City of Virginia BeachDepartment of EMS

OSHA Refresher ProgramBloodborne Pathogens and Tuberculosis

Exposure Control Plan

Refresher Program GoalTo reduce the occupational transmission of infections caused by microorganisms that may be found in human blood and other potentially infectious materials. This is accomplished by continuing to inform, educate and update the EMS provider on infectious disease, infection control, and methods that may prevent or reduce exposure.

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Key Players:

Bloodborne Pathogens Standards: Occupational Safety & Health Administration (OSHA)

Tuberculosis (TB) Guidelines, Disease Monitoring, & outbreak info: Centers for Disease Control (CDC)

Virginia Disease Monitoring: Virginia Department of Health

Program Notes:This is a refresher program, and is designed to provide an annual update to our members who have already taken our Initial OSHA program. Taking notes is suggested.

Need more information?There is a list of reference websites at the end of the programAccess and review our full Initial OSHA online programContact us

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Have a question about this update?If you have a question that you aren’t able to find an answer to, in this program, please contact:

Normal Business hours: (8AM-5PM)The VBEMS Administration Office (757) 385-1999

Attention: Division Chief John Biancoor

The VBEMS Training Center (757) 385-2975Attention: Instruction Supervisor Eric de Forest

After hours*: (5PM-8AM) EMS 5 (Shift Commander) – (757) 635-7695EMS 6 (Duty Field Supervisor) – (757) 274-2946EMS 7 (Duty Field Supervisor) – (757) 284-7247EMS 8 (Duty Field Supervisor) – (757) 536-0510* In the event that your call is not answered, please do not leave a message – try back in a few minutes.

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Update in Focus:

Essentials ReviewStandard PrecautionsExposure?Prevention

Disease Statistics Monitoring: U.S. & VirginiaDisease Watch Spotlight: U.S. & Global

Essentials Review: Transmission Based Precautions

Standard Precautions for the pre-hospital providerAll exposures to body fluids, under any circumstances, are potentially infectiousContact precautions: blood and body fluid – gloves for contact, mask & eye protection for splatter/coughAirborne and droplet precautions: surgical mask for patient or provider* and utilize eye protection

CDC identifies masking patient within 3 feet for droplet diseasesGross body fluid protection: personal fluid-resistant gown and contamination precautions

*Providers should have the patient wear a surgical mask when needed

If the patient refuses, utilize a surgical mask yourself 7

Essentials Review: Masks

EMS Providers use Surgical Masks

Filters infectious particles during inhalation & exhalation Limits spread of respiratory secretions Good external droplet protectionSome masks have face shield visorsMuch less expensive than N-95 masks

N-95 maskFilters incoming infectious particles from the air a provider breathesN-95 particulate respirators are minimum level of protection “for emergent settings, where there is a need for emergency intubation and open suctioning of airway.” (CDC, 9/16/2010)

We use closed-canister suctioning in EMSThere is no evidence to show N-95s are more protective than surgical masks

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Essentials Review: Prehospital Housekeeping

Decontamination/DisinfectionClean-up gross contamination first (fluids)OSHA recommends primary use of 1:10 dilution of bleach and water (must be mixed fresh daily)May also use appropriate cleaning solution (EPA approved germicide)

“Sani-Cloths or germicidal wipes” Rinse (if recommended)Air dry

For metal and electronic equipment70% isopropyl alcoholAllow to air dry

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Reminder:

When cleaning unit and equipment for c. diff. (clostridium difficile) and norovirus, a chlorine based cleaning agent is needed

Hand washing post-care of a patient with c. diff. is with warm water and soap

Waterless alcohol-based cleaners are not effective

Essentials Review: Prehospital Housekeeping

Essentials Review: Uniforms & Clothing**Always carry a change of clothing with you on duty

For small fluid spot/stain:Remove article of clothingIf soaked through to skin, clean skin with soap and waterClean spot with soap and waterHydrogen peroxide may help lift blood stainsPat dry

Larger exposuresRemove soiled clothes and place in red bagTake to dedicated decontamination site for washingCan take clothes home to dryFor scrubs – Call EMS 5/6/7/8

Must sign for, launder and return (not always available, see above**)

DO NOT TAKE UNWASHED, CONTAMINATED CLOTHING HOME 11

Essentials Review: What is an exposure?

An “exposure incident” is defined as:A specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood or other potentially infectious materials that results from the performance of an employee’s duties

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Essentials Review:I think I Have an Exposure

Clean/flush the affected areaContact EMS 5/6/7/8 immediately and they will meet you at the hospitalEMS 5/6/7/8 will make contact with Occupational Health during business hours (or the contracted consultant after hours) who will determine if an exposure occurred and what the next steps are

If an exposure did not occur: The situation is treated as an injury (assaults, etc.) No exposure paperwork is completed 13

Essentials Review:I Have an Exposure

If an exposure did occur:EMS 5/6/7/8 will provide a standardized form to the hospital for blood to be drawn on the source patientEMS 5/6/7/8 will also complete the rest of the required paperwork such as a DF-75 and other standardized forms for exposuresYou will need to complete a written statement of the eventsYou will be directed to occupational health for your baseline lab testing

If after hours, this could mean the next morning There are instances in which you will be directed to VBGH or Now-Care for baseline lab testing if it is determined to be necessary 14

Essentials Review:Exposure – Occupational Health & Follow up

An Occupational Health/Exposure Control Consultant will counsel you and determine your course of action (monitoring, medication, etc.)All result notifications and follow-up will be conducted and coordinated by Occupational Health

Your privacy is very important…EMS starts the process and that is the end of our involvement unless you contact us

Essentials Review:The Common Cold vs. Flu

Treatment of Colds and FluSupportive

Rest, plenty of Fluids Minimize contact with othersAntibiotics do not treat viruses 16

Sneezing Virus Muscle aches

Low-grade fever possible

Sore throat Severe cough

Runny nose High fever

Cough GI symptoms

Headache

Cold Both Flu

Essentials Review: Influenza – Prevention

EMS Providers should get the vaccine annuallyVaccine comes as injection or nasal mist The viruses in the flu shot are killed (inactivated), so you cannot get the flu from a flu shotSome minor side effects that could occur are:

Soreness, redness, or swelling where the shot was given, fever (low grade), ache

Tamiflu (influenza antiviral medication – not a vaccine)Not a substitute for early and annual influenza vaccination (www.tamiflu.com)Influenza antiviral prescription drugs (such as Tamiflu) can be used to treat influenza or to prevent influenzaCDC does not recommend seasonal or pre-exposure antiviral chemoprophylaxis with medications like Tamiflu, but antiviral medications can be considered for chemoprophylaxis in certain situations (note: “chemoprophylaxis” is not the same as “vaccination”) (http://www.cdc.gov/flu/professionals/antivirals/summary-clinicians.htm)

Patient Contact:Good hand hygiene is beneficialGloves and mask when within 3 feet of patientKeep patient area well ventilated

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Essentials Review:Who should not get a Flu Vaccination? (CDC)

Persons/providers who or with:Experienced a severe life threatening allergy to a prior dose of seasonal flu vaccineA history of Guillain-Barre Syndrome (GBS)Children younger than 6 monthsAn active fever

Most egg-allergic patients can safely receive the inactivated influenza vaccine. Those with a history of severe life-threatening allergy to eating eggs should consult with a specialist with expertise prior to receiving the vaccine. 18

Essentials Review:Hepatitis B (HBV) Testing & Treatment

Titer is done if an exposure occurs Once you have a positive titer, you never have to titer test again, even if an exposure occurs

Medications include:Baraclude (anti-viral medication)Interferon

For chronic Hepatitis BDoes not prevent spread of infection

Essentials Review:Rapid HIV Testing

Virginia HIV Testing – Random testing for HIV unless declined by patient, except if a health care worker has a possible exposure (patient then can’t decline test)

RAPID HIV TESTING IS THE STANDARD OF CARE FOR EMS WORKERS IN THE EVENT OF EXPOSURE

Results available in as little as 5 minutesTest for virus, not antibodiesIf source patient is negative

No more testingIf source patient positive

Further testing 20

Essentials Review:Post Exposure Prophylaxis (PEP) (If source is HIV+ )

Specialist physician may prescribe anti-viral drugs based on circumstancesStart PEP ASAP after exposure

Regard as a medical emergencyBegin PEP within hours if possible

Pregnancy not a contraindicationMake an informed decision with physician

PEP FOLLOW UP / MONITORINGExtremely important & MandatoryTolerating the treatment? Report any side effects… Treatments may change…21

HIV/Aids TreatmentsAIDS “cocktail” drugs have improved outcomes and 96% of patients are unable to transmit the diseaseHIV/AIDS patients are living from time of diagnosis to end-of-life – 50 years now (NIH, May 2011)

Relatively new triple drug therapy used together (48 weeks) reduces the virus to 0% in body (CDC, 10/2012)

AtripilaStribild Truvada

Caused by strains of mycobacteriaTransmitted through the air by patients with an active TB infection (cough, sneeze, etc.)Signs & symptoms: chronic cough, blood-tinged sputum, fever, night sweats, weight lossMost infections do not have symptoms (latent TB) About 1 in 10 latent infections eventually progresses to active disease (If left untreated, kills more than 50% of those so infected)

< States in Blue have higher incidence of TB

Essentials Review: Tuberculosis

Essentials Review: Tuberculosis Virginia Beach is a low-risk area Provider Risk Assessment Tool*:

Low-risk: transported less than 3 confirmed TB Patients within last 12 monthsMedium-risk: transported more than 3 confirmed TB patients within the last 12 months

24*(CDC TB Guidelines 2005)

About 80% of the population in many Asian and African countries tests positive in tuberculin tests, while only 5–10% of the United States population tests positive

Essentials Review:Tuberculosis Exposure Risk

Depends on:Time spent with untreated individual

Not contagious 14 days after treatment started in most cases

Ventilation present during time with patient?2-10 hours in confined, non-ventilated space = possible infection exposure

Prevention measures used: masking pt., good hand washing, good provider health and immune system, ventilation

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VBEMS and TB Testing

Annual testing of TB is no longer required. However, all members must be trained annually in TB risk factors and all members must be offered the opportunity for a risk assessment screening and evaluation.

The Department of EMS offers all VBEMS providers the opportunity to complete Virginia Department of Health recommended TB Risk Assessment Screening with the consultation of the Registered Nurses. Any provider wishing to complete an annual TB Risk Assessment form should contact Division Chief John Bianco or call (757)385-1999.

What should I protect myself from?

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~ Bloodborne pathogens• Hepatitis B • Hepatitis C• Hepatitis D • HIV• West Nile Virus• Viral Hemorrhagic Fevers

~ Droplet▪ Influenza▪ N. Meningitis▪ Mumps▪ Enterovirus D68▪ Pertussis▪ SARS-Corona Virus▪ Ebola

~Airborne- Measles - Chicken Pox- Tuberculosis

~ Additional/Contact - Hepatitis A

- MRSA - CA-MRSA - VRE - Norovirus - Common Cold -Rhinovirus - Syphilis

Monitoring Disease in the US2013 - 2014

2013:HIV – N/A**Hepatitis B – 3,050Hepatitis C – 2,138Syphilis – 17,375TB – 9,582

2014:N/A**2,636 1,75218,131 8,420

28Showing decrease or increase from previous year

CDC, MMWR, Jan/2015 - Provisional

**CDC has redefined – statistics not available

Monitoring Other Active Diseases in the US

2013 Measles – 184 Mumps – 1,238Pertussis – 24,231 (whooping cough) Chickenpox – 9,987Rubella – 9

20146281,15128,660

9,0588

29Showing decrease or increase from previous year

Disease Monitoring in Virginia2014

HIV – ** (2013 – 1,151)Hepatitis B – 165Hepatitis C – 55TB – 175 Syphilis – 289 Measles – 0Mumps 18Rubella – 0Chickenpox -240Pertussis - 464

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VBEMS Exposures* in 2014Bloodborne?

3 (3 incidents)

Airborne/droplet?4 (1 incident)

*The number of exposures reported here is the number of potential exposures reported to occupational health and does not represent whether or not the source patient tested positive or whether or not the provider contracted the disease

Disease Watch: U.S.Almost all the confirmed cases of EV-D68 infection were among children, who had a history of asthma or a history of wheezing. Infants, children, and teenagers are most likely to get infected. Those with a history of asthma have a higher risk for severe respiratory Illness associated with D68. There are no vaccines or treatments currently for EV-D68 infections.

States with Lab-confirmed Enterovirus D68

Enterovirus D68 (Non-Polio) 2015 UpdateMid-August through January 15, 2015, CDC & state public health laboratories have confirmed a total of 1,153 patients in 49 states and the District of Columbia with EV-D68 related respiratory illness. 14 patients have died. (CDC 3/2015)

Disease Watch: U.S.CRE – (Carbapenem-resistant Enterobacertiaceae) are a family of germs that are difficult to treat because they have high levels of resistance to antibiotics. Some of our normal gut bacteria can develop resistance.

Healthy People don’t usually get CRE infections. They occur typically in patients in the hospital, nursing homes, and healthcare settings. Those who are on ventilators, or have urinary or venous catheters, or those who take long courses of antibiotics are at greatest risk.Some CRE bacteria have become resistant to most available antibiotics. Mortality may reach up to 50%.

States reporting NDM- producing CRE Jan 2015

Global Awareness:Travel History

Travel history now recommended for all patients (CDC)If patient is ill after returning from overseas, find out when they arrived, what airline and flight numberTravel History is especially important with patients who have respiratory Symptoms:

SARS – (Severe Acute Respiratory Syndrome) Coronavirus Co-Virus MERS – (Middle Eastern Respiratory Syndrome)Bird FluEbolaH1N1

Disease Watch: GlobalEBOLA Update 2015

The 2014 West Africa Ebola Epidemic (Hemorrhagic Fever Virus) Thought to have started from a single case in Guinea 12/20134 total cases & 1 death in U.S. through 9/2015Total Suspected cases in Africa 28,388 – total deaths in Africa: 11,296 (CDC, 9/27/15)

CDC - Detailed EMS Checklist for EBOLA Preparedness

Ebola Information for EMS Providers – VA OEMS

Provider Health:How else should I protect myself ?

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~ Control your Blood Pressure• Stop Smoking• Decrease and track sodium

intake• Lower your and maintain

your weight• Learn your BMI score• Be more active

~ Maintain a healthy Weight● Eat smart, healthy choices● Get 150 minutes a week of Moderate Exercise● Pack a meal in place of unhealthy “fast food”● Limit or avoid fried, sugary, and salty foods

~ Discover Well Being- Get 7-8 hours of sleep daily- Stay well hydrated (Soda, coffee, Black Tea, Alcohol do not count)- Know your Cholesterol level-Know your Blood Pressure- Get a physical annually- Take time to de-stress

~ Prevent Disease - Stop Smoking

- Stop dipping or chewing tobacco- Limit Alcohol intake- Avoid sugary food and drinks- Get Annual Flu Shot

Provider Health:How else should I protect myself ?

Provider Health:How else should I protect myself ?

The CDC recommends all HealthCare Workers (including EMS) get the annual flu shot

3 recent studies show EMS participation is lower than for any other Healthcare Worker group

Summary: How can I protect myself?

Engineering and work practice controlsGood hand hygiene – before & after each patientUse Standard PrecautionsContact PrecautionsDroplet precautions Use Appropriate PPE (personal protective equipment)Be alert for hazardsAvoid cross contamination between patient and unit equipment, door handles, overhead bar…etc.Clean unit & equipment thoroughly at the start of your shift and after each call

Good personal health careEat right/healthy choicesStay well hydrated (Improves memory, and decision making)Getting plenty of rest boosts immune systemGood physical fitness helps lower stress and prevents injuryAvoid friends and co-workers who are sick

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OSHA Online Refresher Course OSHA online content revision:

Division Chief John Bianco, NRPVirginia Beach Department of Emergency Medical ServicesDesignated Infection Control Officer

Captain Jerry Sourbeer, NRPVirginia Beach Department of Emergency Medical ServicesAssistant Designated Infection Control Officer

Training Support & Development:

Eric de Forest, NRPInstruction Supervisor, VBEMS Training DivisionOSHA ICO

Lani de Forest, NRPInstruction Supervisor, VBEMS Training Division OSHA ICO Rev. 9/15

www.vabeachems.com – Virginia Beach Department of EMS

www.HealthyVB.com – City of Virginia Beach

www.flu.gov – US Department of Health and Human Service

www.vdh.state.va.us – Virginia Department of Health

www.osha.gov – US Department of Labor: Occupational Safety & Health Administration

www.cdc.gov – Centers for Disease Control

www.who.int/en/ - The World Health Organization41

Recommended Web Sites

You have completed reviewing the OSHA Refresher update.

The person most responsible for your safety and awareness of hazards is…you!

To access the post-test, exit this program and click on the link at the Refresher Course home page.