MIEMSS
INFECTIOUS DISEASE
PREVENTION
Saving the Lives of
Our Providers
1
Infectious Disease Prevention





Awareness
Prevention
General infection
control principles
and practices
Specific diseases
Immunizations





Infectious disease
laws & guidelines
Notification laws
MAIS run report
Infection control plan
Designated infection
control officer
2
Infectious Disease Prevention

Public health
concern
45
40
35

Health care
providers
30
AIDS
HBV
HCV
TB
25
20
15

Understanding
10
5
0
1992
1993
1994
1995
CASES PER 100,000 POPULATION
3
Infectious Disease Prevention

Routes of Transmission:
•
•
•
•
•
Direct contact
Indirect contact
Droplet contact
Airborne transmission
Common vehicle transmission
4
Infectious Disease Prevention
Infectious
Agent
Susceptible
Host
Means of
Entry
Reservoir
Means of
Exit
Mode of
Transmission
Chain of Infection
5
Infectious Disease Prevention

Bloodborne Pathogen OSHA / MOSH
Update
• Occupational Safety and Health Act MOSH
09.12.31 Maryland
• OSHA Standard 29 CFR 1910.1030
6
Infectious Disease Prevention

Make sure your department has an
accessible copy of the Bloodborne
Pathogen Standard 29 CFR 1910.1030
7
Infectious Disease Prevention

Develop a general understanding of
the epidemiology & symptoms of
bloodborne pathogens
8
Infectious Disease Prevention

Bloodborne Pathogens
• microorganisms that can cause disease in
humans
• can be transmitted from one person to
another

Exposure occurs through broken skin:
percutaneous
or
through a mucous membrane:
mucocutaneous
9
Infectious Disease Prevention
Bloodborne Pathogens of Special
Concern To Health Care Providers
•
•
•
•
HBV: Hepatitis B virus
HCV: Hepatitis C virus
Other emerging viral hepatitis
HIV: Human Immunodeficiency
virus
10
Infectious Disease Prevention
Hepatitis B (HBV)
• Infection of liver caused by HBV
• Virus is in blood and other body
fluids
• Spread by exposure to blood and
body fluids
• Some people are at higher risk of
HBV
11
Infectious Disease Prevention
Hepatitis B (HBV) Symptoms:
Tiredness
 Loss of appetite
 Fever
 Vomiting

Yellow skin &
eyes (jaundice)
 Dark-colored
urine.
 Light colored
stool

12
Infectious Disease Prevention
HBV Treatment
No cure
 Fluids
 Rest
 Right diet
 Avoid alcohol & some medicines

13
Infectious Disease Prevention
Hepatitis B Prevention
Avoid exposure
 Get complete vaccination
series

14
Infectious Disease Prevention
Hepatitis C (HCV)
Infection of the
liver
 Virus is in blood
and other body
fluid

HCV mainly spread
by exposure to
blood and blood
products
 Certain people are at
higher risk of getting
HCV

15
Infectious Disease Prevention
Hepatitis C (HCV) Symptoms:
Tiredness
 Loss of appetite
 Abdominal pain
 Nausea

Vomiting
 Yellow skin &
eyes (jaundice)
 Urine that is
dark in color

16
Infectious Disease Prevention
Hepatitis C (HCV) Treatment
No cure
 Treatment limited
 Rest & fluids
 Avoid alcohol & some medicines

17
Infectious Disease Prevention
Hepatitis C (HCV) Prevention
Avoid exposure
 No vaccine

18
Infectious Disease Prevention
Human Immunodeficiency Virus (HIV)


AIDS is caused by
the HIV virus
Some people at
higher risk than
others


HIV is in blood and
other body fluids
HIV is spread by
exposure to HIV
infected blood and
HIV infected body
fluids
19
Infectious Disease Prevention
AIDS annual rates per 100,000 population United States, January - December 1996
4.0
14.5
3.9
MD. 44.4
6.1
26.6
D.C. 232.3
12..0
30.1
25.3
50.9
13.4
14.2
20
Infectious Disease Prevention
HIV




Certain symptoms &
conditions may be
associated with
HIV/AIDS
Fever
Weight loss
Swollen lymph
nodes



White patches in
mouth (thrush)
Certain cancers
eg. Kaposi’s sarcoma,
certain lymphomas
Infections
eg. pneumocystis
pneumonia, TB, etc.
21
Infectious Disease Prevention
HIV




A blood test may tell
if you have HIV
infection or AIDS
HIV treatment
No cure
Treatment includes
drug “cocktails”

Combination
therapy with a
variety of
medications help
people with HIV by
slowing the
disease process
22
Infectious Disease Prevention
HIV and AIDS are Preventable
There is NO vaccine however
 Avoid exposure
 Follow standard (universal
precautions) such as the use of:
gloves, eye protection, gowns, etc.

23
Infectious Disease Prevention
Transmission of Bloodborne Pathogens

Percutaneous: through the skin

Mucocutaneous: through a mucous
membrane
24
Infectious Disease Prevention
Chain of Infection
Infectious Agent
 Reservoir
 Means of Exit
 Mode of Transmission
 Means of Entry
 Susceptible Host

25
Infectious Disease Prevention
Local Exposure Control Plan

How can each member get a copy?
26
Infectious Disease Prevention
Identify tasks and other activities
that may involve exposure to blood
or other potentially infectious body
materials
27
Infectious Disease Prevention



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Patient assessment
Airway management
Assisting
respirations
Bleeding control
Contact with body
fluids




Clean-up of scene &
equipment
Establishing an IV
Emergency childbirth
Other patient care
activities where
contact with blood or
body fluids occur
28
Infectious Disease Prevention
Methods that will prevent or reduce
exposure include:
Engineering controls
 Work practices
 Personal protective equipment

29
Infectious Disease Prevention
Engineering Controls That Help Prevent
Contact With Blood & Body Fluids
Include:



Isolation supplies
Hand washing
facilities
Waterless hand
cleaners




Sharps containers
Ventilation
Medical waste
containers
Self sheathing
needles or needleless
systems
30
Infectious Disease Prevention
Work Practice Controls Include:


Washing hands
Prohibited in work
areas (ambulance)
• Eating, drinking,
smoking, applying
cosmetics or lip
balm, handling
contact lenses



Never bend, break or
recap needles
Avoid causing
splashes and
splatters of blood or
body fluids
Properly handle
contaminated items
31
Infectious Disease Prevention
Personal Protective Equipment (PPE)
must be used when in contact with blood
or other body fluids.
Examples include:




Gloves
Gowns
Face shields or masks
Eye protection



Mouth pieces or
pocket masks
Disposable
resuscitation bags
Lab coats
32
Infectious Disease Prevention
Personal protective equipment: types,
storage location, removal, handling and
disposal

Each department may have some
variation (different manufacturer) of PPE.
Discuss your department’s PPE types,
storage location, etc.
33
Infectious Disease Prevention

Following use, PPE should be
removed and properly
decontaminated or disposed of in an
approved container

Handle contaminated PPE as little as
possible
34
Infectious Disease Prevention

Review your department’s policy on
the proper decontamination, storage
and disposal of contaminated PPE
35
Infectious Disease Prevention
Selection of Personal Protective
Equipment:
PPE shall be provided at no cost to the
provider
 Considered “appropriate” if it does not
permit blood or other potentially
infectious materials to pass through

36
Infectious Disease Prevention
Standard Precautions
Hand washing
 Patient care
 Gloves
equipment
 Gown
 Environmental
control
 Mask, eye protection,
face shield
 Linen
 Respiratory protection

(N95 or (9508) HEPA, (99%))
37
Infectious Disease Prevention
Hepatitis B (HBV) Immunization
Three shot series over six months
 Vaccine determined to be safe by the
Centers for Disease Control &
Prevention
 Majority of vaccine recipients develop
adequate antibodies against HBV

38
Infectious Disease Prevention
HBV Immunization is provided at no
cost to the member
 Should be provided prior to working
in an area where occupational
exposure could occur
 Discuss HBV vaccination availability
in your department

39
Infectious Disease Prevention
Other Common Vaccines
Td - Tetanus diphtheria
 MMR - Measles, Mumps & Rubella
 Influenza
 Varivax - Varicella virus vaccine
(Chicken pox)

40
Infectious Disease Prevention
Appropriate actions to take & persons to
contact following an exposure incident

Each department has a written Infection
control plan. Discuss your department’s
plan and determine appropriate contacts
and actions.
41
Infectious Disease Prevention
Appropriate actions to take after an
exposure incident typically include:
Contacting your immediate
supervisor and / or infection control
officer
 Go to an approved treatment facility
or provider
 Complete all required written reports

42
Infectious Disease Prevention
Procedure to follow if an exposure
incident occurs:
Discuss your departments policy on
post exposure evaluation
 In general, always report the incident &
document the route of exposure

43
Infectious Disease Prevention
Medical Follow-Up & Treatment
Should be provided as soon after
exposure as possible (within one to
two hours with HIV exposure)
 Shall be consistent with U.S.
Department of Health & Human
Services, Public Health Service, and
CDC Prevention Guidelines

44
Infectious Disease Prevention
General Post Exposure Evaluation &
Follow-Up Guidelines:
Document route of exposure &
circumstances under which the
exposure occurred
 Identification & documentation of
source individual information

45
Infectious Disease Prevention

Obtain source individual’s blood
testing for HBV, HCV, and HIV
(if source gives consent).

If obtained, results of source
individuals blood test provided to
exposed provider
46
Infectious Disease Prevention
Exposed provider baseline blood
testing as soon after exposure as
possible (with consent)
 Post exposure prophylaxis shall be
provided when medically indicated,
according to the U.S. Public Health
Service (CDC) Standards

47
Infectious Disease Prevention
Signs, Labels and / or Color
Coding Required by the
Bloodborne Pathogen Standard:

Communications of hazards to
employees (members) shall be
accomplished by the use of signs and
labels
48
Infectious Disease Prevention
Warning labels shall be affixed to
containers of regulated waste
 Universal biohazard symbol (orange
or red-orange in color)
 Red bags or red containers may be
substituted for labels
 Contaminated sharps containers and
bags must be labeled appropriately

49
Infectious Disease Prevention

Signs shall be posted at the entrance
of work areas where occupational
exposure may occur, e.g. areas used
for cleaning and decontamination, or
storage of medical waste
50
Infectious Disease Prevention
Maryland’s Run Sheet (MAIS)
A “runsheet” box for reporting an
exposure is located next to the
“hospital signature” section
 This is for tracking purposes ONLY
and does not meet the
documentation necessary to report
an exposure incident

51
Infectious Disease Prevention
Notification Laws
Federal Law:
1990 Ryan White Comprehensive
AIDS Resources Emergency Act
Subtitle B, 42 U.S.C 300 ff-80
 Maryland Notification Law:
Health General 18-213

52
Infectious Disease Prevention

Hospitals are required to:
• develop written procedures
• make copies available upon request
• provide notification of possible exposure
within 48 hours of confirmation of
diagnosis
• protect the confidentiality of the patient
and the “first responder”
53
Infectious Disease Prevention

HG §18-213
• Disease notification
– All forms of viral hepatitis including but not
limited to Hepatitis A,B,C,D,E,F, and G
– HIV
– Meningococcal meningitis
– Tuberculosis
– Mononucleosis
– Diphtheria
– Plague
– Hemorrhagic fevers
– Rabies
54
Infectious Disease Prevention

HG §18-213
• Provides notification after contact with a
person with certain diseases.
– Notification 48 hours after confirmation of the
disease by the hospital
• Hospital makes notification in writing to
Infection Control Officer.
55
Infectious Disease Prevention
Communicable Disease Fact Sheets
This program includes a series of “fact
sheets” on more than forty
communicable diseases
 Provided by the Maryland Department of
Health & Mental Hygiene with Web Site:
www.edcp.org/html/index.html

56
Infectious Disease Prevention
Tuberculosis
57
Infectious Disease Prevention
MMWR
MORBIDITY AND MORTALITY
WEEKLY REPORT
October 28, 1994 / Vol. 43 / No. RR-13
Guidelines for Preventing
the Transmission of
Mycobacterium tuberculosis in
Health-Care Facilities, 1994
58
Infectious Disease Prevention

Who does this document apply to?
Health Care Workers (HCWs)

“HCWs refers to all paid and unpaid
persons working in health-care
settings who have the potential for
exposure to M. tuberculosis. This
may include... emergency medical
service (EMS) personnel.”
59
Infectious Disease Prevention
Specific measures to reduce the risk
for transmission of M. tuberculosis
include assigning responsibility:
Designated Officer
60
Infectious Disease Prevention
Specific measures to reduce the risk for
transmission of M. tuberculosis include:
Conducting a risk assessment to
evaluate the risk for transmission of M.
tuberculosis in your community and
work setting
 Develop a written TB Infection Control
Program based on your risk assessment

61
Infectious Disease Prevention

Periodically repeating the risk
assessment to evaluate the
effectiveness of the TB Infection
Control Program
62
Infectious Disease Prevention

Developing, implementing, and
enforcing policies and protocols to
ensure early identification of patients
who may have infectious TB
63
Infectious Disease Prevention
A diagnosis of TB should be suspected in
any patient with the following:
Productive cough (<2 to 3 wks duration)
 Fever - Chills
 Night sweats
 Easily fatigable
 Loss of appetite (anorexia) weight loss
 Hemoptysis (bloody sputum)

64
Infectious Disease Prevention
Managing patients who may have TB in
ambulatory care setting and emergency
departments:

Attempt to identify any potentially TB
infected patient e.g. history, signs &
symptoms, any previous positive TB
treatment, or any current
anti-tuberculosis medications
65
Infectious Disease Prevention
Utilize engineering controls where
possible and use of approved PPE
when treating and transporting a patient
suspected of having TB
 TB patients, if medically stable, should
remain in the transport unit (with a
provider) until receiving facility is
notified and ready to accept the patient

66
Infectious Disease Prevention
Developing, implementing, maintaining,
and evaluating a respiratory protection
program:


Personal Protective Equipment (PPE):
Respiratory Protection (NIOSH approved mask
e.g. N-95 or HEPA and other PPE as per local
protocol)
Meets adequate filtration standards
67
Infectious Disease Prevention
Qualitatively or quantitatively fit tested
 Respirators available in at least three
sizes
 Ability to be checked for face piece fit
(OSHA)
 Must comply with CFR 1910.134
(OSHA Respiratory Standard)

68
Infectious Disease Prevention
Use precautions while performing
cough-inducing and other high hazard
procedures:





Characterized by potential to generate
airborne / droplet secretions
Aerosolized medication treatment
Endotracheal Intubation
Suctioning
Transporting a patient with active
TB disease in a closed vehicle
69
Infectious Disease Prevention
Educating and training HCWs about TB,
effective methods for preventing transmission
of M. tuberculosis, and the benefits of medical
screening programs.
Tuberculosis
Training
Program
70
Infectious Disease Prevention
What Is Tuberculosis?
Mycobacterial disease
 Caused by the infectious agent:
Mycobacterium tuberculosis
 Transmitted by infected airborne
particles called droplet nuclei

71
Infectious Disease Prevention
What Is infectious?
Capable of causing infection
 Caused by a pathogen
 Illness resulting from an invasion of
a host by a disease producing
organism

72
Infectious Disease Prevention
TB Infection can result from exposure
to infectious droplet nuclei
 Positive PPD but, no clinically
apparent signs or symptoms of TB
 Negative CXR & negative smears and
cultures which means usually not
infectious
 May develop into TB disease

73
Infectious Disease Prevention
TB disease develops in a person with
tuberculosis infection
 Usually is infectious if not treated
 Signs and symptoms apparent with
positive lab test

74
Infectious Disease Prevention
Develop and implement a program for
routine periodic counseling and
screening of HCWs for active and latent
TB infection:

PPD skin testing is used to detect TB
infection
75
Infectious Disease Prevention




Skin test conversion from negative to
positive indicates a new infection with TB
A person with a positive PPD should be
clinically evaluated for active tuberculosis
A person with a positive PPD should be
evaluated for preventive therapy if no
active disease is present
If TB disease is detected, begin treatment
per local policy
76
Infectious Disease Prevention
Interpretation of TB Skin Test
Indurations of:
5 mm or larger considered positive
after close personal contact, abnormal
CXR or in known HIV infected persons
 10 mm or larger considered positive in
persons with other known risk factors
(HCW)
 15 mm or larger considered positive in
all other populations

77
Infectious Disease Prevention
Promptly evaluate possible episodes of
M. tuberculosis transmission in your
health care setting



An exposure to TB is defined as:
Potential exposure to the exhaled air of an
individual with suspected or confirmed TB
disease
Exposure to high hazard procedure
performed on persons with suspected or
confirmed TB disease
78
Infectious Disease Prevention
Risk Factors for TB Disease Development
Only about 1 in 10 people infected ever
suffer active disease
 Reactivation of TB is likely if the host
has impaired immunity, including
diabetes, chronic renal failure,
malnourished, high-dose corticosteroid
therapy, some hematologic disorders, or
HIV infection

79
Infectious Disease Prevention
Treatment of Tuberculosis


Drug susceptibility testing should be
performed on all initial isolates from
patients with TB
Until results are known, two
basic principles of therapy apply:
1) Start with the four primary drugs
used in the treatment of TB until
sensitively and resistance are known
2) Continue treatment regimen with at least
two drugs known to be effective on the
isolate
80
Infectious Disease Prevention
Drug Resistant Tuberculosis



Where therapy is not continuous or
incomplete, multi-drug resistant
tuberculosis can develop (MDR-TB).
MDR-TB can be treated but, treatment is with
second line drugs that are less effective.
MDR-TB requires longer treatment regimens:
18 to 24 months (due to lower efficacy)
81
Infectious Disease Prevention
TB Surveillance & Reporting





Skin test conversions among personnel
PPD done at time of employment and
(annually) periodic re-testing thereafter
Evaluation of exposure incidents
Evaluations & management of positive PPD
skin tests or symptoms of TB
Follow-up of personnel with positive PPD
skin test
82
Infectious Disease Prevention
Follow-up After TB Exposure




Clinically evaluate for active TB
Negative PPD in preceding 3 months
- repeat 12 weeks after exposure
Negative PPD longer than 3 months ago,
repeat baseline and if this one is negative,
repeat in 12 weeks
A positive PPD requires clinical evaluation
and management
83
Infectious Disease Prevention
Tuberculosis Prevention & Control



Unit ventilation: keep adequate ventilation in
the treatment area of the transport vehicle
e.g., windows, exhaust fans, air out vehicle
after run
Work practices to prevent the spread of
airborne droplets
When treating and transporting HIV infected
patients, IVDAs, foreign born, and other high
risk groups for TB, PPE should routinely
include airborne protection
84
Infectious Disease Prevention
TB Prevention & Control - Continued





Face & eye protection during exposure
prone activities, e.g. endotracheal intubation,
suctioning, positive pressure demand valve
ventilation
Decontamination with E.P.A. approved
hospital grade detergent disinfectant
Tuberculosis screening program
Preventive therapy or treatment
Documentation
85
Infectious Disease Prevention
Preventive Therapy

Coordinating activities with the local public
health department, emphasizing reporting,
and ensuring adequate follow-up and
continuation and completion of therapy
86
Infectious Disease Prevention

Preventive drug therapy substantially
reduces the risk of developing clinically
active tuberculosis in infected persons

If an infected person is a candidate for
preventive therapy he/she could be placed
on six to twelve months of daily (specific)
anti-tuberculosis drug therapy
87
Infectious Disease Prevention
5.3 - 10.4
0.0 - 5.2
> 15.6
Wash. DC
>15.6
0.0 - 5.2
5.3 - 10.4
> 15.6
Alaska - 5.3 - 10.4
Hawaii - >15.6
10.5 - 15.6
10.5 - 15.6
Tuberculosis in the U.S.
Rates per 100,000 Population by State
88
Prevention and Vigilance
is Your Only Cure
89