Importance

·          High risk situations

·          Uncontrollable situations

·          All incidents are potentially infectious

Defense Mechanisms

Physical Barriers

·          Intact skin - 1st line of defense against the transmission of most diseases

·          Mucous membrane - Includes the eyes, mouth, and nose (as well as linings of digestive, respiratory, reproductive and urinary tract). The mucous secreted by these membranes entrap foreign particles, so they can be swept away or destroyed.

Chemical Barriers

·          Sweat, skin oils and stomach acids are toxic to many types of bacteria.

Inflammatory Response

·          A tissue reaction to an injury or disease causing agent (may include pain, swelling, itching, redness and warmth).

Immune Response System:

Recognize invading organisms:

·        Macrophages: reconnaissance cells float through the body in search of invading organisms

 Establish defenses:

·        T-4 Helper Cells: Determine the appropriate response necessary to destroy the invading foreign body

Attack:                    

·        B-Cells: Manufacture antibodies to neutralize or tag the invader to be attacked by other cells and chemicals

Suppression of the immune response:    

·        T-4 Killer Cells: Recruited by the Helper T-Cells to kill human cells that have been invaded

·        T-Suppressor Cells: Slow down or call off the attack after the infection has been conquered

·        Memory Cells: Generated during the initial infection, make an impression    of the foreign invader and store the imprint so it will be recognized at a later time should it reinfect the body

Requirements for an Infection to Occur:

Infectious Agent:

·        Disease causing organisms (i.e.: bacteria, fungi, worms, virus, yeast)

Chain of Transmission

·        Reservoir - The location where infectious agents grow, are nourished and reproduce, such as the fluids and organs of the human body

·        Portal of Exit - The opening through which the infectious agent leaves the body (i.e. mouth, nose or cut)

·        Means of Transmission - The vehicle by which the infectious agent leaves the reservoir and enters the new host (airborne, direct/indirect contact, enteric or vector)

·        Portal of Entry - The opening through which the infectious agent enters the new host (i.e.: mouth, nose or cut)

·        Susceptible Host - The host organism or body that is vulnerable to the infectious agent

  Pathophysiology

·        Origin remains unknown, like the viruses that cause chicken pox, measles, and polio

·        Attack of Immune System

·          Takes over helper T cells: HIV requires a "host" cell in order   to live and reproduce

·        HIV Disease Spectrum

HIV INFECTION

SEROCONVERSION

SYMPTOMS

AIDS

No symptoms; negative test result

      Average time:

                   -----

 Average time:

                   ----

               <------

Antibodies can be detected; positive test result

3 months

---------->

5 years

------------------------

Once Infected Always

-------------------------

Fatigue, night sweats, fever, diarrhea, weight loss

----------------------

Infected

----------------------

HIV positive &

T-cell level < 200

                or

HIV positive & one or more opportunistic infections (i.e. pneumocystis carinii, Kaposi's sarcoma, etc.)

---->

---->

Transmission:

·        Unprotected sexual intercourse with an infected person

·        Exposure to infected blood

·        Exposure to infected breast milk

Exposure:

·        Fluid or substance capable of transmitting an infectious agent in a manner that may have a harmful effect  (infected blood enters the body - not that it was splashed on intact skin or clothing)

Infection:

·        The condition in which the body or a part of it is invaded by a disease causing agent, that under favorable conditions multiplies and produces harmful effects

 Body Fluids Linked and Not Linked with Transmission

 LINKED

   · Blood

   · Amniotic fluid (around fetus)

   · Peritoneal fluid (abdominal cavity)

   · Synovial fluid (around joints)

   · Vaginal secretions

   · Any fluid visibly contaminated with blood

   NOT LINKED

   · Tears

   · Sputum

   · Saliva

   · Vomitus

· Semen

· Pericardial fluid (around heart)

· Pleural fluid (around lung)

· Cerebrospinal fluid

· Nasal secretions

· Sweat

· Urine

· Feces

Chain of Transmission:

Reservoir: human  (symptomatic or asymptomatic)

o       Incubation period: variable - refer to disease spectrum

o       Period of Communicability: unknown, presumed to begin early after infection and extends throughout life.

·        Portal of Exit: broken skin, penis, rectum, vagina, breast milk, blood

·        Means of Transmission:

            direct contact: blood, fluids from wounds, mucous membranes, exchange of semen, vaginal/cervical secretions

            indirect contact: sharing needles, needlesticks, tattooing & ear piercing with contaminated needles

·        Portal of Entry: broken skin, urethra, rectum, vagina, mouth, eyes

·        Susceptible Host: anyone

AZT for Postexposure Prophylaxis to HIV:

·          AZT: (Zidovudine) Inhibits an essential enzyme that the HIV virus needs in order to develop and reproduce

·          Effectiveness: According to the CDC, the efficacy for humans after exposure to HIV cannot be assessed because of insufficient data

·          When to consider: The routine use of AZT prophylaxis following occupational exposure remains controversial.

            DRs PRO AZT: Want it offered after certain exposures due to the severity of the illness which may result, and since the effects of acute toxicity appear to be reversible.

            DRs ANTI AZT: Should not be offered due to the lack of data demonstrating efficacy; limited data on toxicity in uninfected individuals has been shown to produce cancer in rats and mice.

City of Long Beach Occupational Health does offer AZT prophylaxis; treatment can be accepted or declined.

·          Side effects: Current recommended doses are tolerated well by health-care workers; short-term toxicity associated with high doses may cause gastrointestinal symptoms, fatigue, and headache.

Other side effects from long-term use include: fever, fatigue, severe anemia, headache, muscle pain,loss of appetite, diarrhea, hepatitis, meningitis and muscle inflammation.

Emergence of New Drugs:

New antiretroviral agents have been approved for use within the last couple of years due to increasing resistance to AZT

Use of AZT in combination with other drugs increase the antiviral activity

Other Postexposure Prophylaxis (PEP) Recommended by                    Occupational Health:

3TC (Lamivudine) - antiretroviral agent

·          Used in combination with AZT

·          Combat the many HIV strains resistant to AZT

·          Studies show no increase in side effects

·          No data available to predict toxicity in healthy persons

·          Side effects:  in HIV-infected adults, it has been shown to cause gastrointestinal symptoms and, in rare cases, pancreatitis

Indinavir - protease inhibitor

·          Used in combination with other antiretroviral drugs

·          Potent antiviral activity/Recommended only for massive exposures

·          Side effects:  toxicity with this drug may cause gastrointestinal symptoms, and prolonged use may cause hyperbilirubinemia (10%) and kidney stones (4%)

Postexposure Prophylaxis (PEP)

·          Should be initiated promptly, preferably within 1 - 2 hours postexposure

·          Probably not effective when started later than 24 - 36 hours postexposure

·          Recommended administration period: 4 weeks

CITY OF LONG BEACH OCCUPATIONAL HEALTH

Postexposure Follow-Up

·          Periodic examinations (2 weeks, 4 weeks, 6 weeks, 3 months, 6 months, and 12 months, if on PEP)

·          HIV testing (baseline, 3 months, 6 months, and 12 months)

·          Education and counseling

·          Recommends condoms/ safe sex precautions

·          Inflammation of liver

·          Hepatitis can be mild and brief, or severe and life-threatening

·          Signs and symptoms: loss of appetite, abdominal pain, clay-colored stools, dark urine, enlarged liver and jaundiced (or no symptoms). 

·          Types of hepatitis: HAV, HBV, HCV, HDV, HEV

·          (HAV, HEV: oral/fecal)

·          (HBV, HCV, HDV: Bloodborne)

Chain of Transmission

·          Reservoir: human

            Incubation period: 45-180 days, average 60-90 days, can be as short as 2 weeks

            Period of Communicability: Can be infectious many weeks before the onset of first symptoms (some may become chronic carriers)

·          Portal of Exit: urethra, vagina, blood vessels

·          Means of Transmission:

            Direct contact:  blood, fluid from draining wounds, splash to mucous membranes, saliva, semen, cervical/vaginal secretions, human bites

            Indirect: sharing needles, needles sticks, tattooing & ear piercing with contaminated needles

·          Portal of Entry: urethra, vagina, mucous membranes, broken skin, rectum

·          Susceptible Host: anyone who has not become immune after vaccination

HBV Vaccine

·          Safety

             Administered in 3 doses over a 6 months period

             1 in 6 people experience mild fever, headache, fatigue, nausea. 

             No severe side effects have been reported

·          Immunity

             10% do not become immune after receiving the vaccine

              Employer not required to do post-vaccine titer or 4th shot

·          Effectiveness

             Length of immunity is still being studied.  CDC unable to               recommend if booster is necessary

Chain of Transmission

·          Reservoir: human

            Incubation Period: 2 weeks to 6 months; most commonly, within 6-9 weeks

            Period of Communicability: From 1 or more weeks before onset of the 1st symptoms through the acute clinical course of the disease (some may become chronic carriers)

·          Portal of Exit: blood vessels, urethra, vagina

·          Means of Transmission:

          Direct contact: blood, semen, vaginal secretions

          Indirect contact: sharing needles, transfusions, needlesticks

·          Portal of Entry: mucous membranes, broken skin, rectum, urethra, vagina

·          Susceptible Host: anyone

·          Characteristics:

           · Small

           · Remain airborne with normal air currents

·          Signs and Symptoms:

           · General: feeling weak, weight loss, fever &/or night sweats

           · Pulmonary: cough, chest pain, coughing up blood

·          Infection:

            · Infection without active disease: Immune system limits TB's           multiplication and spread of bacteria; it lies inactive and is not        communicable

            · Active disease: Occurs when bacteria becomes established in the    lung cells and spreads throughout the body resulting in active symptoms.

            · MDR - TB (multi-drug resistant TB):  Spread the same but            resistant to most TB antibiotics due to noncompliance with medications.

·          Testing

            · Unless there is documentation of a previous positive TB skin test,  each employee should be provided with a TB skin test every 6 months if they provide health care, and either have prolonged regular exposure to TB cases or are involved in high-risk procedures.

Chain of Transmission

·          Reservoir: human

            Incubation Period: 2 to 10 weeks after exposure, a person may develop a positive response to a TB skin test.  Without treatment, active disease can occur in 5-10% of the infected people sometime in their lives.        

            Period of Communicability: Persons with active disease who have been placed on medication and are compliant for at least 2 weeks usually become noninfectious.  (medication is usually continued for a period of 6 to 18 months)

·          Portal of Exit: mouth or nose

·          Means of Transmission: airborne: inhaling infectious droplets

·          Portal of Entry: mouth or nose

·          Susceptible Host: anyone, especially those listed in the high risk groups listed below

High Risk Groups

·          People who share the same breathing space with someone with TB in the communicable stage (family, friends, co-workers)

·          Poor & homeless

·          Correctional facility personnel

·          Nursing home residents & employees

·          Immigrants from other countries with high TB rates

·          Medical conditions such as diabetes, certain CA, those underweight

·          HIV infected persons

·          Workers who serve any of the above high risk groups

General Prevention Measures

·          Good Health

           · Physical

           · Mental

·          Immunizations

          · Tetanus

          · Hepatitis B Vaccine

·          Universal Precautions

Universal Precautions

·          Handwashing: as soon as possible after patient contact

·          Gloves: all patient contacts, when cleaning equipment

·          No recapping, bending or breaking needles or sharp objects

·          Masks, protective eyewear, and gowns should be worn when splashes of blood and other body fluid is expected

·          Ventilatory devices: no mouth to mouth

·          Cover open cuts or sores with dry bandage

·          Treat all patients as potentially infectious

Decontamination of Equipment

·          Disposable

           · Sharps: puncture resistant containers

           · Contaminated supplies: infectious waste bags

·          Non Disposable

           · Clothing: change and decontaminate ASAP

           · Delicate equipment: scope, radios: mild detergent

           · Large rescue equipment: traction splints, backboards:  wexcide

           · Vehicle: passenger spaces, seats: wexcide

·          No decontamination of equipment should be done in food preparation areas

Determining Exposure

·        Airborne: Any contact with patients with productive cough, sneezing, etc.

·        Bloodborne - Ask two questions:

            1.         Is the fluid or substance with which you came in contact with any of the following:  

                        blood, semen, vaginal secretions, or any fluid visibly contaminated with blood

            2.         Did this fluid enter my body through any of the following:

                        needlestick, laceration by contaminated object (i.e.: broken glass, blade, or other sharp object), open cut, wound, eyes, mouth, or nose (mucous membranes)

            If the answer to both questions is "yes", then an exposure HAS occurred; if the answer to either question is "no", then there HAS NOT been an exposure.

·        Enteric(fecal - oral): ingestion of contaminated food or water

·        Vector: bitten by an insect or animal

Long Beach CD Exposure Procedures

·          Inform Captain of Exposure

·          Call AO who will contact an EMS Educator

·          EMS Educator will provide information, direction & assistance

·          Wound care

Long Beach Reporting Procedures

·          Exposure & Notification Report (FR-109)

·          Enter into fire station log

·          Workers Comp. Form (SF-372)

·          OSHA injury/Exposure Report (SF-314)

Legal Aspects

·          Americans with disabilities Act: prohibits discrimination due to disabilities, those with contagious diseases are considered disabled

·          Health & Safety Code

            199.2: unable to ID anyone having or being tested for HIV

            199.95: requires that information vital to the health & safety of the public   be given to medical personnel, firefighters, police, victim of sexual assault so that precautions may be taken

            199.96: allows sexual assault victims to petition court to have attacker tested for AIDS

            199.97: allows personnel to petition court if source person charged with criminal complaint & the person interfered with the official duties of firefighter, police, medical personnel

·          Penal Code 1524.1: allows victim of any crime to petition court, if there was probable cause of transfer of fluids capable of causing HIV

·          Prophylactic Treatment (H&S Code 1797.186): entitles employees exposed on the job to prophylactic treatment

·          Royce Bill (H&S Code 1797.188): allows prehospital workers to be notified  if exposure to a reportable disease has occurred

·          Ryan - White: allows prehospital workers to be notified if exposed to HIV, hepatitis, TB, meningitis, diphtheria, plague, rabies, hemorrhagic fevers; limits time frame of 48 hours for each step of notification

·          Russell Bill (H&S Code 199.65): allows testing of source person's blood for HIV without consent; does not allow blood to be drawn without consent, test must be done on  available blood samples if source person denies consent   

Duty to Provide Care

Legislative Counsel of California

·          Emergency care providers have the general duty to provide CPR to the cardiac arrest victim. Personnel cannot wait for mechanical breathing devices. "The delay caused by the lack of a mechanical device would be a breach of duty".

·          "It is possible that the court might find a refusal to provide services as reasonable when the firefighter is bleeding, whereas, since no reported cases of HIV have been spread through saliva, refusal to do CPR without a pocket mask might not be found as reasonable".