Infectious Disease

1. Infectious Disease

2. Introduction • EMS vehicle rolling emergency rooms • Patient advocate…protect ourselves 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.

3. Practical Skills • Don and doff your PPE in the proper sequence • Take appropriate measures to protect yourself against infectious diseases

4. Objectives • Identify the types of PPE and how and when they should be applied. • Identify the characteristics infectious diseases that are a threat to EMS providers. (HEPC, HBV) • Describe appropriate measures for protecting yourself against infectious diseases obtaining 3 of 3 test items correct. • Explain the appropriate actions to take for exposure to an infectious disease. • Explain the purpose of PEP • Distinguish between the infectious diseases EMS providers can encounter.

5. 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. Body Substance Isolation (BSI) – An infection control practice that assumes all body substances including blood, urine, saliva, feces, tears, etc., are potentially infectious.

6. Terms Epidemic — An outbreak of a contagious disease that spreads among many individuals in an area or a population at the same time. MRSA – Methicillin-resistant Staphylococcus Aureus (MRSA) are a type of staphylococcus or "staph" bacteria that are resistant to many antibiotics. 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.

7. Terms Parasite — An organism that grows, feeds, and is sheltered on or in a different organism while contributing nothing to the survival of its host. Pathogen — An agent that causes disease such as a bacterium, virus or fungus. 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).

8. Terms 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.

9. Personal Protective Equipment • Treat every scene having 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. • Universal precautions should be universal – they should be observed on every incident.

10. 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 You must wear full PPE with any patient who is potentially infectious especially those with a history of a fever and cough.

11. Donning PPE • Put on PPE before entering the patient area. The sequence for donning PPE is MEGG: • 1. Mask • 2. Eye protection • 3. Gown • 4. Gloves

12. 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: Gloves Gown—hand washing min 20 sec. Eye protection Mask—hand washing min 20 sec.

13. 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

14. Equipment Decontamination • After 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.

15. 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

16. MRSA – healthcare facilities • Weakened immune systems • Undergo procedures • MRSA in healthcare facilities – tend to be severe

17. MRSA - community • University of Washington Study • MRSA in fire stations • http://depts.washington.edu/envhlth/topic/firefighters.php • Widespread – anyone is at risk • Usually infections of skin: • Cuts & abrasions • Crowded living conditions

18. MRSA • 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.

19. MRSA • Prehospital 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 • Can also burrow deep into body, causing potentially life-threatening infections in bones, joints, surgical wounds, the bloodstream, heart valves, & lungs.

20. MRSA • 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.

21. 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

22. HIV • Transmission: • Unprotected sex with an infected partner • Infected blood given during a transfusion (extremely rare) • Sharing of needles by IV drug users • Infected mother to her baby • Occupational transmission usually by a needlestick of infected blood

23. HIV • Prehospital Presentation: • Dehydration & hypotension secondary to diarrheal diseases • Seizures or altered mental status secondary to nervous system infection • Dyspnea secondary to respiratory infection (pneumonia, tuberculosis, etc.) • Medication reactions • End of life issues

24. HIV • Occupational Risk: • Occupational risk of acquiring AIDS is VERY LOW Prevention: • Focus on preventing significant blood exposures (needlesticks). • Post-exposure prophylaxis (PEP) if exposed

25. Hepatitis C • Approximately 3.5 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 Viral hepatitis most common cause of Macronodular Cirrhosis

26. Hepatitis C • Prehospital Presentation • Hepatitis C infection generally produces no signs or symptoms during early stages; may produce none for years • If encountered, symptoms may include: • Fever • Fatigue • Dark urine • Clay-colored stool • Abdominal pain • Loss of appetite • Nausea • Vomiting • Joint pain • Jaundice • Transmission • Blood & other bodily fluids • Sharing needles with infected person • Sex with infected person • From a woman to her baby during birth

27. Hepatitis C • Prevention • No effective vaccine for hepatitis C • Only way to protect yourself – avoid exposure to infected blood • Occupational Risk • After needlestick 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

28. Hepatitis C • Of every 100 people infected with Hepatitis C virus, about • 75–85 people will develop chronic Hepatitis C virus infection; of those, • 60–70 people will go on to develop chronic liver disease • 5–20 people will go on to develop cirrhosis over a period of 20–30 years • 1–5 people will die from cirrhosis or liver cancer Long term effects:

29. 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

30. Hepatitis B • Transmission: • - Sex with infected person • - Blood & other bodily fluids • - Sharing needles with infected person • From a woman to her baby during birth

31. Hepatitis B • Prehospital 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

32. Hepatitis B • Occupational Risk: • - Occupational risk for acquiring HBV from unvaccinated person is significant • - Risk for vaccinated person is VERY LOW Prevention • - Take care to protect yourself from blood exposure • - Be vaccinated against the disease

33. Tuberculosis (TB) • Kills more people than any other infectious disease • About 2 million people a year die – worldwide • 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

34. TB • TB remains a problem in urban centers • Rate of active cases in King County in 2010 was 5.9 per 100,000 • This is one and one half times the national rate of 3.6 per 100,000, and the Washington state rate of 3.5

35. TB – King County Epidemiology • Higher case rate reflects international community • People of color have disproportionately high rates • Native Hawaiian or Pacific Islander (48.3 cases per 100,000) • Black (25.9 cases per 100,000) • Mostly individuals born outside the U.S. • TB endemic in many parts of the world • Diagnosed in King County – 23 different countries

36. Tuberculosis • 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

37. Tuberculosis • Prehospital Presentation: • - Cough, often productive of blood-tinged sputum • - Fatigue & weakness • - Night sweats • - Low-grade fever • - Loss of appetite & weight loss

38. Tuberculosis • 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

39. Influenza (flu) • Caused by influenza virus which attacks respiratory system • Occurs seasonally from November to April in the northern hemisphere • Structure of virus changes slightly but frequently over time • Accounts for appearance of different strains each year

40. Influenza (flu) • Transmission: • - Coughed droplets • - Touching contaminated surfaces (less common) Prehospital Presentation Sudden onset of: • - High fever • - Malaise • - Headache • - Dry cough • - Body aches

41. Influenza (flu) • 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 flu vaccine, which must be taken yearly Best flu prevention is the flu vaccine

42. Bacteria and Virus Videos • View video clip of white blood cells searching for pathogens • View video clip of white blood cell engulfing destroying organism • View video clip of “How a Virus Infects a Cell”

43. 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 • Difficult to accurately predict which strain of influenza may give rise to next pandemic

44. 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

45. Pandemic • View Videos • Hospital Full-Up – John Hoskins Center for Civilian Biodefense Studies • Business Not As Usual – King County Public Health

46. Masks • Don fit-tested mask before entering scene • Place mask on patient, if tolerated • Fitted masks provide highest level of protection • Remove and dispose of mask without self contamination • View Information on masks - FDA

47. 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

48. Gloves • Wear medical gloves on all calls • Most bodily fluids, such as vomit or urine, do not typically carry bloodborne 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 • Wash hands before and after use • View information - FDA Glove Up!

49. 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

50. Sharps • Needlesticks represent greatest risk of occupational bloodborne 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