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Overview of CBT 621Infectious Disease
Complete course available at www.emsonline.net
Copyright 2009 Seattle/King County EMS
Introduction
Given the worldwide concern about infectious Given the worldwide concern about infectious diseases—as an EMS provider and a citizen—you diseases—as an EMS provider and a citizen—you
are responsible to help recognize infectious are responsible to help recognize infectious disease, treat your patients properly, and keep disease, treat your patients properly, and keep
yourself safe.yourself safe.
Given the worldwide concern about infectious Given the worldwide concern about infectious diseases—as an EMS provider and a citizen—you diseases—as an EMS provider and a citizen—you
are responsible to help recognize infectious are responsible to help recognize infectious disease, treat your patients properly, and keep disease, treat your patients properly, and keep
yourself safe.yourself safe.
• Bio-terrorism • Pandemic flu• Respiratory infections• Blood borne pathogens
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New Termsbody substance isolation (BSI) – An infection control practice that assumes all body substances are potentially infectious.
MRSA – Methicillin-resistant Staphylococcus aureus is a type of staphylococcus or "staph" bacteria that is resistant to many antibiotics.
personal protective equipment (PPE) – Specialized clothing or equipment worn for protection against health and safety hazards.
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MRSA
Methicillin-resistant Staphylococcus aureus• Type of staph bacteria resistant to common antibiotics• Associated with hospitals/nursing homes • An increasing epidemic of EMS/ community-acquired MRSA• Multiplies rapidly causing infections ranging from skin infection to septicemia and toxic shock syndrome
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MRSA, continued
• Best defense against MRSA is to wash your hands often, especially after contact with other people• Thorough washing of hands with soap and water or alcohol-based disinfecting gels is effective against MRSA
Electron micrograph of MRSA
Image credit: CDC/ Janice Carr/ Jeff Hageman (public domain)
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Hepatitis C
• Caused by hepatitis C virus found in blood of persons who have this disease
• Spread by contact with blood of infected person
• Most common chronic bloodborne viral infection in the US
• Can cause cirrhosis of the liver and liver cancer
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Hepatitis C, continued
Transmission:• Blood and other bodily fluids • Sharing needles with infected person • Sex with infected person • From woman to her baby during birth
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Hepatitis C, continued
Prehospital presentation:
• Infection generally produces no signs or symptoms during early stages — may be years
• Symptoms may include fatigue, nausea, vomiting, poor appetite, muscle and joint pain, or low-grade fever
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Hepatitis C, continued
Occupational risk:
• After a needlestick or sharps exposure to HCV positive blood, about 2 healthcare workers out of 100 become infected
Prevention:• No effective vaccine for hepatitis C• Only way to protect yourself is to
avoid exposure to infected blood
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Personal Protective Equipment• Treat potentially infectious patient
as a biological hazmat• Avoid infection from fluids and
airborne particles• Decontaminate equipment and
surfaces after use and wash your hands frequently
• Observe PPE measures on every incident
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Types of PPE
• Fit-tested masks (N95 and N100 masks)• Eye protection (glasses, face shields,
goggles)• Gowns (or suits)• Gloves
You must wear full PPE with any patient who You must wear full PPE with any patient who is potentially infectious especially those is potentially infectious especially those
with a history of a fever and cough.with a history of a fever and cough.
You must wear full PPE with any patient who You must wear full PPE with any patient who is potentially infectious especially those is potentially infectious especially those
with a history of a fever and cough.with a history of a fever and cough.
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Donning PPEPut on PPE before entering the patient area Sequence for donning is MEGG:
1. Mask2. Eye protection3. Gown4. Gloves
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Doffing PPE• Remove PPE once call is complete or you have left patient area • Be careful not to contaminate yourself taking it off
To remove PPE, reverse MEGG:
1. Gloves2. Gown — hand washing min 20 sec.3. Eye protection4. Mask — hand washing min 20 sec.
1. Gloves2. Gown — hand washing min 20 sec.3. Eye protection4. Mask — hand washing min 20 sec.
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Hand Washing is Vital• Single most effective way to prevent the spread of disease
• Soap and water for at least 20 seconds or with waterless alcohol-based gel
• After all patient contact, even if you wore gloves
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Equipment Decontamination
After completing a response to an infectious patient, decontaminate everything touched:
• Equipment that was exposed or cross-contaminated• Outside of kits• Stethoscopes• Radios• AEDs, etc.
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HIV
• AIDS is caused by the Human Immunodeficiency Virus (HIV)
• HIV attacks the cells of the immune system
• Immune system fails and patient becomes susceptible to opportunistic diseases and infections
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HIV, continued
Transmission:
• Unprotected sex with an infected partner • Infected blood given during a transfusion (extremely rare) • Sharing of needles by IV drug users • An infected mother to her baby • Occupational transmission usually by a needlestick of infected blood
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HIV, continued
Prehospital presentation:• Dehydration and hypotension secondary to diarrheal diseases • Seizures or altered mental status secondary to a nervous system infection • Dyspnea secondary to a respiratory infection (pneumonia, tuberculosis, etc.) • Medication reactions • End of life issues
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HIV, continued
Occupational risk:
• Occupational risk of acquiring AIDS is VERY LOW
Prevention:
• Prevention should focus on preventing significant blood exposures (needlesticks)
• Post-exposure prophylaxis (PEP) if exposed
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Hepatitis B
• Caused by the hepatitis B virus (HBV), which damages liver
• Vaccination against HBV has been available since 1982
• Spread by contact with blood of person infected with disease, or by sexual transmission
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Hepatitis B, continued
Transmission:
• Sex with infected person • Blood and other bodily fluids • Sharing needles with infected person • From a woman to her baby during birth
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Hepatitis B, continued
Prehospital presentation:
• Most signs/symptoms of Hep B are mild• Unlikely that you will be called to respond to an 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
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Hepatitis B, continued
Occupational risk:
• Significant for unvaccinated person• Very low for vaccinated person
Prevention:• Best way to prevent an occupational
exposure, in addition to protecting yourself from blood exposure, is vaccination
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Tuberculosis (TB)• Caused by small bacteria that travels
from the small airways to cells of lungs
• Less than 10% of people infected with TB will develop active disease
• In others, bacteria hides, causing no disease until host (patient) becomes immuno-compromised or otherwise debilitated
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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
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Tuberculosis, continued
Prehospital presentation:
• Cough, often productive of blood-tinged sputum • Fatigue and weakness • Night sweats • Low-grade fever • Loss of appetite and weight loss
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Tuberculosis, continued
Occupational risk:
• Occupational risk is low but has been very 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 and symptoms (PPE)
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SARS• A virulent respiratory infection reported in
Asia
• 2003: over 8,000 people worldwide, 700 died
• US: 192 possible cases (of these, 33 considered "probable"), no deaths
• A relatively high case fatality rate among young, healthy people
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SARS, continued
Transmission:
• Droplets spewed from the cough or sneeze of an infected person
• Close person-to-person contact
• Touching object and then touching mouth, nose, or eyes
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SARS, continued
Prehospital presentation:
• Fever, headache • Malaise, body aches, and diarrhea • Cough and possible respiratory symptoms • Most develop pneumonia and may require ventilatory
assistance and supplemental oxygen
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SARS, continued
Occupational risk:
• Minimal due to lack of recent cases – follow local and CDC guidelines for identification of high-risk patients
Prevention:
• Wash hands, wash surfaces and use contact precautions: gown, gloves, and protective eyewear
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Influenza (flu)• Caused by influenza virus which attacks
respiratory system
• Occurs seasonally from November to April in northern hemisphere
• Structure of virus changes slightly but frequently over time; this accounts for appearance of different strains each year
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Influenza (flu), continued
Transmission:
• Coughed droplets • Touching contaminated surfaces
(less common)
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Influenza (flu), continued
Prehospital presentation:
• High fever • Malaise • Headache • Dry cough • Body aches
Sudden onset of:
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Influenza (flu), continued
Occupational 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
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Norovirus
• Highly contagious virus responsible for outbreaks of GI disease on cruise ships
• Norovirus is 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 Norovirus
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Norovirus, continued
Transmission:• Fecal-oral route• Food handler does not wash his hands after
using the bathroom; you then ingest food contaminated with fecal matter
A person with Norovirus is considered A person with Norovirus is considered contagious from the time he or she contagious from the time he or she starts feeling ill to as long as two starts feeling ill to as long as two
weeks after recovery.weeks after recovery.
A person with Norovirus is considered A person with Norovirus is considered contagious from the time he or she contagious from the time he or she starts feeling ill to as long as two starts feeling ill to as long as two
weeks after recovery.weeks after recovery.
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Norovirus, continued
Prehospital presentation:• Nausea, vomiting and diarrhea • Stomach cramps • Low-grade, transient fever • General feeling of malaise, headache, body aches
Symptoms begin suddenly, may last one Symptoms begin suddenly, may last one to three days, and usually resolve on to three days, and usually resolve on
their own. Because the disease is caused their own. Because the disease is caused by a virus, antibiotics are useless.by a virus, antibiotics are useless.
Symptoms begin suddenly, may last one Symptoms begin suddenly, may last one to three days, and usually resolve on to three days, and usually resolve on
their own. Because the disease is caused their own. Because the disease is caused by a virus, antibiotics are useless.by a virus, antibiotics are useless.
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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 and nursing homes
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Norovirus, continued
Prevention:• Wear gloves• Wash your hands thoroughly• Use protective eyewear and mask• Surfaces contacted by patient must be thoroughly disinfected
If you become sick, wait two days after If you become sick, wait two days after the last of your symptoms before the last of your symptoms before
returning to work.returning to work.
If you become sick, wait two days after If you become sick, wait two days after the last of your symptoms before the last of your symptoms before
returning to work.returning to work.
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West Nile Virus
• First identified in Africa
• The virus causing the disease infects certain types of birds (ravens, crows, and jays), mosquitoes, horses, and other animals
• Humans are an incidental, rather than primary, host
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West Nile Virus, continued
Transmission:• WNV is transmitted through bite of infected mosquito
• WNV is NOT transmitted person-to-person except in rare case of blood transfusion from infected person
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West Nile Virus, continued
Prehospital presentation:• Fever • Headache • Fatigue • Rarely, a rash and swollen lymph nodes
Less than 1% of the people infected Less than 1% of the people infected with WNV will develop severe illness. with WNV will develop severe illness. These people may present with high These people may present with high
fever, headache or altered LOC.fever, headache or altered LOC.
Less than 1% of the people infected Less than 1% of the people infected with WNV will develop severe illness. with WNV will develop severe illness. These people may present with high These people may present with high
fever, headache or altered LOC.fever, headache or altered LOC.
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West Nile Virus, continued
Occupational risk:
• None
Prevention:
• Since WNV disease is not transmitted person-to-person, no specific disease prevention precautions are necessary at work
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Risk
• In last 25 years, estimated 57 healthcare workers in US have contracted HIV from a documented occupational exposure
• Thousands of health care workers EVERY YEAR contracted Hepatitis B from occupational exposure, and it is estimated that as many as 200 per 200 per year diedyear died (prior to vaccine).
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Masks
• Don fit-tested mask before entering scene
• Place a mask on patient, if tolerated• Fitted masks provide highest level of
protection• Remove and dispose of mask without
self contamination
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Eye Protection
Wear eye protection on all calls — prepare for unanticipated splashes:
• Vomiting• Blood flicked from bloody hand• Violent spit• Glucometer strips• Splashing fluids• Respiratory infection • Violent cough or sneeze
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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 and body substance exposure are present, wear latex or nitrile inner gloves and other protective outer gloves
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Limits of Gloves
• Gloves are for use during patient contact
• Wash your handsWash your hands after all patient contact, even if you wore gloves
• Gloves will not protect you from sharp objects such as needles
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Sharps• Needlesticks represent the greatest risk
of occupational blood borne transmission
• Many "exposures" involve cases in which EMS providers inadvertently stuck themselves with used needles
• Keep an eye on paramedics and needles, and watch where you put your hands
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Needlestick
For needlestick exposures:• Wash area well with soap and water• Do NOT use bleach or other harsh chemicals • Report the exposure immediately to your officer for testing and possible post-
exposure prophylaxis (PEP)
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Skin/Mucus
For exposures to non-intact skin:• Wash with soap and water• Report exposure immediately to your officer for testing and
possible post-exposure prophylaxis (PEP)
Blood on intact skin is not considered a Blood on intact skin is not considered a significant exposure. Non-intact skin significant exposure. Non-intact skin
includes abrasions and cuts.includes abrasions and cuts.
Blood on intact skin is not considered a Blood on intact skin is not considered a significant exposure. Non-intact skin significant exposure. Non-intact skin
includes abrasions and cuts.includes abrasions and cuts.
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Skin/Mucus, continued
For exposures to mucus membranes:• Flush liberally with water• Report exposure immediately to your officer for testing and
possible post-exposure prophylaxis
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Airborne• Report possible exposure to your
company officer• Hospital may notify exposed responders
if patient is diagnosed with an airborne disease (e.g., TB or bacterial meningitis)
• Some diseases may require automatic and immediate post-exposure prophylaxis
• Others may require post-exposure testing and then treatment only if you become positive
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PEP for HIV
• Any possible exposure to blood borne disease must be reported immediately to your company officer
• Post-exposure prophylaxis reduces already very low risk of acquiring
• The medications taken for PEP are TOXIC
• If patient is HIV-negative, PEP medications can be stopped
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Summary• Hand washing is the most effective
method of preventing infectious disease
• Clean visible contamination first, and then disinfect the surface
• Wear gloves when disinfecting equipment
• Occupational risk of acquiring AIDS is VERY VERY LOWLOW
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Summary, continued
• Best way to prevent an 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
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Summary, continued
• If you suspect TB, put a mask on patient (if tolerated), and wear a mask yourself
• Needlesticks represent by far greatest risk of occupational blood borne transmission
• If PEP is to be started, start IMMEDIATELY after exposure, if at all possible within two hours