1. EMS Blood Borne Pathogens and Other Dangers Dan O’Donnell Indiana University Emergency Mecicine 2/19/06

2. Goals Recognize infectious disease risks assumed by EMS personnel Recognize infectious disease risks assumed by EMS personnel Understand post-exposure management of needlestick injuries, respiratory exposure, and contact exposure involving EMS personnel Understand post-exposure management of needlestick injuries, respiratory exposure, and contact exposure involving EMS personnel Review the Clarian policy on post-exposure HIV prophylaxis Review the Clarian policy on post-exposure HIV prophylaxis

3. Why should we care Estimated 4.1 million Americans infected with HCV Estimated 4.1 million Americans infected with HCV 3.2 million chronic infection 3.2 million chronic infection Estimated 946,00 people in US with HIV/AIDS Estimated 946,00 people in US with HIV/AIDS Estimated rate in Indiana 6.5 per 100,000 Estimated rate in Indiana 6.5 per 100,000 14,097 new cases of TB reported in the US in 2005 14,097 new cases of TB reported in the US in 2005 Source: www.cdc.gov

4. Early Universal Precautions WEAR GLOVES

5. It is A LOT Different Now You are called for unresposive person You are called for unresposive person As you get vitals and begin to start an IV, the patient begins to seize and you stick yourself As you get vitals and begin to start an IV, the patient begins to seize and you stick yourself What information do you need? What information do you need? Do you need to get any shots? Do you need to get any shots? Can we draw blood on him? Can we draw blood on him?

6. Infectious Diseases & EMS Hepatitis B Hepatitis B Hepatitis C Hepatitis C HIV/AIDS HIV/AIDS Tuberculosis Tuberculosis Meningitis Meningitis Terrorist Attacks Terrorist Attacks

7. New Case Called to the local dialysis center for chest pain Called to the local dialysis center for chest pain As you they are unhooking his port some blood splashes onto your arm As you they are unhooking his port some blood splashes onto your arm Patient is HBV + and HCV + Patient is HBV + and HCV + What testing do you need? What testing do you need?

8. Hepatitis B Virus Blood-borne exposure Blood-borne exposure Risk of infection after percutaneous exposure reported from 2-40% Risk of infection after percutaneous exposure reported from 2-40% OSHA requires EMS employers to provide HBV vaccination series free of charge OSHA requires EMS employers to provide HBV vaccination series free of charge Vaccination given at 0, 1, 6 month intervals Vaccination given at 0, 1, 6 month intervals Follow-up testing at 1-3 months to ensure immunity Follow-up testing at 1-3 months to ensure immunity

9. Hepatitis B Virus Prevention is important Prevention is important Associated with 6-10% incidence of chronic liver disease and primary hepatocellular carcinoma Associated with 6-10% incidence of chronic liver disease and primary hepatocellular carcinoma

10. HBV Prophylaxis for Needlestick Exposed EMT is unvaccinated Exposed EMT is unvaccinated If source patient not tested or unknown If source patient not tested or unknown initiate HBV vaccine series initiate HBV vaccine series If source patient HBsAg negative If source patient HBsAg negative initiate HBV vaccine series initiate HBV vaccine series If source patient HBsAg positive If source patient HBsAg positive HBIG (0.06 ml/kg IM up to 10 ml) single dose and initiate HBV vaccine series HBIG (0.06 ml/kg IM up to 10 ml) single dose and initiate HBV vaccine series

11. HBV Prophylaxis for Needlestick Exposed EMS provider is previously vaccinated and known responder (anti-HBsAB >10 mIU/ml) Exposed EMS provider is previously vaccinated and known responder (anti-HBsAB >10 mIU/ml) Source patient not tested or unknown: no tx Source patient not tested or unknown: no tx Source patient HBsAg negative: no tx Source patient HBsAg negative: no tx Source patient HBsAg positive: test exposed and if titer >10 mIU/ml: no tx; if titer 10 mIU/ml: no tx; if titer < 10 mIU/ml: HB vaccine booster dose

12. HBV Prophylaxis for Needlestick Exposed EMT is previously vaccinated and is known non-responder Exposed EMT is previously vaccinated and is known non-responder Source patient not tested or unknown: if a high- risk source may treat as HBsAg + Source patient not tested or unknown: if a high- risk source may treat as HBsAg + Source patient HBsAg negative: no tx Source patient HBsAg negative: no tx Source patient HBsAg positive: HBIG two doses or HBIG one dose and HBV vaccine one dose Source patient HBsAg positive: HBIG two doses or HBIG one dose and HBV vaccine one dose

13. HBV Prophylaxis for Needlestick Exposed EMT previously vaccinated but response unknown Exposed EMT previously vaccinated but response unknown Source patient not tested or unknown: test EMT for anti-HBsAb and if adequate no tx, if inadequate, give one HB vaccine booster Source patient not tested or unknown: test EMT for anti-HBsAb and if adequate no tx, if inadequate, give one HB vaccine booster Source patient HBsAg negative: no tx Source patient HBsAg negative: no tx Source patient HBsAg positive: test exposed, if inadequate HBIG x 1 & booster Source patient HBsAg positive: test exposed, if inadequate HBIG x 1 & booster

14. HBV Exposure and Work Duty Does not need to be removed from pt care Does not need to be removed from pt care Counsel to practice safe sex for 6 mos Counsel to practice safe sex for 6 mos Document baseline and 6 mos HB titer Document baseline and 6 mos HB titer If infected with acute HBV should wear gloves for invasive procedures or those involving mucous membrane contact until antigenemia resolves If infected with acute HBV should wear gloves for invasive procedures or those involving mucous membrane contact until antigenemia resolves HB carriers: avoid invasive procedures HB carriers: avoid invasive procedures

15. Hepatitis C Virus Blood-borne exposure Blood-borne exposure Risk of infection after percutaneous exposure reported from 3 - 10% Risk of infection after percutaneous exposure reported from 3 - 10% No current vaccine No current vaccine Ig prophylaxis post-exposure no proven benefit and not currently recommended Ig prophylaxis post-exposure no proven benefit and not currently recommended ? Role for alpha-interferon ? Role for alpha-interferon

16. Hepatitis C Virus Prevention is important Prevention is important Causes chronic liver disease in up to 67% affected and associated with hepatocellular carcinoma Causes chronic liver disease in up to 67% affected and associated with hepatocellular carcinoma

17. HCV and Needlestick Injury Test source patient for HCV Test source patient for HCV If source patient positive for HCV: Provider testing for hepatitis C antibody titer and LFTs at baseline and in 6 mos If source patient positive for HCV: Provider testing for hepatitis C antibody titer and LFTs at baseline and in 6 mos

18. HCV Exposure and Work Duty Does not need to be removed from pt care Does not need to be removed from pt care Counseling regarding safe sex for 6 mos Counseling regarding safe sex for 6 mos Same precautions with invasive procedures as with HBV Same precautions with invasive procedures as with HBV

19. Next Case Called for possible overdose Called for possible overdose Upon arrival find a 20ish male obtunded with needle sticking from arm Upon arrival find a 20ish male obtunded with needle sticking from arm You go to start an 18g IV and stick yourself You go to start an 18g IV and stick yourself His girlfriend is HIV+ but doesn’t know his status His girlfriend is HIV+ but doesn’t know his status What do you do now? What do you do now?

20. HIV/AIDS Blood-borne as well as other body fluids to lesser extent Blood-borne as well as other body fluids to lesser extent Risk of infection after percutaneous exposure reported from 0.2 - 0.5% Risk of infection after percutaneous exposure reported from 0.2 - 0.5% No existing vaccine No existing vaccine Prevention important for obvious reasons of currently incurable disease, devastating financial and emotional aspects, etc. Prevention important for obvious reasons of currently incurable disease, devastating financial and emotional aspects, etc.

21. HIV and Needlestick Increased risk Increased risk deep injury deep injury viremic blood on device causing injury viremic blood on device causing injury device used in pt vein or artery (hollow needle) device used in pt vein or artery (hollow needle) source pt dies from AIDS within 60 days of exposure (assumes pt had high viral load) source pt dies from AIDS within 60 days of exposure (assumes pt had high viral load)

22. HIV and Mucous Membranes Risk approximate 0.1% Risk approximate 0.1% For intact skin even <0.1% For intact skin even <0.1% Increased risk Increased risk high volume of blood high volume of blood high viral load of HIV high viral load of HIV prolonged contact prolonged contact membrane/skin integrity compromised membrane/skin integrity compromised extensive area of contact extensive area of contact

23. HIV Exposure Prophylaxis “A Walk Through the EMTC” Initial Initial Clean affected area as promptly as possible with copious amounts of water or sailine and cleansing with soap or alcohol based products Clean affected area as promptly as possible with copious amounts of water or sailine and cleansing with soap or alcohol based products Notify EMS supervisor Notify EMS supervisor Taken from the 2007 Clarian Guidelines for EMS needlestick exposures

24. Once You Get to the EMTC You will be immediately triaged to the fast track You will be immediately triaged to the fast track EMTC health care provider witll assess the exposure EMTC health care provider witll assess the exposure The provider will esnure the affected areas are clean as promptly as possible The provider will esnure the affected areas are clean as promptly as possible The OUCH nurse will be notified The OUCH nurse will be notified

25. Then What? Blood draws Blood draws CBC, CMP, b-HCG CBC, CMP, b-HCG 1 st dose of emtricitabine and tenofovir, lopinavir/ritonavir 1 st dose of emtricitabine and tenofovir, lopinavir/ritonavir If very high risk this will be broadened If very high risk this will be broadened You will be d/c with You will be d/c with Emtricitabine Emtricitabine Tenofovir Tenofovir kaletra kaletra

26. The Next Day Occupational health will be responsible for drawing baseline Hepatits B, C and HIV lab work Occupational health will be responsible for drawing baseline Hepatits B, C and HIV lab work

27. What About the Patient? The Clarain OUCH nurse will coordinate getting blood for Rapid HIV, HBV, HCV The Clarain OUCH nurse will coordinate getting blood for Rapid HIV, HBV, HCV What if they refuse draws? What if they refuse draws? The employer or the Indiana State Health department may petition the court The employer or the Indiana State Health department may petition the court Physical restraint may NEVER be used Physical restraint may NEVER be used What if we are not going to EMTC? What if we are not going to EMTC? The staff physician or charge nurse will complete all steps The staff physician or charge nurse will complete all steps

28. HIV Exposure Prophylaxis Other drugs Other drugs Zidovudine (AZT) Zidovudine (AZT) Lamivudine (Epivir) Lamivudine (Epivir) Indinavir (Crixivan) Indinavir (Crixivan) All have shown to have great results at preventing seroconversion All have shown to have great results at preventing seroconversion

29. Issues in HIV Prophylaxis Current ZDV doses well tolerated Current ZDV doses well tolerated Short term toxicity seen in higher doses includes GI symptoms, fatigue, headache Short term toxicity seen in higher doses includes GI symptoms, fatigue, headache Contraindicated in pregnancy/breastfeeding Contraindicated in pregnancy/breastfeeding Toxicity of other antiretrovirals not well studied in HIV negative individuals Toxicity of other antiretrovirals not well studied in HIV negative individuals In HIV +, 3TC can cause GI symptoms, pancreatitis In HIV +, 3TC can cause GI symptoms, pancreatitis

30. Issues in HIV Prophylaxis IDV toxicity in HIV + individuals includes GI symptoms and with prolonged use, increased incidence of: IDV toxicity in HIV + individuals includes GI symptoms and with prolonged use, increased incidence of: hyperbilirubinemia hyperbilirubinemia kidney stones (<5%) kidney stones (<5%) Prophylaxis should be initiated ASAP, preferably within 1-2 hours post-exposure. Prophylaxis should be initiated ASAP, preferably within 1-2 hours post-exposure. No absolute cut-off for prophylaxis start No absolute cut-off for prophylaxis start

31. HIV Exposure and Work Duty Does not need to be removed from pt care Does not need to be removed from pt care Counsel to practice safe sex for 6 mos Counsel to practice safe sex for 6 mos Baseline and follow-up HIV testing at 6 weeks, 3 months, and 6 months Baseline and follow-up HIV testing at 6 weeks, 3 months, and 6 months For HIV positive EMTs, avoid invasive procedures For HIV positive EMTs, avoid invasive procedures

32. Needle stick Prevention in EMS No needle recapping No needle recapping Avoid two handed techniques Avoid two handed techniques Needle less drug administration Needle less drug administration Proper and immediate disposal of needles Proper and immediate disposal of needles Attention to task and patient behavior Attention to task and patient behavior Communication with EMS driver Communication with EMS driver Reassessment of need for IV, meds Reassessment of need for IV, meds

33. Next Case Called for Cough and Fever Called for Cough and Fever Find a homeless gentelman on the streets. Find a homeless gentelman on the streets. Claims he has been coughing up blood for the past year progressively worsening Claims he has been coughing up blood for the past year progressively worsening

34. Tuberculosis Airborne transmission in droplets < 5 micrometers in diameter Airborne transmission in droplets < 5 micrometers in diameter Symptoms associated with active TB: Symptoms associated with active TB: persistent cough > 3 weeks persistent cough > 3 weeks bloody sputum bloody sputum night sweats night sweats weight loss weight loss fever fever

35. Tuberculosis Exposure CXR most useful study for contemporaneous assessment of exposure risk CXR most useful study for contemporaneous assessment of exposure risk Exposed EMT should have Mantoux skin test for TB at baseline and again in 12 weeks Exposed EMT should have Mantoux skin test for TB at baseline and again in 12 weeks

36. Mantoux Skin Test < 5mm: negative < 5mm: negative > 5mm and 5mm and < 10 mm: negative UNLESS: HIV + or risk factors for HIV HIV + or risk factors for HIV recent TB contact recent TB contact CXR shows fibrotic changes of TB CXR shows fibrotic changes of TB >10 mm and 10 mm and < 15 mm: negative UNLESS: several risk factors for TB several risk factors for TB > 15 mm: positive > 15 mm: positive

37. Tuberculosis Prevention HEPA filter masks to filter particles 1 micrometer diameter or more HEPA filter masks to filter particles 1 micrometer diameter or more Suspected patients wear surgical masks over mouth and nose Suspected patients wear surgical masks over mouth and nose Open windows of ambulance Open windows of ambulance Air conditioning/heat on nonrecirculation mode Air conditioning/heat on nonrecirculation mode

38. Tuberculosis Treatment Refer to pulmonary/infectious disease consultants Refer to pulmonary/infectious disease consultants Multidrug resistent TB increasing Multidrug resistent TB increasing Selection of antituberculosis meds based on local sensitivities and profiles Selection of antituberculosis meds based on local sensitivities and profiles

39. Tuberculosis and Work Duty Does not need to be removed from pt care unless EMT has active disease Does not need to be removed from pt care unless EMT has active disease If EMT has a prior history of treated TB needs to be counseled on symptoms of active TB If EMT has a prior history of treated TB needs to be counseled on symptoms of active TB

40. Last Case Called to a local ECF for “Altered Mental Status” Called to a local ECF for “Altered Mental Status” Find an 87 y/o female who has had fever 104 and headache Find an 87 y/o female who has had fever 104 and headache Transport Transport 2 days later the doc lets you know that she was diagnosed with meningitis 2 days later the doc lets you know that she was diagnosed with meningitis What do you do? What do you do?

41. Bacterial Meningitis Neisseria meningitidis Neisseria meningitidis Haemophilus influenzae Haemophilus influenzae Streptococcus pneumoniae Streptococcus pneumoniae Who needs prophylaxis Who needs prophylaxis

42. Meningitis Exposure Prophylaxis Neisseria meningitidis Neisseria meningitidis if contact with oral secretions, intubation, suctioning if contact with oral secretions, intubation, suctioning rifampin 10 mg/kg/dose max 600mg BID x 2d rifampin 10 mg/kg/dose max 600mg BID x 2d ciprofloxacin 500mg single dose ciprofloxacin 500mg single dose Haemophilus influenzae Haemophilus influenzae same exposures as with n. meningitidis same exposures as with n. meningitidis rifampin 600mg qd x 4 days rifampin 600mg qd x 4 days

43. Meningitis Exposure Prophylaxis Streptococcus pneumoniae Streptococcus pneumoniae no specific post-exposure prophylaxis recommended no specific post-exposure prophylaxis recommended All meningitis exposures All meningitis exposures counsel exposed providers on signs and symptoms of meningitis counsel exposed providers on signs and symptoms of meningitis

44. Meningitis and Work Duty Does not need to be removed from pt care unless signs and symptoms of meningitis develops Does not need to be removed from pt care unless signs and symptoms of meningitis develops

45. Summary Universal precautions at all times Universal precautions at all times Practice good needle safety Practice good needle safety Be aware of the HIV post-exposure prophylaxis Be aware of the HIV post-exposure prophylaxis Remember respiratory isoloation as part of universal precautions Remember respiratory isoloation as part of universal precautions When in doubt…ask! When in doubt…ask!