Infectious Diseases and Blood-Borne
Pathogens
Silver Cross EMS system CME
2nd Trimester, June 2012
Sources: Pat Futterer, JFD; CDC; Mosby’s Paramedic
Textbook 3rd Ed
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
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
WHO IS PROTECTED UNDER THE LAW?
• Physicians
• Medical staff (nurses, employees of clinical
offices)
• Firefighters, Paramedics
• Police Officers
• Home Health Care Workers
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.
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.
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)
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)
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.
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.
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)
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
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
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
• 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 nonalcoholic patients.
• Hepatitis C considered more serious than
Hepatitis B
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.
Groups at risk for exposure to TB
•
•
•
•
HIV-infected people
Nursing home residents and care workers
Immigrants
People in prisons, including employees
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)
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.
Symptoms of TB
•
•
•
•
Weight loss
Night sweats
Swollen lymph glands
Cough, productive or nonproductive, that
persists for more than a few weeks.
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)
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
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
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
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
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
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
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
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
Infectious Disease
• Rubella
– Communicable 5-7 days after rash
– Immunization for pregnant women not
recommended, may cause developmental defects
Infectious Disease
• Rubella
– Management
•
•
•
•
BSI, masks
Handwashing
Screening for immunity
Immunized during first trimester are at risk for
abnormal fetal development
• No specific treatment
Infectious Disease
• Rubeola
– Measles virus
– Fever, conjunctivitis, cough
– Bronchitis, blotchy red rash
– Found in blood, urine and
pharyngeal secretions
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
Measles
Koplik’s Spots
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
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
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
Infectious Disease
 Chickenpox
Chicken Pox
Pneumonia
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
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
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
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
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
Infectious Disease
• Mononucleosis
– Epstein-Barr virus (EBV)
– Transmitted person to person via oral route
– “kissing” disease
– Fever, soar throat, splenomegaly with abdominal
pain
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
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
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.
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.
PPE
Personal protection equipment
 PPE is additional layer of protection against all
transmission, but only if used.
 PPE includes any or all of the following:
gloves,
heavy duty rubber gloves for cleaning
hand washing
protective eye wear
masks
full gowns
respiratory assist devices (bag/mask or pocket mask)
 By law, PPE must be available for all employees.
Gloves
• Latex or vinyl
– If using latex be sure that you, your partner, and
most of all the patient is not allergic to latex.
Protective eye wear
To block any splatter of bodily fluids or blood
onto the surface of the eye.
To be used:
During intubation
Suctioning of the patient.
Wound irrigation.
Patient is actively vomiting
Any other splash possibility
Masks
• Masks should be used to keep bodily fluids or
blood from coming in contact with the inner
surface of the mouth or nose.
Gowns
• Gowns are recommended for protection
against large splash situations.
Infection Control’s
Golden Rule
If it’s wet and it’s
not yours….
DON’T TOUCH!!!
Disposal of PPE
Properly dispose of used PPE and soiled
equipment, including:
Gloves
Masks
Bag/mask devices
O2 Adjuncts
C-Collars
Place all used disposable items into bio bags.
Red colored Bio-Hazard bags
Hospital Disposal
• Dispose of all bio hazardous waste at the
hospital in the proper area.
– Bio-hazard bags in Silver Cross ambulance bay.
– Do NOT put sharps in regular garbage in bay or in
ER.
Cleaning of EMS equipment
Clean all used equipment that is not disposable.
Clean ambulance interior after every call.
Clean cot and place fresh linen for next patient.
Be sure you and uniform are ready for the next call.
WASH YOUR HANDS AFTER EVERY CALL!
Sink and soap in Silver Cross and St. Joes medic
rooms.
The 8 steps of washing your hands
Add soap and
lather hands
including
backs and
wrists
Wet your
hands
Turn on
the water
Wash each
finger and
scrub for 1015 seconds
Rinse
under
running
water
Turn off
water using
Dry hands paper towel
with paper
towel
Check
hands and
fingernails
for
cleanliness
EMS personnel should use waterless hand
wash as an adjunct to handwashing to help
prevent the risk of transmission of
microorganisms
Soiled Hospital linen
• Place contaminated linen in appropriate bin at
the hospital.
– Linen bin in ambulance bay
– Linen bin outside medic room
• DO NOT place any needles or sharps into the
linen for disposal.
Cleaning blood soaked items
Many of us carry commercially-available
cleansers.
Or clean blood-covered areas with
bleach/water solution per CDC.
• 1:10 bleach solution used to disinfect excrement and
bodies.
• 1:100 bleach solution used to disinfect surfaces,
medical equipment, patient bedding, reusable
protective clothing before laundering
Can be kept in opaque container for 24 hours.
Infectious control policy
• Law says every fire/EMS service must have an
infection control policy.
• Must be updated annually.
• Must include contact information for infection
control officer.
– We don’t know who is in charge of infection
control for every provider agency.
• Policy must be presented to all personnel and
trained upon annually.
Infectious control policies
Every policy must contain the following:
• Departmental education and training for Blood
Borne Pathogens.
• A review of workplace specific infection control
procedures.
• Post exposure policy and follow up testing and
documentation.
So what should you do if you are
exposed to something?
• Silver Cross EMS has a new exposure form
checklist.
• They are in the ER. So the first thing you
should do is immediately report the exposure
to the ER.
– You will get the checklist and also some misc
forms from the CDC.
– Your infectious disease officer, the ER and the Lab
all have roles in the process (shown on checklist).
New Silver Cross EMS Exposure
Report, part 1
New Exposure Report, part 2
Date of Exposure:________________ Description of
Exposure:____________________________________________________
EMS Provider MUST report exposure to EMS System via email to
mmacblane@silvercross.org Include the above information.
EMS Provider - immediately report exposure to the ER of the receiving
hospital of the source patient in order for source testing to be performed.
ER – register the EMS provider, as the source patient’s order is ordered
under the EMS provider’s information.
ER – order a “NEEDLE STICK PANEL” STAT on the source patient
(Rapid HIV antibody, Hep-B surface antigen, and Hep C antibody).
REGISTER EMS PROVIDER
ER – order a “NON-EMPLOYEE NEEDLE STICK PANEL” STAT on the
EMS provider (Same as the source patient PLUS Hep B surface antibody
and CMP) ONLY IF the EMS provider chooses to utilize the ER for their
baseline testing.
ER - If the EMS provider chooses NOT TO UTILIZE Silver Cross Hospital,
for their own blood draw, have them sign
here___________________________________ as verification they were
given the option and declined at this time.
New Exposure Report, part 3
EMS provider - immediately notify your department/agency infection
control officer of exposure:

EMS provider’s Agency/Department:
_____________________________________________

Agency’s Infection Control Officer:
_________________________________________________

Phone Number of Agency’s IC Officer:
______________________________________________
ER call 815-791-4808, Silver Cross EMS System Operations Coordinator to
notify System of exposure so System can ensure follow-up procedures (for
QA purposes ONLY).
ER – Give the EMS provider a medication sheet for HIV Prophylaxis and
Exposure to Blood sheet from CDC while waiting for results from Lab (packet
attached to this form).
LAB – Call the ER with the SOURCE patient’s Rapid HIV results ASAP
ER – inform EMS provider of need for immediate testing and/or need for
prophylaxis within 1 hour of reporting/testing.
ER – inform EMS provider agency’s infection control officer of same
(see above contact information for notification)
New Exposure Report, part 4
ER – If the EMS provider remains in the ER and consents to HIV prophylaxis,
give the 1st dose within 1 to 2 hours of occurrence. 1st dose shall be ordered in
the ER. EMS provider may be given a prescription for a 7-day supply of
medication.
ER – If the EMS provider leaves the ER and refuses HIV prophylaxis, have
them sign here____________________________ as a declination of receiving
prophylaxis treatment from the ER for this occurrence.
ER – Return this completed form to Silver Cross EMS System, Marilyn
MacBlane, Operations Coordinator
EMS System – review form and assure ER made notifications, including Hep
B and C result counseling.
EMS providers shall follow-up with their personal physician or employer’s
occupational health physician per agency protocol. EMS provider may obtain
personal medical records from treating hospital and forward to occupational
health or personal physician. This form is not a permanent part of the medical
record. EMS shall forward a copy of this form to SCH QRM Infection Control
Officer.
Notes on exposure report…
• Email to Marilyn at mmacblane@silvercross.org
is a new requirement.
– So system is aware of exposure and can assure
follow-up procedures.
• But be assured this is for QA purposes only.
– No system staff member receives results.
– In Marilyn’s absence another staff member will
assure follow-up procedures.
• Reporting of results is done by ER staff.
Resources:
Your EMS coordinator has copies available of the
Silver Cross EMS System Infectious Disease
protocols.
Some other useful references:
Advanced Designated Officer Book written by:
Infection Control/Emerging Concepts INC. 7715
Knightshayes Drive Manassas, VA
Train the Trainer OSHA Blood borne Pathogens &TB
written by: Infection Control/Emerging Concepts INC.
7715 Knightshayes Drive Manassas, VA
Centers for Disease & Control websites
Silver Cross Strip-o-the-Month – Atrial
Fibrillation
Atrial Fibrillation – p-wave is lost since atria are
fibrillating (quivering) instead of contracting.
Sinus Rhythm – p-wave seen as atria contracts.
Afib characteristics
• Absence of P-waves.
• Instead: wiggles, squiggles or bumps.
• “Irregularly irregular”, with irregular R-to-R
intervals and no rhyme or reason to the rate.
• QRS is narrow/normal.
• Irregular rhythm may be hard to see if the rate
is very fast.
Afib Can be mistaken for…
• …SVT if rate is too fast (>150) to see irregularity...
– … when in doubt, treat for SVT.
• …Junctional Rhythm if fibrillations are too weak to
create wiggles, squiggles or bumps…
– …but in junctional the R-to-R interval is regular.
• …Sinus Arrhythmia if irregular rate isn’t obvious…
– …but in sinus arrhythmia, P-waves will still be obvious and
identical.
12-lead of atrial fibrillation
Why is Afib Bad?
• Atrial Fibrillation by itself doesn’t cause patient to call 911.
• Most people with afib do well under a doctor’s care.
– Many are on blood thinners, BP meds and lasix.
• But eventually afib can lead to:
– Significantly increased stroke risk due to pooling/coagulating blood in atria
creating clots.
– Syncope, weakness and chest pain, especially during new or sudden onset.
– Decreased cardiac output as atria fail to do their job properly.
Who Has Afib?
• Many causes, but…
– Most common afib patients we see are elderly, with high blood
pressure and/or Congestive Heart Failure (CHF)
• Afib should be a red flag that you may be dealing with
hypertension and/or CHF.
• So if patient calls for difficulty breathing, is elderly, in afib, has
high blood pressure, pedal edema and noisy lungs…
– … consider treating for CHF (CPAP, nitro before neb).
– Call medical control with questions.
Thank you!
•If you are viewing the live presentation,
feel free to type questions in the text box
now!
•If you are watching the prerecorded
version, direct questions and comments to
afinkel@silvercross.org
•Thanks