile inner gloves & other protective outer gloves
Glove Up!
© 2013 Seattle / King County EMS
Limits of Gloves
Gloves are for use during patient contact.
Wash your hands after all patient contact, even if you wore gloves.
Gloves will not protect you from sharp objects such as needles.
© 2013 Seattle / King County EMS
Sharps
Needlesticks represent greatest risk of occupational blood borne transmission
Many "exposures" involve cases where EMS providers inadvertently stuck themselves with used needles!
Keep eye on paramedics & needles Watch where you put your hands
© 2013 Seattle / King County EMS
Needlestick
For needlestick exposures: Wash area well with soap & water Do NOT use bleach or other harsh
chemicals These may damage the skin, making it
more likely for the virus to enter the body Report exposure immediately to your
officer for testing and possible post-exposure prophylaxis
© 2013 Seattle / King County EMS
Skin/Mucus
For exposures to non-intact skin: Wash with soap and water. Report the exposure immediately to
your officer for testing and possible post-exposure prophylaxis.
Blood on intact skin is not considered a significant exposure. Non-intact skin
includes abrasions and cuts.
Blood on intact skin is not considered a significant exposure. Non-intact skin
includes abrasions and cuts.
© 2013 Seattle / King County EMS
Skin/Mucus, continued
For exposures to mucus membranes (eyes, mouth): Flush liberally with water Report exposure immediately to your
officer for testing & possible post-exposure prophylaxis
© 2013 Seattle / King County EMS
Airborne Report possible exposure to your
company officer The hospital may notify exposed
responders if patient is diagnosed with airborne disease (e.g., TB or bacterial meningitis)
Some diseases may require automatic & immediate post-exposure prophylaxis
Others may require post-exposure testing & then treatment only if you become positive
© 2013 Seattle / King County EMS
PEP for HIV
Any possible exposure to a blood borne disease must be reported immediately to your company officer
Post-exposure prophylaxis reduces the already very low risk of acquiring the disease
Medications taken for PEP are TOXIC
If patient is determined to be HIV-negative, PEP medications can be stopped
© 2013 Seattle / King County EMS
Summary
© 2013 Seattle / King County EMS
Summary
Hand washing is the most effective method of preventing infectious disease
Clean visible contamination first, then disinfect surface
Wear gloves when disinfecting equipment
Occupational risk of acquiring AIDS is VERY LOW
© 2013 Seattle / King County EMS
Summary, continued Best way to prevent occupational exposure to HBV, in addition to taking care to protect yourself from blood exposure, is to be vaccinated Remove gloves when you are done with patient contact, before getting into your rig, talking on the radio, or driving
© 2013 Seattle / King County EMS
Summary, continued If you suspect TB, put a mask on patient (if tolerated), & wear a mask yourself Needlesticks represent the greatest risk of occupational blood borne transmission If PEP is to be started, it should be started IMMEDIATELY after exposure, if at all possible within two hours
© 2013 Seattle / King County EMS
Resources
The recertification exam for this module is based on a variety of resources. We recommend that you review the following:
Chapter 2 – Wellbeing of the EMT in Emergency Care and Transportation of the Sick and Injured, 9th edition (AAOS).
© 2013 Seattle / King County EMS
Questions
Dr. Mickey EisenbergMedical DirectorAsk the Doc: http://www.emsonline.net/doc.asp
EMS OnlineGuidelines and Standing Ordershttp://www.emsonline.net/downloads.asp
Susan KolwitzProgram ManagerEmail support: [email protected]