20 Infectious Disease

Objectives Learn how infection spreads and how to protect yourself from disease. Identify multi-resistant organisms. Discuss influenza. Recognize current infectious diseases prevalent in the community. Discuss the role of EMS in public health. Discuss the objectives.

Introduction From the common cold to multi-resistant organisms, infectious disease is a topic that should be on every provider’s mind. Today’s Advanced EMTs are faced with not only protecting themselves from microorganisms but also preparing for pandemic outbreaks and medication-resistant diseases. EMS has evolved from a world of “gloves and maybe goggles” to a world of assisting with vaccinations and preparing for what seem like doomsday scenarios. We can no longer rely on minimum training to face today’s infectious disease threat.

Introduction (cont’d) This topic will focus on the evolving threats that infectious disease poses to the Advanced EMT and discuss the key concepts in personal protection. Discuss as needed.

Spreading Infection Infectious disease is defined as pathogenic microorganisms that can spread directly or indirectly from one person to another. Bacteria Viruses Parasites Fungi This definition of infectious disease is from the World Health Organization.

Spreading Infection (cont’d) Communicable disease is one that is transmitted easily from one person to another. Standard precautions help to prevent the transmission of disease. In your basic EMT class you learned about the basics of disease transmission. Diseases that were caused by organisms (or vectors) were discussed, as well as diseases that were bloodborne, airborne, and foodborne. Disease transmission has changed little since the dawn of time, and the concepts you learned remain very important.

Standard Precautions are required to protect you from disease.

Spreading Infection (cont’d) Bloodborne diseases pose a particular threat to the Advanced EMT. Advanced skills such as intravenous therapy and medication administration require the use of needles and other sharps that can pose a serious risk of injury when not used safely. Discuss the importance of safety when using needles and sharp-related equipment.

Communicable Diseases

Epidemiology The Center for Disease Control and Prevention (CDC) estimates that roughly 82% of healthcare workers being exposed to bloodborne diseases occur as a result of needle or sharp-related incidents. Improved safety strategies have demonstrated a 96% decline in the number of incidents since 1983. Review the basic statistics.

Hepatitis Translates into inflammation of the liver. Generally caused by a viral infection. Classified as hepatitis A, B, C, D, or E. A and E – food and waterborne B, C, and D – bloodborne CDC estimates roughly 80,000 new infections of hepatitis in the U.S. each year. Introduce hepatitis.

Hepatitis (cont’d) Hepatitis virus seeks out healthy liver cells and invades them. Reproduction destroys these cells and causes an immune response in the liver. Liver destruction occurs both immediately and over a period of time while the disease persists. The pathophysiology of hepatitis is not simple and depends greatly on the type (classification) of the hepatitis strain.

Hepatitis (cont’d) Chronic hepatitis Acute hepatitis Long term decline in the function of the liver Acute hepatitis Short term, “flare ups” Roughly 4.4 million Americans live with chronic hepatitis and are essentially asymptomatic It is important to remember when you are treating all patients that they have the potential to be carrying a bloodborne infection. Not all patients will be forthcoming in sharing this information with you. Therefore, it is imperative to protect yourself as if all patients are carrying a bloodborne disease.

Hepatitis (cont’d) Signs and symptoms Fatigue Abdominal pain Nausea Vomiting Jaundice Discuss the signs and symptoms of hepatitis.

HIV/AIDS Human immunodeficiency virus (HIV) is a bloodborne pathogen that potentially leads to acquired immune deficiency syndrome (AIDS). The CDC estimates that slightly fewer than 700,000 Americans are infected with HIV. AIDS, if developed, is deadly. Although HIV is significantly more difficult to transmit than hepatitis, its potential consequences make it a high-level threat to health care workers.

HIV/AIDS (cont’d) AIDS affects the immune system by destroying essential T cells thus leaving the body vulnerable to opportunistic infections. Most AIDS deaths are caused by secondary diseases such as respiratory infections and malignancies. Recent treatment advances have prevented many HIV-infected patients from developing AIDS. As a result, the true incidence and mortality of HIV and AIDS has become difficult to assess.

HIV/AIDS (cont’d) Bloodborne disease transmitted through needle stick and sharp-related injuries. Only about 3 in 1000 needle stick injuries will actually transmit disease. It is important to remember that even in the case of an infected patient, not every needle stick injury will transmit disease. However, the most effective way to protect against occupational transmission of HIV is to promote safe sharp handling and disposal.

HIV/AIDS (cont’d) Factors that contribute to the probability of transmission Amount of blood on or in the sharp How deep the needle penetrated Whether or not it penetrated an artery or vein How high the viral load in the patient Nonetheless, despite the factors listed above, any needle stick or sharp-related injury is a high-risk exposure and should be handled seriously.

Tuberculosis Spread by a bacterium known as Mycobacterium tuberculosis. Transmitted through respiratory droplets. Roughly ⅓ of the world’s population is currently infected with the TB bacillus. In latent TB, the patient is infected with Mycobacterium tuberculosis, but does not have active tuberculosis disease. Those in congregate settings include jail, nursing homes, shelters, etc.

Tuberculosis (cont’d) Vast majority have latent tuberculosis. Those at higher risk are drug users, HIV patients, and those in congregate settings. In latent TB, the patient is infected with Mycobacterium tuberculosis, but does not have active tuberculosis disease. Those in congregate settings include jail, nursing homes, shelters, etc.

Tuberculosis (cont’d) Active TB develops in 5-10% of those exposed. Characterized by a massive immune response in the lining of the airway and parenchymal tissue. Inflammation and lung cell changes cause poor diffusion and destruction of lung tissue. Tuberculosis can be diagnosed from a chest x-ray or tuberculin skin test and treatment includes long term antibiotic treatment.

Tuberculosis (cont’d) Signs and symptoms Blood tinges sputum Fever Weight loss Night sweats N-95 type respirator protects from droplet transfer of tuberculosis. An N-95 type respirator will protect you from the respiratory droplet transfer of a TB patient; in order for any respirator to be effective, however, a proper fit test must be completed prior to using the mask in a high-risk environment.

Multidrug-Resistant Organisms Enhanced by partial and unfinished courses of antibiotic treatment. Bacteria is exposed to the medication but is not completely eradicated when the full course of treatment is not received. Remaining bacteria reproduce and develop resistance. In recent years, we have witnessed an explosive evolution of microorganisms resistant to traditional therapies.

MRSA Methicillin-Resistant Staphylococcus aureus About 25% of the population carries staphylococcus bacteria on their skin/nose. Methicillin-resistant Staphylococcus aureus (MRSA) has evolved in much the same way as TB, but at a much more profound pace. Staph bacteria are very common. MRSA is the drug-resistant variant of the simple Staphylococcus aureus bacteria. Hospital-acquired MRSA results from transmission of the disease in a health care setting, typically from surgical procedures, catheters, and endotracheal tubes. The rate of MRSA versus simple staph infection is highest in this group. Community-acquired MRSA occurs when the bacteria is passed by contact in otherwise healthy people. This commonly occurs in populations living in close proximity to one another. Children in day care, athletes, and members of the military are common victims of this type of transmission.

MRSA (cont’d) Transmitted by skin or respiratory contact Divided into two groups Hospital-acquired Community-acquired Methicillin-resistant Staphylococcus aureus (MRSA) has evolved in much the same way as TB, but at a much more profound pace. Staph bacteria are very common. MRSA is the drug-resistant variant of the simple Staphylococcus aureus bacteria. Hospital-acquired MRSA results from transmission of the disease in a health care setting, typically from surgical procedures, catheters, and endotracheal tubes. The rate of MRSA versus simple staph infection is highest in this group. Community-acquired MRSA occurs when the bacteria is passed by contact in otherwise healthy people. This commonly occurs in populations living in close proximity to one another. Children in day care, athletes, and members of the military are common victims of this type of transmission.

MRSA (cont’d) Remember as an EMS provider, you are exposed to Staphylococcus aureus and MRSA every day. MRSA can be transmitted by skin contact and/or by respiratory contact. Utilize the appropriate level of personal protective equipment to prevent the spread of bacteria. Frequently we transport patients with known (and unknown cases) of MRSA. In addition to proper personal protective equipment and handwashing, quality decontamination procedures are also necessary to prevent transmission to staff and other patients. In one study of an urban ambulance fleet, 10 of 21 ambulances were found to harbor MRSA colonies in the ambulances and on the equipment used.

Hand washing is vital for preventing the spread of disease.

Handwashing When washing, remember the key elements to proper handwashing Warm flowing water and soap At least 15 seconds of scrubbing over all the surfaces Thorough rinsing Review the proper handwashing techniques.

Alcohol-based hand cleaner is effective and can be used when soap and water are not available.

Influenza Influenza (flu) is a viral infection that has multiple different classifications and subclassifications. Influenza A, B, C H1N1, H5, N1 Various strains of influenza strike regionally each year. Discuss and introduce influenza.

Influenza (cont’d) The Center for Disease Control and Prevention estimates that influenza kills somewhere between 3,000 and 50,000 people each year in the United States. In 2009, Influenza A (H1N1) killed more than 18,000 people and was found in 214 countries. The WHO designated H1N1 a pandemic. Review the basic statistics.

Influenza (cont’d) Influenza is quite virulent. Spread via airborne droplets and through contact with respiratory fluids. Immune response causes inflammation and changes in the lining of the respiratory tract. Cytokines and other chemicals released from infected cells cause S/S. To a healthy person, most influenza is not usually life-threatening, but in some cases it can be dangerous. Influenza can create a life-threatening situation in patients who are already compromised by chronic illness, pregnancy, and underlying disease.

Influenza (cont’d) Signs and symptoms Fever Fatigue Chills Muscle pains Cough Review the signs and symptoms of influenza.

Influenza (cont’d) EMS is at high risk to be exposed. Consider getting vaccinated each year. Protect yourself from respiratory droplet contact in patients with a high suspicion of influenza. Handwashing and decontamination are essential. Discuss methods of preventing transmission of influenza.

EMS and Public Health EMS has developed a significant responsibility within public health. Especially in the context of infectious disease. EMS frequently partners with other health care entities to develop and enact strategies to prevent and stop the spread of infectious disease. Besides the traditional roles, today’s EMS provider is responsible for a variety of additional functions in the lager public health partnership. Consider the tactics for fighting disease and think about how the Advanced EMT plays a part.

EMS in the public health setting.

EMS in the public health setting.

EMS as an Agent of Public Health

Summary It is imperative that all EMS providers protect themselves from, and prevent the spread of, infectious disease. As diseases become challenging to fight, partnerships continue to develop in health care to provide an optimal response. Review as appropriate.

Summary (cont’d) EMS plays a vital role in developing and carrying out action plans against disease. Review as appropriate.