CERT Infectious Disease AwarenessCapt. Pete Masters

Infection Control & Prevention OfficerSafety & Personnel Services Division

…what were your 3 favorite movies that had some kind of infectious disease outbreak?

…and how was it handled?

…what was the outcome?

…mine were

1.The Andromeda Strain2. The War of the Worlds3. Contagion

…what were your 3 favorite disaster

movies?

…was the threat of disease even thought

of?

Generally we are concerned with diseases that can be passed from one person to another by contact with blood and body fluid, or unprotected airborne exposures

Pathogens are the causative agents of disease, whether they are viruses, bacteria, parasites, fungi, etc….

…which can then have life changing consequences

CERT responders will be identifying victims of large scale

disasters, and providing basic stabilization and care

With respect to exposures, are you only concerned

with infectious organisms from human exposures?

Tornado

Earthquake

Hurricane

Flood

Pandemic

What are the unique features of patients in each of

these different disaster conditions?

Tornado – mostly penetrating and blunt trauma

Earthquake – mostly crush injuries

Hurricane – crush injuries, exposure to weather and contaminated water

Flood – contaminated water

Pandemic – airborne and bloodborne pathogens

CERT responders must be aware of the potential for exposure to infectious diseases from contact with people they know, live next

door to, and are friends with

…but don’t know the intimate details of their medical history..

What about dirt, dust, and air kicked up by the

disaster?

Realistically.. The threat to responders would only be from

two sources

1. Patients2. Contaminated water

…and this was seen in the Joplin, Missouri tornado, where a mold in the ground caused necrotizing fungal infections that infected 13 victims with penetrating trauma from the tornado, killing 5

…but working in the same environment

no care providers were affected.

And realistically.. What is present in your environment, and what is

a threat to you are two very different things

The first realization of the study of infectious organisms and the transmission of disease is that

humans have developed a complex defense system that

protects us from organisms that we are exposed to all the time

Your body has three lines of defense…what are the other

two?

In disasters that are environmentally disruptive…

what potentially happens to the water supply?

sewage containment?

In disasters that are environmentally disruptive…

increased potential for water rescues

longer time in exposure conditions

patients who are more likely to panic

conditions and injuries that are out of the norm for ANY patient care provider

In disasters that are environmentally disruptive…

Infectious organisms that are not normally considered, from sources not normally considered

How does that change things?

Wearing more PPE, for longer periods

Make sure you are not already immunocompromised, or sick

Gloves

o They aren’t impervious to rips

o Assess for leaks, and assess your hands

o Wear them for all patient encounters

o Carry extras. Change’em out as needed

o Remove so as not to spray contaminants

Personal Protective Personal Protective EquipmentEquipment

Eye Protectiono Wear for protective

coverage when anything could splash

o Wear while around dust and water, not just patients

Personal Protective Personal Protective EquipmentEquipment

N95 respirator

Personal Protective Personal Protective EquipmentEquipment

oWear to be protected not just from human contagions, wear to protect from dusts, water sprays, and mold spores that could cause disease

Post Exposure Clean UpPost Exposure Clean Up

• Good hand washing practices

• Proper removal technique for gloves

• Proper removal technique for N95

• Proper removal technique for soiled clothing

Post Exposure Post Exposure Clean UpClean Up

oWear appropriate dedicated clothing

oDecon it before washing, if necessary

oWash it separately from other laundry

oHot wash, Hot dry cycles

oShower after significant exposures

oShower before going home if possible

Exposure ReportingExposure Reporting

• When Fire and Rescue resources arrive report your exposure to a unit officer

• You will be documented as a Good Samaritan exposure, and management of your exposure will be coordinated with the Health Dept.

• That means if there’s medical testing that’s needed the Health Dept. pays for it

Chain of Infection

oinfection is not an accident, it’s a defined chain of events, which happen in chronological order.

osame regardless of type of pathogen.

o“breaking” any link of the chain means the chain of events can’t progress to infection

…you’re given all the tools you need to protect yourself

Chain of infection components*

1.Adequate number of pathogenic organisms (dose)

2.Pathogenic organisms of sufficient virulence

3. A susceptible host

•An appropriate mode of transmission

5. The correct portal of entry into the host

*Guidelines for Environmental Infection Control in Health-Care Facilities. Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC), 2003

Which do you think is regarded as the most significant

determinant of infection?

Answer: The susceptible host

This population consists of the immunocompromised, those with invasive surgical wounds, burns, catheters, undergoing radiation or chemotherapy…and those already fighting an existing infection

oAmplifies the significance of other chain of infection components

oPathogens that would not normally be infectious by casual exposure can be infectious to this population by all modes of transmissionFor this reason you don’t work if you have burns, sutures, and infectious skin conditions, and it’s one of the reasons you have to go through PSOHC for return to work status

…be aware of when you are more vulnerable

Prompt treatmentDecontamination

Rapid Identification

Hand hygieneAirflow Control

Disinfection/SterilizationProper food handlingIsolation Precautions

Good Health & hygiene

Environmental

sanitation

Disinfection/

sterilizationProper

attire

Hand hygiene

Trash & Waste

disposal

Control of secretions

Aseptic technique

Wound care

Hand hygiene

Catheter care

Treatment of primary

disease

Recognize high risk patients

Hand hygieneAirflow Control

Disinfection/SterilizationProper food handlingIsolation Precautions

Proper attire

Hand hygiene

Trash & Waste

disposal

Control of secretions

Aseptic technique

Wound care

Hand hygiene

Catheter care

Actions that break these links are the most significant for us.

They represent our interaction with patients

Modes of Transmission

In medicine, transmission is the passing of a

disease from an infected individual or group to a previously uninfected individual or group

direct physical contact - touching an infected person, including sex

indirect contact - touching soiled or contaminated surfaces droplet transmission - coughing or sneezing on another person

airborne transmission - the microorganism can be suspended in air

fecal-oral transmission - from contaminated food or water vector borne transmission - carried by insects or other animals

Modes of Transmission

How does the pathogen enter the host?

•Ingestion

•Inhalation

•Absorption

•Injection

Modes of Transmission

An important distinction to be made is whether something is

infectious

…..or contagiousA lot of diseases are infectious that are not contagious

Modes of Transmission

If the organism can be easily transmitted by direct casual host to host exposure (or contact with secretions) then the infectious disease is contagious

Does the mode of transmission for that pathogen make it contagious? Or potentially infectious (due to exposure event)?

…examples?

Modes of Transmission

Transmission = disease from infected to uninfected

Colonization = residence

Infection = invasion and proliferation

Disease = compromise of health

Transmission vs. Colonization vs. Infection vs. Disease

Modes of Transmission

Incubation

An incubation period in medicine is the time between being exposed to a pathogen and showing first symptoms of infection

Different for different pathogens

Generally 2 – 12 days, most often 3 – 4 days.

....But, it can be weeks or months

Modes of Transmission

Acute Infection vs. Spontaneous Clearing vs. Chronic Infection

Acute Infection = replication vs. immune system

Spontaneous Clearance = immune system wins

Chronic Infection = immune system loses A lot of factors determine clearance or progression to infection

Modes of Transmission

HIV can only survive for minutes outside a host

Hepatitis C can survive at least 16 hrs …and possibly up to 4 days

Hepatitis B can survive at least 7 days

Can pathogens survive outside the body of a host?

Modes of Transmission

different pathogens have different amounts of live organisms needed to produce infection from an exposure

ex. One (1) Hepatitis B virus in 1 milliliter of blood is all that is needed to cause infection, while HIV would require 100,000 viral particles.

host resistance or susceptibility to infection is significant in determining whether exposure becomes infection

Immunocompromised patients at higher risk

Co-infected patients at higher risk

Keep yourself healthy, and your immune system healthy

Human Immunodeficiency Virus

(HIV)

Present in blood, or body fluids containing blood, semen, vaginal fluid,

amniotic fluid, cerebrospinal fluid, synovial fluid, and breast milk No Vaccine

Effective post-exposure prophylaxis (PEP)

In USA (2012)

o1.2 million infected = 1:260 and 1/5 unaware of infection

o50,000 new cases / year

HIV is the most studied entity in the history of medical science

Human Immunodeficiency Virus (HIV)

Modes of Transmission

(general population)

•Sexual contact

•Blood transfer (IV drug use)

•Mother to child

Each 10-fold increase in the level of HIV in the blood (viral load) is

associated with an 81% increased rate of HIV

transmission.

Modes of Transmission

(FD/EMS providers)

Contact with infected fluids to • non intact skin

• mucosal

membranes

• from sharps

injuries

Hepatitis B Virus (HBV)

Present chronic infection in U.S. population = 1.2 million......approx. 1:260

Vaccination series given at birth – six months

Vaccinated protection = (almost) 100%

Non vaccinated exposure seroconversion

= approx. 30%

USA population 2012 = 312.8 million

Hepatitis B Virus (HBV)Present in any body fluid; blood, saliva, semen, vaginal secretions, etc. of chronic carriers

65% of HBV infected are unaware of

infection

Incubates 45-180 days before

symptomatic presentation

Prevention with vaccination because

“stable” DNA genome

Hepatitis C Virus (HCV)

Present chronic infection in U.S. population

= 3.2 million.......approx. 1:100 (1%)

USA population 2012 = 312.8 million

CDC estimates 1:30 baby boomers (1946– 1964)

Most common bloodborne infection in U.S.

75% of HCV infected unaware that they are

Hepatitis C Virus (HCV)Present in blood, or any body

fluid containing blood (blood must be present)

No Vaccine, changing RNA genotype (mutates)

Treatment… but no guarantee to

cure

• Hepatitis C in population 1:70

Keep this in mind…

Bloodborne conditions are potentially infectious, not contagious

Practice smart patient care…

wear PPE, and maintain an awareness for the possibility of splash exposures

• Hepatitis C in population 1:70

Keep this in mind…

Airborne pathogen exposures would be very unlikely for CERT providers to encounter

… but, never say never.

• Hepatitis C in population 1:70

Keep this in mind…

Don’t put yourself in a position where you could be the next potential victim

…the two things that I respect the most

Electricity, and fast moving water