Infectious Disease info for Telecommunicators

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The Role of the Call Handler in the Face of Ebola and Other Emerging and Deadly Infectious Diseases

G. Moore, Dr.PH. and H. Pierce

Introduction The recent Ebola epidemic in West Africa and the isolated cases within the United States are a reminder of the concern for responder safety. There is an expectation that every first responder should regularly practice the standard or “universal” precautions before having patient contact. However, particularly concerning the Ebola Virus, the CDC has recommended that PSAPs take responsibility for screening callers for risk factors and notify responders of such before arrival on scene. This recommendation poses the question of whether further efforts should be made to mitigate the risk of exposure to new or emerging infectious diseases.

The World Health Organization defines an infectious disease as an illness caused by microorganisms, such as bacteria, viruses, parasites, or fungi. The disease can be directly or indirectly spread from one person to another. Exposure may also occur from animal to human. The term "emerging infectious diseases" refers to diseases of infectious origin whose incidence in humans has either increased within the past two decades or threatens to increase in the near future. Diseases such as Ebola, pandemic Flu, and Tuberculosis fit this classification.

The normal role of a call taker is to perform a high level risk assessment, initiate a response, and provide instruction to ensure scene safety. Scripted protocols provide the structure for the early detection of risk factors and guide the immediate intervention. This method of call processing has proven to significantly enhance response and has increased the measures for the preservation of life and public safety. However, previously the focus of call handling has been on the recognition of priority symptoms or factors that pose an immediate risk. Screening for the risk factors associated with the exposure to infectious diseases slightly shifts this focus.

Certainly PSAPs will want to take the necessary steps to further mitigate risk and enhance the safety of responders and the public; however, the proposal of screening for potential exposure to infectious disease warrants additional consideration. This isn’t a step to be taken in reaction to one particular virus. The scope needs to be broader to include infectious diseases with potential deadly consequences such as multi-‐drug resistant tuberculosis, pandemic flu, Ebola, and other hemorrhagic fevers. Time is a precious commodity in call processing. Seconds do count and need to be used wisely. Screening every caller for infectious disease may not be the most efficient use of resources as not every call poses the same level of risk to responders. Agencies need to have the tools in place to respond when conditions indicate that the level of risk is elevated. Call takers need to be trained to recognize the symptoms and conditions that warrant further assessment.


Emergency medical services (EMS) personnel, along with other emergency services staff, have a necessary and important role in responding to requests for help, triaging patients, and providing emergency treatment to patients. Unlike patient care in the controlled environment of a hospital or other fixed medical facility, EMS patient care before getting to a hospital is provided in an environment without such controls. The EMS environment is often limited to a very small physical space (i.e. within an ambulance) and time window, and usually requires quick medical decision-‐making and interventions with limited information. EMS personnel are often unable to determine the patient history before having to administer emergency care. Therefore, this information must come from the 911 Public Safety Answering Points (PSAPs), which should be coordinating with healthcare facilities, and the public health system when responding to patients with suspected infectious diseases that pose a high potential for mortality.

What are the triggering point(s) for asking secondary or additional questions for disease-‐related conditions that may pose a risk to responding personnel? Ebola, Pandemic Influenza, Tuberculosis, and possibly others are reportable diseases that should be tracked by local and state health departments. Should these diseases manifest themselves in your area, you should be prepared to provide additional screening questions. You should establish a liaison with your local and state health department to receive notices of such diseases that may be appearing in your vicinity.

Contact information for your State Health Department is available at the following link: http://www.cdc.gov/mmwr/international/relres.html.

When the risk of Tuberculosis, Pandemic Flu, and Ebola are elevated in your community based on information from your local or state health department, it is important for PSAPs to question callers about:

• Residence in, or travel to, a country, state, or location where an outbreak is occurring • Signs and symptoms of these diseases (such as fever, coughing, vomiting, diarrhea, unexplained

bleeding) • Other risk factors, like having touched someone or being in close contact with someone with the

disease

PSAPs should tell EMS personnel this information before they get to the location so they can put on the correct personal protective equipment (PPE) (described below). EMS staff should check for symptoms and risk factors for Pandemic Flu, Ebola, or Tuberculosis. Staff should notify the receiving healthcare facility in advance when they are bringing a patient with one of these suspected diseases so that proper infection control precautions can be taken. The caller should be instructed to have as few people as possible come in close contact with the patient because of the infectious environment.

Each 911 and EMS system should include an EMS medical director to provide appropriate medical supervision.

Reasons for the Emergence of Infectious Disease There are a number of specific explanations responsible for disease emergence that can be identified in most cases. Factors responsible for the emergence of infectious diseases may include:


Ecological changes. This occurs when people may expand into an area where the animal host thrives, as thought to be the case for the fruit bat and other animals carrying the Ebola virus.

Human demographic changes. Increased population density in urban areas, along with migration to cities in hopes of a better, more comfortable lifestyle, has surpassed basic services, including clean water supplies, sanitary conditions such as sewage disposal, and adequate housing. This has increased the risk of diseases spreading among such populations.

Travel and commerce. Increased economic growth into national and international boundaries has led to increased travel, contributing to the notion of "diseases without boundaries.” This is clearly the case for recent Ebola cases arriving in the United States. Pandemic flu outbreaks are another example.

Microbial adaptation and change (resistance). There is growing concern that bacterial pathogens such as tuberculosis are developing a resistance to antibiotics as a result of patients not completing the prescribed course of treatment or the inappropriate and over-‐prescribing of common antibiotics by physicians. Multi-‐drug resistant TB is only one example of this problem.

Breakdown of public health measures. The funding of public health programs has been reduced globally and within this country because of increased competition in the global market and increased pressures to cut expenditures.

Specific Emerging Diseases

Viruses

Pandemic Influenza • Background As the nation cringes in fear from the possible horror of Ebola, it is easy to overlook an

old familiar foe: the flu. Ebola has claimed fewer than 4,000 lives globally to date, one in the United States. Flu claims between 250,000 and 500,000 lives every year, including over 20,000 in the United States—far more American lives than Ebola will ever claim.

• The Disease Influenza is normally characterized by a fever (100°F to 103°F); respiratory symptoms include cough, sore throat, stuffy nose; muscle aches and pain; and extreme fatigue.

There are about 20,000 deaths annually in the United States with the majority of serious illness and death occurring in the aged, very young, and debilitated.

• Epidemiology To this date there have been more than 30 pandemics of influenza with three occurring within the last 80 years.

The Spanish Flu (1918-‐19) caused an estimated 500,000 deaths in the United States and 20 million deaths worldwide.


Ebola: Killer Virus

An outbreak of the deadly Ebola virus is spread by close contact and kills between 25 and 90 percent of victims. There is no cure or vaccine.

Preventative measures

• Stop contact with infected animals and the consumption of their meat

• Isolate the sick • Prompt disposal of victims’ bodies • Disinfect homes of dead and

infected • Protective clothing for healthcare

workers

Source: Daily Mirror UK

Ebola • Background Ebola and Marburg viruses belong to a family of viruses called Filoviridae. Their

extreme pathogenicity combined with the lack of effective vaccines or antiviral drugs classify them as biosafety level four agents.

• The Disease Ebola fever typically starts suddenly 4 to 16 days after infection with malaise, fever and flu-‐like symptoms which can be followed by rashes, bleeding and kidney and liver failure.

Generalized bleeding occurs with massive internal hemorrhaging of the internal organs, with bleeding into the gastrointestinal tract, from the skin, and even from injection sites as the clotting ability of the blood is diminished.

The death of the patient usually occurs from shock within 7 to 16 days and is accompanied by extreme blood loss.

• Epidemiology Infections from Ebola virus were first reported in 1976 when two outbreaks occurred at the same time but in different locations and with different subtypes of the Ebola virus. There is currently a significant epidemic in Western Africa with more than 3500 dead. Cases are now reported to have arrived in the US.

Bacteria

Tuberculosis • Background Tuberculosis (TB) is a chronic

infectious disease of the lower respiratory tract caused by Mycobacterium tuberculosis. Tuberculosis (TB) is an infectious disease that most often infects the lungs, but can attack almost any part of the body. Tuberculosis is usually spread from person to person through the air and by a person with TB that coughs, laughs, sneezes, sings, or even talks. If another person breathes in these bacteria, there is a chance that they will become infected with tuberculosis. It is not easy to become infected with tuberculosis. A person has to be close to someone with TB disease for a period of time. TB is usually spread between family members, close friends, and people who work or live together. TB is spread most easily in closed spaces over a long period of time.


TB can be fatal if it is not treated. TB can almost always be treated and cured if you take medicine as directed by your healthcare provider. TB has emerged that is resistant to many forms of treatment and this increases the risk of the disease substantially. Drug-‐resistant TB is difficult and costly to treat and can be fatal.

Once you begin successful treatment, you will no longer be contagious within a few weeks but must remain in the medication for the length of time prescribed to prevent return of the infection.

• The Disease Symptoms of TB disease depends on where in the body the TB bacteria are growing. TB disease symptoms may include a bad cough that lasts 3 weeks or longer; pain in the chest; coughing up blood or sputum (phlegm from deep inside the lungs); weakness or fatigue; weight loss; no appetite; chills; and fever.

• Epidemiology Tuberculosis kills over 3 million people worldwide each year, and many more become ill from it.

Tuberculosis was declared a U.S. public health emergency in 1992. Today, a total of 9,582 TB cases (a rate of 3.0 cases per 100,000 persons) were reported in the United States in 2013. Both the number of TB cases reported and the case rate decreased; this represents a 3.6% and 4.3% decline, respectively, compared to 2012.

The most recent surveillance report, Reported Tuberculosis in the United States, 2013, has TB data from the 60 reporting areas. If you need additional state-‐specific data not available in this report, you can contact your state TB control office: http://www.cdc.gov/tb/links/tboffices.htm.

In 2013, a total of 65% of reported TB cases in the United States occurred among foreign-‐born persons. The case rate among foreign-‐born persons (15.6 cases per 100,000 persons) in 2013 was 13 times higher than among U.S.-‐born persons (1.2 cases per 100,000). This is again a reason to question the origin of persons with a suspected infectious disease.

Standard Precautions and Transmission-‐Based Precautions

Standard precautions are a set of basic infection prevention practices intended to prevent transmission of infectious diseases from one person to another. Because we do not always know if a person has an infectious disease, standard precautions need to be applied every time there is a person with a suspected deadly transmissible disease to assure that transmission of disease to responders does not occur. These precautions were formerly known as “universal precautions.”


Universal Precautions

• Use Barrier Protection to prevent skin and mucous membrane contact with blood or other body fluids.

• Wear gloves to prevent

contact with blood, infectious materials, or other potentially contaminated surfaces or items.

• Wear face protection if blood

or bodily fluid droplets may be generated during a procedure.

• Wear protective clothing if

blood or bodily fluid may be splashed during a procedure.

• Wash hands and skin

immediately and thoroughly if contaminated with blood or bodily fluids.

• Wash hands immediately after

gloves are removed. • Use care when using or

handling sharp instruments and needles. Place used sharps in labeled, puncture-‐resistant containers.

• If you have sustained an

exposure or puncture wound, immediately flush the exposed area and notify your supervisor.

Source: Compliance Signs

Source:

Although call handlers are typically removed from the scene and are not personally at risk of exposure, it is important to be knowledgeable of how infectious diseases can be transmitted and what actions should be taken to prevent exposure.

Personal protective equipment. There are certain types of clothing or equipment that a person wears to protect his/her body from injury and infection.

• Face mask/face shield/eye protection (goggles) may be worn if contact with blood or body fluids may occur. This is true for Flu, Ebola, and TB.

• Gloves may be worn if contact with blood, body fluids, mucous membranes, non-‐intact skin, or contaminated items in the patient/resident’s environment may occur.

Transmission-‐based precautions. There are three types of transmission-‐based precautions: contact precautions (for diseases spread by direct or indirect contact), droplet precautions (for diseases spread by large particles in the air), and airborne precautions (for diseases spread by small particles in the air). Each type of precautions has some unique prevention steps that should be taken, but all have standard precautions as their foundation.

These are used for patients/residents that have an infection that can be spread by contact with the person’s skin, mucous membranes, feces, vomit, urine, wound drainage, or other body fluids, or by contact with equipment or environmental surfaces that may be contaminated by the patient/resident or by his/her secretions and excretions.

• Airborne and droplet precautions. Examples of infections/conditions that require airborne or droplet precautions include chickenpox, measles, tuberculosis, and flu. In addition to standard precautions, wear a mask or respirator prior to room entry, depending on the disease-‐specific recommendations. Most diseases will require N95 or higher respiratory protection.

• Contact precautions. Used for patients/residents that have an infection that can be spread by contact with the person’s skin, mucous membranes, feces, vomit, urine, wound drainage, or other body fluids, or by contact with equipment or environmental surfaces that may be contaminated by the patient/resident or by his/her secretions and excretions.


o Wear a gown and gloves when treating a patient/resident on contact precautions. o Use disposable single-‐use or patient/resident-‐dedicated noncritical care equipment (such as

blood pressure cuffs and stethoscopes). o In addition to the measures above, perform hand hygiene using soap and water and

consider use of a hypochlorite solution (e.g. bleach) for environmental cleaning.

Conclusion Scientists are predicting that the current outbreak of Ebola will not significantly impact the health of the majority of the United States population. The decision to conduct Ebola-‐specific caller screenings should be made by medical authorities when the conditions indicate an elevated risk to responders. Other infectious diseases, such as Tuberculosis, have been present in the United States for several years and continue to pose a risk to the health of responders.

Conducting additional screenings for potential risk factors and symptoms is a proactive method of early detection. Yet the screening of every call is an inefficient use of resources. The recommendation is that PSAP administrators liaise with local medical authorities to regularly monitor conditions within the community they serve. Call takers should be trained to recognize the risk factors and symptoms that may warrant additional assessment as the situation dictates. Procedural updates may also be necessary to facilitate the effective communication of information to responders.

Call takers are the first line of defense in detecting situations that may pose harm to responders and the public. With the proper preparation and support, including training and call processing guides, this defense can be strengthened.

Referenced Material • American Lung Association, http://www.lung.org/lung-‐disease/tuberculosis/symptoms-‐

diagnosis.html. • American Lung Association, http://www.lung.org/lung-‐

disease/tuberculosis/?gclid=CMORz4Cgm8ECFVEQ7AodymQAJw • American Lung Association, http://www.lung.org/lung-‐disease/tuberculosis/factsheets/multidrug-‐

resistant.html • American Lung Association, http://www.lung.org/lung-‐disease/tuberculosis/symptoms-‐

diagnosis.html • CDC and Prevention, http://www.cdc.gov/tb/publications/factsheets/statistics/TBTrends.htm • “Ebola Is Bad. But the Flu Is Worse.” Politico. October 07, 2014.

http://www.politico.com/magazine/story/2014/10/ebola-‐is-‐bad-‐but-‐the-‐flu-‐is-‐worse-‐111662.html#.VDfzUhawU04

• Standard Precautions and Transmission-‐Based Precautions, Virginia Department of health, 2014, http://www.vdh.virginia.gov/epidemiology/surveillance/hai/StandardPrecautions.htm

• American Lung Association, http://www.lung.org/lung-‐disease/tuberculosis/symptoms-‐diagnosis.html


• Interim Guidance for Emergency Medical Services (EMS) Systems and 9-‐1-‐1 Public Safety Answering Points (PSAPs) for Management of Patients with Known or Suspected Ebola Virus Disease in the United States, Oct 1, 2014, http://www.cdc.gov/vhf/ebola/hcp/interim-‐guidance-‐emergency-‐medical-‐services-‐systems-‐911-‐public-‐safety-‐answering-‐points-‐management-‐patients-‐known-‐suspected-‐united-‐states.html

• Voice of America, WHO Expects Liberia's Ebola Caseload Will Surge, September 08, 2014 8:06 PM, http://www.voanews.com/content/obama-‐international-‐response-‐ebola/2442141.html

• Mirror, Ebola outbreak: US Peace Corps volunteers put in isolation following exposure to person who died from virus, July 31, 2014, http://www.mirror.co.uk/news/uk-‐news/ebola-‐outbreak-‐peace-‐corps-‐volunteers-‐3940179#ixzz3FjszprHi

• Blogspot, http://about-‐-‐tuberculosis.blogspot.com/p/symptoms-‐of-‐tuberculosis.html

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Infectious Disease info for Telecommunicators