Communicable disease

Infectious DiseaseInfectious DiseaseInfectious DiseaseInfectious Disease

Infectious DiseaseInfectious DiseaseInfectious DiseaseInfectious Disease Invasion of body by organismInvasion of body by organism

– VirusVirus» must invade host cell to reproducemust invade host cell to reproduce

» can not survive outside host cellcan not survive outside host cell

– BacteriaBacteria» self-reproducing without host cellself-reproducing without host cell

» endotoxins and exotoxins often most harmfulendotoxins and exotoxins often most harmful

– FungiFungi» Protective capsules surround the cell wall and protect from Protective capsules surround the cell wall and protect from

phagocytesphagocytes

– ProtozoaProtozoa

Infectious DiseaseInfectious DiseaseInfectious DiseaseInfectious Disease

Infectious diseases affect entire Infectious diseases affect entire populations of humanspopulations of humans

ConsiderConsider– needs of patient needs of patient

– potential consequence on public healthpotential consequence on public health

– consequences of person-to-person consequences of person-to-person contacts with family members, friendscontacts with family members, friends

Communicable DiseaseCommunicable DiseaseCommunicable DiseaseCommunicable Disease

Infectious disease transmissible Infectious disease transmissible from one person to anotherfrom one person to another


AgentAgent ReservoirReservoir

– Living or non-living place where agent residesLiving or non-living place where agent resides

– May not produce symptomsMay not produce symptoms

Portal of exitPortal of exit– Route for agent to leave one host to infect another Route for agent to leave one host to infect another

hosthost


Route of TransmissionRoute of Transmission– DirectDirect

– IndirectIndirect

– Airborne (droplets)Airborne (droplets)

– VectorsVectors

– VehiclesVehicles


Portal of entryPortal of entry– mechanism of entry into new hostmechanism of entry into new host

– exposure does not always equal infectionexposure does not always equal infection

Host susceptibilityHost susceptibility– Age, genderAge, gender

– General health, immune statusGeneral health, immune status

– Cultural behaviorsCultural behaviors

– Sexual behaviorsSexual behaviors


Manifestation of clinical disease dependent Manifestation of clinical disease dependent upon:upon:– Degree of pathogenicityDegree of pathogenicity– Dose of infectious agentDose of infectious agent– Resistance of hostResistance of host– Correct mode of entryCorrect mode of entry

All must exist to create riskAll must exist to create risk Exposure does not mean person will become Exposure does not mean person will become

infectedinfected

Communicable DiseaseCommunicable DiseaseCommunicable DiseaseCommunicable Disease Latent PeriodLatent Period

– period after infection of a host when infectious agent period after infection of a host when infectious agent cannot be transmitted to another hostcannot be transmitted to another host

– clinical symptoms may be manifestedclinical symptoms may be manifested Communicable PeriodCommunicable Period

– period after an infection when agent can be period after an infection when agent can be transmitted to another hosttransmitted to another host

– clinical symptoms may be manifestedclinical symptoms may be manifested Incubation PeriodIncubation Period

– time between exposure and first appearance of Sxtime between exposure and first appearance of Sx

Communicable DiseaseCommunicable DiseaseCommunicable DiseaseCommunicable Disease Disease PeriodDisease Period

– time between first appearance of Sx and resolution time between first appearance of Sx and resolution of Sxof Sx

– resolution does not mean agent is destroyedresolution does not mean agent is destroyed Window PhaseWindow Phase

– period after infection in which antigen is present but period after infection in which antigen is present but no antibodies are detectedno antibodies are detected

Defense MechanismsDefense MechanismsDefense MechanismsDefense Mechanisms

– SkinSkin– Respiratory Respiratory

systemsystem– Normal floraNormal flora– GI/GU systems GI/GU systems – Inflammatory Inflammatory

ResponseResponse

– Humoral immunityHumoral immunity– Cell-mediated Cell-mediated

immunityimmunity– Nonspecific effector Nonspecific effector

cellscells– Reticuloendothelial Reticuloendothelial

SystemSystem– Complement systemComplement system

Anti-InfectivesAnti-InfectivesAnti-InfectivesAnti-Infectives

BacteriocidalsBacteriocidals: penicillins, cephalosporins, : penicillins, cephalosporins, Vancomycin, BacitracinVancomycin, Bacitracin

BacteriostaticsBacteriostatics: sulfonamides (Septra, Bactrim), : sulfonamides (Septra, Bactrim), Gentamycin, erythromycin, Biaxin, Zithromax, Gentamycin, erythromycin, Biaxin, Zithromax, TetracyclineTetracycline

Anti TBAnti TB: Isoniazid, Rifampin, Ethambutol: Isoniazid, Rifampin, Ethambutol AntiviralAntiviral: acyclovir, Zidovudine (AZT), Amantidine: acyclovir, Zidovudine (AZT), Amantidine AntifungalAntifungal: nystatin, fluconazole, clotrimazole: nystatin, fluconazole, clotrimazole AntiparasiticAntiparasitic: Flagyl, Kwell, Quinine: Flagyl, Kwell, Quinine

AntipyreticsAntipyreticsAntipyreticsAntipyretics

Acetylsalicylic acid (Aspirin)Acetylsalicylic acid (Aspirin) Acetaminophen (Tylenol®)Acetaminophen (Tylenol®) Ibuprofen (Advil®, Motrin®)Ibuprofen (Advil®, Motrin®)

Anti-Inflammatory AgentsAnti-Inflammatory AgentsAnti-Inflammatory AgentsAnti-Inflammatory Agents

Acetylsalcyclic acid (Aspirin)Acetylsalcyclic acid (Aspirin) Ibuprofen (Advil®, Motrin®)Ibuprofen (Advil®, Motrin®) Indomethacin (Indocin®)Indomethacin (Indocin®) Naproxen (Anaprox®, Naprosyn®)Naproxen (Anaprox®, Naprosyn®) Ketorolac (Toradol®)Ketorolac (Toradol®) Sulindac (Clinoril®)Sulindac (Clinoril®)

HepatitisHepatitisHepatitisHepatitis

Inflammation of liver Inflammation of liver Produced by: Produced by:

– Infection Infection

– Toxins Toxins

– Drugs Drugs

– HypersensitivityHypersensitivity

– Immune mechanismsImmune mechanisms

Viral HepatitisViral HepatitisViral HepatitisViral Hepatitis

TypesTypes– Hepatitis AHepatitis A

– Hepatitis BHepatitis B

– Hepatitis CHepatitis C

– Hepatitis DHepatitis D

– Hepatitis EHepatitis E

Hepatitis AHepatitis AHepatitis AHepatitis A TransmissionTransmission

– Hepatitis A virusHepatitis A virus– Fecal oral contactFecal oral contact– Water, food-borne outbreaksWater, food-borne outbreaks– Blood borne (rare)Blood borne (rare)

SeveritySeverity– mild severity, rarely seriousmild severity, rarely serious– usually lasting 2-6 weeksusually lasting 2-6 weeks

Hepatitis AHepatitis AHepatitis AHepatitis A

High risk populationsHigh risk populations– Household/sexual contacts of infected personsHousehold/sexual contacts of infected persons– International travelersInternational travelers– Day care center employees and childrenDay care center employees and children– Homosexually active malesHomosexually active males– Eating food prepared by othersEating food prepared by others

» can survive on unwashed hands for up to 4 hourscan survive on unwashed hands for up to 4 hours


Incubation: 25-40 daysIncubation: 25-40 days 125,000 to 200,000 cases/yr (U.S.)125,000 to 200,000 cases/yr (U.S.) 84,000 to 134,000 symptomatic cases/yr (U.S.)84,000 to 134,000 symptomatic cases/yr (U.S.) 100 deaths/yr (U.S.)100 deaths/yr (U.S.) Does not cause chronic liver disease or known Does not cause chronic liver disease or known

carrier statecarrier state

33% of Americans have evidence of past infection

Hepatitis AHepatitis AHepatitis AHepatitis A Signs and SymptomsSigns and Symptoms

– Abrupt onset withAbrupt onset with» feverfever

» weaknessweakness

» anorexiaanorexia

» abdominal discomfortabdominal discomfort

» nauseanausea

» darkened urinedarkened urine

» possible jaundicepossible jaundice


TreatmentTreatment– Support & Preventive careSupport & Preventive care

» fluids and treatment of dehydrationfluids and treatment of dehydration

» infection control proceduresinfection control procedures

» handwashing critically importanthandwashing critically important

» Hepatitis A vaccine now availableHepatitis A vaccine now available

» Prophylactic Ig may be administered w/I 2 weeks Prophylactic Ig may be administered w/I 2 weeks of exposureof exposure

» Prophylaxis if traveling to less developed Prophylaxis if traveling to less developed countriescountries

Hepatitis BHepatitis BHepatitis BHepatitis B TransmissionTransmission

– Hepatitis B virusHepatitis B virus– Blood borneBlood borne

» blood, saliva (tattooing, acupuncture, razors, blood, saliva (tattooing, acupuncture, razors, toothbrushes)toothbrushes)

– SexualSexual» semen, vaginal fluidssemen, vaginal fluids

– PerinatalPerinatal

Hepatitis BHepatitis BHepatitis BHepatitis B

High risk populationsHigh risk populations– HemophiliacsHemophiliacs

– Dialysis patientsDialysis patients

– IV drug abusersIV drug abusers

– Health care personnelHealth care personnel

– Homosexually active malesHomosexually active males

– Heterosexuals with multiple partnersHeterosexuals with multiple partners

– Infants of infected mothersInfants of infected mothers Can survive as dried, visible blood for > 7 daysCan survive as dried, visible blood for > 7 days

Hepatitis BHepatitis BHepatitis BHepatitis B Incubation: 42-160 daysIncubation: 42-160 days 140,000 to 320,000 infections/yr (U.S)140,000 to 320,000 infections/yr (U.S)

– 70,000 to 160,000 symptomatic cases/yr (U.S.)70,000 to 160,000 symptomatic cases/yr (U.S.)

– 140 to 320 deaths/yr (U.S.)140 to 320 deaths/yr (U.S.)

– 6 to 10% develop chronic hepatitis6 to 10% develop chronic hepatitis 5,000 to 6,000 deaths/yr from chronic liver 5,000 to 6,000 deaths/yr from chronic liver

disease, including primary liver cancerdisease, including primary liver cancer Chronic carrier state existsChronic carrier state exists

– 5-10% of infected become asymptomatic carriers5-10% of infected become asymptomatic carriers

Hepatitis BHepatitis BHepatitis BHepatitis B Sx/SxSx/Sx

– Within 2-3 months, gradually develop non-Within 2-3 months, gradually develop non-specific Sxspecific Sx

» AnorexiaAnorexia» N/V, FeverN/V, Fever» Abdominal discomfortAbdominal discomfort» Joint pain, FatigueJoint pain, Fatigue» Generalized rashesGeneralized rashes» Dark urine, clay-colored stoolDark urine, clay-colored stool» May progress to jaundiceMay progress to jaundice

Hepatitis BHepatitis BHepatitis BHepatitis B

Treatment & Preventive careTreatment & Preventive care– Supportive careSupportive care– Prevention: BSI and HandwashingPrevention: BSI and Handwashing– Vaccine availableVaccine available

» protective immunity develops if HBV antigen protective immunity develops if HBV antigen disappears and HBV antibody is present in disappears and HBV antibody is present in serumserum

» provide long lasting immunity, 95-98% of timeprovide long lasting immunity, 95-98% of time

Hepatitis CHepatitis CHepatitis CHepatitis C

TransmissionTransmission– Hepatitis C virusHepatitis C virus

– Primarily bloodbornePrimarily bloodborne

– Also sexual, perinatalAlso sexual, perinatal High risk populationsHigh risk populations

– IV drug abusersIV drug abusers

– Dialysis patientsDialysis patients

– Health care personnelHealth care personnel

– Multiple sex partnersMultiple sex partners

–Homosexually active malesHomosexually active males

–Transfusion before 1992Transfusion before 1992

–Clotting factors before 1987Clotting factors before 1987

Hepatitis CHepatitis CHepatitis CHepatitis C Transmission from household/sexual contact lowTransmission from household/sexual contact low

– Health care workers: up to 10% probability of Health care workers: up to 10% probability of infection when exposed to infected bloodinfection when exposed to infected blood

– Chronic infection in >85% of casesChronic infection in >85% of cases

– Chronic liver disease in 70% of casesChronic liver disease in 70% of cases

– 8,000 to 10,000 deaths/yr from chronic liver disease 8,000 to 10,000 deaths/yr from chronic liver disease (U.S.)(U.S.)

– Leading indication for liver transplantationLeading indication for liver transplantation

3.9 million Americans infected 2.7 million

chronically

Hepatitis CHepatitis CHepatitis CHepatitis C Sx/SxSx/Sx

– Same as Hepatitis B, less progression to Same as Hepatitis B, less progression to jaundicejaundice

– possible association of Hepatitis C infection possible association of Hepatitis C infection with liver cancerwith liver cancer

Degree of postinfection immunity Degree of postinfection immunity unknownunknown

High percentage of infected become High percentage of infected become carrierscarriers

Hepatitis CHepatitis CHepatitis CHepatitis C Treatment & Preventive CareTreatment & Preventive Care

– Same as Hepatitis BSame as Hepatitis B– BSI, handwashingBSI, handwashing– Experimental treatment with alpha-Experimental treatment with alpha-

interferon shown effective in 20% of casesinterferon shown effective in 20% of cases– No recognized benefit from prophylactic IgGNo recognized benefit from prophylactic IgG

Hepatitis D (Delta Virus)Hepatitis D (Delta Virus)Hepatitis D (Delta Virus)Hepatitis D (Delta Virus)

Defective, requires HBV presence to replicateDefective, requires HBV presence to replicate– Acquired as HBV coinfection or chronic HBV Acquired as HBV coinfection or chronic HBV

superinfectionsuperinfection Increases disease severity, fulminant hepatitis Increases disease severity, fulminant hepatitis

risk (2 to 20%)risk (2 to 20%) Increases chronic liver disease risk (70 to 80%)Increases chronic liver disease risk (70 to 80%)

– When virus becomes active with HBV, resulting When virus becomes active with HBV, resulting disease extremely pathogenicdisease extremely pathogenic

Hepatitis D (Delta Virus)Hepatitis D (Delta Virus)Hepatitis D (Delta Virus)Hepatitis D (Delta Virus) Transmission similar to HBVTransmission similar to HBV Most cases transmitted percutaneouslyMost cases transmitted percutaneously Coinfection can be prevented by HBV vaccineCoinfection can be prevented by HBV vaccine No products exist to prevent superinfectionsNo products exist to prevent superinfections Sx/SxSx/Sx

– abrupt onset with Sx/Sx like HBV infectionabrupt onset with Sx/Sx like HBV infection

– always associated with HBV infectionalways associated with HBV infection Treatment and Prevention similar to HBVTreatment and Prevention similar to HBV

– HBV vaccine indirectly prevents HDVHBV vaccine indirectly prevents HDV

Hepatitis EHepatitis EHepatitis EHepatitis E Major cause of enterically-transmitted non-A, Major cause of enterically-transmitted non-A,

non-B hepatitis worldwidenon-B hepatitis worldwide Transmission by fecal-oral routeTransmission by fecal-oral route Person-to-person transmission uncommonPerson-to-person transmission uncommon Incubation: 15 to 60 daysIncubation: 15 to 60 days All U.S. cases have been travelersAll U.S. cases have been travelers HBV vaccine has no effect on Hepatitis EHBV vaccine has no effect on Hepatitis E

– attention to potable water supply after flood watersattention to potable water supply after flood waters

No commercially available diagnostic test in U.S.No commercially available diagnostic test in U.S.

HepatitisHepatitisHepatitisHepatitis SafetySafety

– Obtain immunization (HBV, HAV)Obtain immunization (HBV, HAV)

– Wear glovesWear gloves

– Wash handsWash hands

– Needle precautionsNeedle precautions

– Bag, label blood samples/contaminated linensBag, label blood samples/contaminated linens

– Wash blood spills (even dried) with bleach Wash blood spills (even dried) with bleach solutionsolution

– Assess Personal behavior risksAssess Personal behavior risks

TuberculosisTuberculosisTuberculosisTuberculosis Produced by bacteriumProduced by bacterium

– Mycobacterium tuberculosisMycobacterium tuberculosis TransmissionTransmission

– InhalationInhalation– Organism forms sporesOrganism forms spores– May contaminate air in closed spacesMay contaminate air in closed spaces

» prolonged exposure to active TB infected personprolonged exposure to active TB infected person

» direct infection through non-intact skin possibledirect infection through non-intact skin possible

TuberculosisTuberculosisTuberculosisTuberculosis

10% of untreated infected persons develop 10% of untreated infected persons develop active TB in 1 -2 yearsactive TB in 1 -2 years

90% have dormant infection (inactive) with 90% have dormant infection (inactive) with risk of activation for life of hostrisk of activation for life of host

Initially affects respiratory systemInitially affects respiratory system– if untreated, can spread to other organ systemsif untreated, can spread to other organ systems

Incubation ~ 4 - 12 weeksIncubation ~ 4 - 12 weeks– clinical manifestation ~ 6 - 12 months after infectionclinical manifestation ~ 6 - 12 months after infection

TuberculosisTuberculosisTuberculosisTuberculosis InfectionInfection

– intial infection referred to as primary infectionintial infection referred to as primary infection» usually has no outward manifestationusually has no outward manifestation

» may be outwardly manifested in elderly, young children may be outwardly manifested in elderly, young children and immunocompromisedand immunocompromised

– cell-mediated immune response walls off bacteria cell-mediated immune response walls off bacteria (tubercle) and suppresses(tubercle) and suppresses

– bacteria are dormant but can reactivate (secondary bacteria are dormant but can reactivate (secondary infection)infection)

TuberculosisTuberculosisTuberculosisTuberculosis Signs and SymptomsSigns and Symptoms

– Cough (productive or non-productive)Cough (productive or non-productive)

» Purulent sputumPurulent sputum

– Fever, low gradeFever, low grade

– Night sweatsNight sweats

– Weight lossWeight loss

– FatigueFatigue

– HemoptysisHemoptysis

TuberculosisTuberculosisTuberculosisTuberculosis Extrapulmonary infection of:Extrapulmonary infection of:

– CardiovascularCardiovascular» pericardial effusionpericardial effusion

– SkeletalSkeletal» affects thoracic and lumbar spine discs and vertebral bodiesaffects thoracic and lumbar spine discs and vertebral bodies

– CNSCNS» subacute meningitis, granulomas in brainsubacute meningitis, granulomas in brain

– GI/GUGI/GU» GI tractGI tract» PeritoneumPeritoneum» LiverLiver

TuberculosisTuberculosisTuberculosisTuberculosis Treatment and Preventive CareTreatment and Preventive Care

– Very low communicabilityVery low communicability

– Identify high-risk patients and suspected active TBIdentify high-risk patients and suspected active TB

» Mask patient (and you) if active TB suspectedMask patient (and you) if active TB suspected

– Routine TB testing of EMS personnelRoutine TB testing of EMS personnel

– Exposure Follow-upExposure Follow-up» Skin test & Repeat Skin testSkin test & Repeat Skin test

» INH prophylaxisINH prophylaxis

– routinely in < 35 years of age with positive PPDroutinely in < 35 years of age with positive PPD

– with caution > 35 in those at high riskwith caution > 35 in those at high risk

– SE: paresthesias, N/V, hepatitisSE: paresthesias, N/V, hepatitis

– Post-incident disinfectionPost-incident disinfection

TuberculosisTuberculosisTuberculosisTuberculosis Treatment and Preventive CareTreatment and Preventive Care

– Long Term Treatment usually involves a Long Term Treatment usually involves a combination of several drugscombination of several drugs

» Isoniazid (INH)Isoniazid (INH)

» RifampinRifampin

» EthambutolEthambutol

» StreptomycinStreptomycin

» PyrazinamidePyrazinamide

– Drug resistant TB may require several of these Drug resistant TB may require several of these drugs simultaneouslydrugs simultaneously

MeningitisMeningitisMeningitisMeningitis

Inflammation of meninges secondary to Inflammation of meninges secondary to infection by bacteria, virus, or fungiinfection by bacteria, virus, or fungi

Most immediately dangerous when Most immediately dangerous when caused by:caused by:– Neisseria meningitisNeisseria meningitis– MeningococcusMeningococcus

MeningitisMeningitisMeningitisMeningitis Colonizes throat. easily spread through Colonizes throat. easily spread through

respiratory secretionsrespiratory secretions 2-10% of population probably carry 2-10% of population probably carry

meningococci at any one time but meninges not meningococci at any one time but meninges not affected (carriers)affected (carriers)

Infants 6 mos - 2 yrs especially vulnerableInfants 6 mos - 2 yrs especially vulnerable TransmissionTransmission

– direct contact with respiratory secretionsdirect contact with respiratory secretions– prolonged, direct contact with respiratory droplets prolonged, direct contact with respiratory droplets

from nose or throat of infected personsfrom nose or throat of infected persons

MeningitisMeningitisMeningitisMeningitis Signs/SymptomsSigns/Symptoms

– Rapid onsetRapid onset– Fever, ChillsFever, Chills– Joint pain, Nuchal Joint pain, Nuchal

rigidityrigidity– HeadacheHeadache– Nausea, vomitingNausea, vomiting– Petechial rash Petechial rash

progressing to large progressing to large ecchymosesecchymoses

– Delirium, seizures, Delirium, seizures, shock, deathshock, death

MeningitisMeningitisMeningitisMeningitis SafetySafety

– BSIBSI» Avoid contact with respiratory secretionsAvoid contact with respiratory secretions

» Breathing same air as patient does Breathing same air as patient does NOTNOT create create riskrisk

– Mask patient and yourselfMask patient and yourself– If close contact or exposure occurs:If close contact or exposure occurs:

» Prophylactic RifampinProphylactic Rifampin

» Others include minocycline, ciprofloxacin, Others include minocycline, ciprofloxacin, ceftriaxone, and spiramycinceftriaxone, and spiramycin

MeningitisMeningitisMeningitisMeningitis SafetySafety

– Wash hands frequentlyWash hands frequently– Air out vehicleAir out vehicle– Send linens to laundrySend linens to laundry– ImmunizationImmunization

» Vaccines available for some strainsVaccines available for some strains

» No current recommendations for routine No current recommendations for routine vaccination for EMS personnelvaccination for EMS personnel


Other sourcesOther sources– Streptococcus pneumoniaeStreptococcus pneumoniae

» Second most common cause in adultsSecond most common cause in adults

» Most common cause of pneumonia in adultsMost common cause of pneumonia in adults

» Most common cause of otitis media in childrenMost common cause of otitis media in children

» Spread by droplets, prolonged contact and Spread by droplets, prolonged contact and contact with linen soiled with respiratory contact with linen soiled with respiratory dischargedischarge


Other sourcesOther sources– Hemophilus influenzaHemophilus influenza type B type B

» Same mode of transmission as for N. meningitidisSame mode of transmission as for N. meningitidis

» Before vaccine in 1981, leading cause of Before vaccine in 1981, leading cause of meningitis in children 6 mos - 3 yrsmeningitis in children 6 mos - 3 yrs

» Also associated with pediatric epiglottitis, sepsisAlso associated with pediatric epiglottitis, sepsis

Human Immunodeficiency VirusHuman Immunodeficiency VirusHuman Immunodeficiency VirusHuman Immunodeficiency Virus

Kills TKills T44 lymphocytes lymphocytes Interferes with Interferes with

immune system immune system functionfunction

Produces acquired Produces acquired immunodeficiency immunodeficiency syndrome (AIDS)syndrome (AIDS)

HIVHIVHIVHIV

TransmissionTransmission– Sexual intercourse (anal, vaginal, oral)Sexual intercourse (anal, vaginal, oral)– Shared injection equipmentShared injection equipment– Prenatal or perinatalPrenatal or perinatal– Breast-feeding after birthBreast-feeding after birth– No documented cases of transmission via No documented cases of transmission via

saliva, tears, urine or bronchial secretionssaliva, tears, urine or bronchial secretions» virus has been found in thesevirus has been found in these

HIVHIVHIVHIV

TransmissionTransmission– Risk of transmission by blood, blood products in U.S. is Risk of transmission by blood, blood products in U.S. is

extremelyextremely low low– Some health care worker infections due to needlestick or Some health care worker infections due to needlestick or

blood splashesblood splashes» risk following direct and specific exposure to infected risk following direct and specific exposure to infected

blood is estimated at 0.2-0.44%blood is estimated at 0.2-0.44%– Only Only one caseone case of patients being infected by a health care of patients being infected by a health care

workerworker– Reported but non-documented cases of paramedics Reported but non-documented cases of paramedics

infectedinfected

HIVHIVHIVHIV

Epidemiology (worldwide)Epidemiology (worldwide)– 34.3 million HIV infected34.3 million HIV infected

» 71% live in Sub-Saharan Africa71% live in Sub-Saharan Africa

» 16% live in South/Southeast Asia16% live in South/Southeast Asia

– 1% of the 15-49 age group infected1% of the 15-49 age group infected» 8.6% in Sub-Saharan Africa8.6% in Sub-Saharan Africa

» >10% in 16 African countries>10% in 16 African countries

HIVHIVHIVHIV

Epidemiology (worldwide)Epidemiology (worldwide)– 2.8 million deaths worldwide in 19992.8 million deaths worldwide in 1999– 18.8 million cumulative deaths18.8 million cumulative deaths

80% of cases have resulted 80% of cases have resulted from heterosexual intercoursefrom heterosexual intercourse

HIVHIVHIVHIV

Epidemiology (U.S.)Epidemiology (U.S.)– 900,000 infected (200,000 of these unaware)900,000 infected (200,000 of these unaware)– 733,374 cases of AIDS as of 12/31/99733,374 cases of AIDS as of 12/31/99– 430,411 deaths430,411 deaths

AIDS is the 5th leading cause of deaths in AIDS is the 5th leading cause of deaths in the U.S. for people ages 24 to 44the U.S. for people ages 24 to 44

HIV New Male Infections (U.S.)HIV New Male Infections (U.S.)HIV New Male Infections (U.S.)HIV New Male Infections (U.S.)

Homosexual sexIV drugsHeterosexual sex

60%

25%

15%

HIV New Male Infections (U.S.)HIV New Male Infections (U.S.)HIV New Male Infections (U.S.)HIV New Male Infections (U.S.)

BlackWhiteHispanic

50%30%

20%

HIV New Female Infections (U.S.)HIV New Female Infections (U.S.)HIV New Female Infections (U.S.)HIV New Female Infections (U.S.)

IV drugsHeterosexual sex

25% 75%

HIV New Female Infections (U.S.)HIV New Female Infections (U.S.)HIV New Female Infections (U.S.)HIV New Female Infections (U.S.)

BlackWhiceHispanic18%

64%

18%

AIDSAIDSAIDSAIDS Virus present in all body fluids, all body tissuesVirus present in all body fluids, all body tissues Virus spread by:Virus spread by:

– BloodBlood

– SemenSemen

– Vaginal fluidVaginal fluid

– Breast milkBreast milk

– Other body fluids containing bloodOther body fluids containing blood Health care workers may be at risk from CSF, Health care workers may be at risk from CSF,

synovial fluid, and amniotic fluidsynovial fluid, and amniotic fluid

AIDSAIDSAIDSAIDS Acquired Immunodeficiency SyndromeAcquired Immunodeficiency Syndrome It is the disease you get when HIV destroys the It is the disease you get when HIV destroys the

immune systemimmune system There is no cureThere is no cure

AIDSAIDSAIDSAIDS Virus present in all body fluids, all body tissuesVirus present in all body fluids, all body tissues Virus spread by:Virus spread by:

– Blood (blood transfusions – small risk)Blood (blood transfusions – small risk)– Semen (sex without condom)Semen (sex without condom)– Vaginal fluidVaginal fluid– Breast milk Breast milk – Sharing a needle or syringe to inject drugsSharing a needle or syringe to inject drugs– Other body fluids containing blood (e.g. mothers can Other body fluids containing blood (e.g. mothers can

pass on the virus to their babies)pass on the virus to their babies) Health care workers may be at risk from CSF, Health care workers may be at risk from CSF,

synovial fluid, and amniotic fluidsynovial fluid, and amniotic fluid

AIDSAIDSAIDSAIDS

Asymptomatic infection (1 to 10 years)Asymptomatic infection (1 to 10 years) About 50% of HIV-infected patients About 50% of HIV-infected patients

develop true AIDS within 10 yearsdevelop true AIDS within 10 years

AIDSAIDSAIDSAIDS

Acute InfectionAcute Infection– Lasts 2 to 4 weeksLasts 2 to 4 weeks– SymptomsSymptoms

» FeverFever» Sore throatSore throat» LymphadenopathyLymphadenopathy

Seroconversion Seroconversion – Occurs at 6 to 12 weeksOccurs at 6 to 12 weeks

AIDSAIDSAIDSAIDS

AIDS - related complex (ARC)AIDS - related complex (ARC)– weight loss > 10%weight loss > 10%

– diarrhea for >1 month diarrhea for >1 month

– fever fever

– night sweatsnight sweats

AIDSAIDSAIDSAIDS

True AIDS = Life-threatening True AIDS = Life-threatening opportunistic infectionsopportunistic infections– Pneumocystis cariniPneumocystis carini– Candida albicansCandida albicans– Cytomegalovirus (CMV)Cytomegalovirus (CMV)– Kaposi’s sarcomaKaposi’s sarcoma

AIDSAIDSAIDSAIDS

Pneumocystis cariniPneumocystis carini– Most common life-Most common life-

threatening threatening opportunistic opportunistic infectioninfection

– PneumoniaPneumonia

– Often leads to AIDS Often leads to AIDS diagnosisdiagnosis

AIDSAIDSAIDSAIDS

Candida albicansCandida albicans– Yeast infectionYeast infection

– Called “thrush” in Called “thrush” in infantsinfants

– Can disseminate to Can disseminate to GI tract, bloodstreamGI tract, bloodstream

AIDSAIDSAIDSAIDS

Cytomegalovirus Cytomegalovirus (CMV)(CMV)– Retinitis, blindnessRetinitis, blindness

– ColitisColitis

– PneumonitisPneumonitis

AIDSAIDSAIDSAIDS

Kaposi’s sarcomaKaposi’s sarcoma– Purple-brown, Purple-brown,

painless lesionspainless lesions

– May enlarge, May enlarge, coalesce, bleedcoalesce, bleed

– Can affect internal Can affect internal organsorgans

AIDSAIDSAIDSAIDS FungiFungi

– AspergillosisAspergillosis pulmonary pulmonary infectioninfection

– CryptococcusCryptococcus meningitis, meningitis, pulmonary infection, pulmonary infection, disseminated infectiondisseminated infection

– HistoplasmaHistoplasma disseminated disseminated infectioninfection

– CoccidiomycesCoccidiomyces disseminated infectiondisseminated infection

– PenicilliumPenicillium disseminated disseminated infectioninfection

VirusesViruses– Herpes simplex skin and Herpes simplex skin and

visceralvisceral

– Herpes zoster skin, Herpes zoster skin, ophthalmic nerve, ophthalmic nerve, disseminated, visceraldisseminated, visceral

– JC virus progressive JC virus progressive multifocal multifocal leukoencephalopathyleukoencephalopathy

AIDSAIDSAIDSAIDS

ParasitesParasites– ToxoplasmaToxoplasma encephalitis encephalitis

– CryptosporidiaCryptosporidia

– IsosporaIsospora

– MicrosporaMicrospora

– GiardiaGiardia

BacteriaBacteria– Streptococcus pneumoniaStreptococcus pneumonia

– Hemophilus influenzaHemophilus influenza

– Nocarida asteroidesNocarida asteroides

– Pseudomonas aeruginosaPseudomonas aeruginosa

– Rhodococcus equiRhodococcus equi

– Bartonella hanselaeBartonella hanselae

– SalmonellaSalmonella

– Staphylococcus aureusStaphylococcus aureus

– Treponema pallidumTreponema pallidum

AIDSAIDSAIDSAIDS

MycobacteriaMycobacteria– Mycobacterium tuberculosisMycobacterium tuberculosis

– M. aviumM. avium

– M. kansasiiM. kansasii

– M. haemophilumM. haemophilum

– M. gordonaeM. gordonae

– M. genavenseM. genavense

– M. xenopiM. xenopi

– M. fortuitumM. fortuitum

– M. malmoneseM. malmonese

– M.cheloneiM.chelonei

AIDSAIDSAIDSAIDS

AIDS Dementia ComplexAIDS Dementia Complex– Infection of CNS cells Infection of CNS cells – Cerebral atrophyCerebral atrophy– Characterized by:Characterized by:

» Cognitive dysfunctionCognitive dysfunction

» Declining motor performanceDeclining motor performance

» Behavioral changesBehavioral changes

AIDSAIDSAIDSAIDS SafetySafety

– BSIBSI

– Wash hands between patientsWash hands between patients

– Clean blood spills with bleach solutionClean blood spills with bleach solution

– All sharp objects potentially infectiveAll sharp objects potentially infective

– Do Do NOTNOT recap needles recap needles

– Wear mask to avoid exposing patientWear mask to avoid exposing patient

– Pregnant paramedics should avoid contact Pregnant paramedics should avoid contact with AIDS patients (risk of CMV exposure)with AIDS patients (risk of CMV exposure)

AIDSAIDSAIDSAIDS TreatmentTreatment

– Support careSupport care

– No immunization availableNo immunization available

– Post Exposure Prophylactic treatmentPost Exposure Prophylactic treatment» Recommended w/I 3 hours of significant exposureRecommended w/I 3 hours of significant exposure

» CDC recommendationsCDC recommendations– zidovudinezidovudine

– lamivudinelamivudine

– indinavirindinavir

– nelfinavirnelfinavir

AIDSAIDSAIDSAIDS

AIDS is AIDS is NOTNOT airborne airborne

AIDS in AIDS in NOTNOT transmissible by transmissible by insectsinsects

Other Sexually Transmitted Other Sexually Transmitted Diseases (STD’s)Diseases (STD’s)


GonorrheaGonorrhea ClamydiaClamydia SyphilisSyphilis Genital HerpesGenital Herpes Human PapillomavirusHuman Papillomavirus Hepatitis Hepatitis TrichomoniasisTrichomoniasis Bacterial VaginosisBacterial Vaginosis



STD’s affect One out of Every 6 AdultsSTD’s affect One out of Every 6 Adults STD’s can causeSTD’s can cause

– CancerCancer

– Impaired fertilityImpaired fertility

– Premature birthPremature birth

– Infant fatalityInfant fatality

– disabilitydisability



GonorrheaGonorrhea ChlamydiaChlamydia SyphilisSyphilis Genital HerpesGenital Herpes Human PapillomavirusHuman Papillomavirus Hepatitis Hepatitis TrichomoniasisTrichomoniasis Bacterial VaginosisBacterial Vaginosis

GonorrheaGonorrheaGonorrheaGonorrhea

Bacterium - Bacterium - Neisseria gonorrheaNeisseria gonorrhea Infection of genital or rectal mucosaInfection of genital or rectal mucosa Ocular, oral infections may occurOcular, oral infections may occur TransmissionTransmission

– direct contact with exudates of mucous membranesdirect contact with exudates of mucous membranes

– usually from unprotected sexual intercourseusually from unprotected sexual intercourse


May progress to: May progress to: – BacteremiaBacteremia– Pericarditis Pericarditis – Endocarditis Endocarditis – MeningitisMeningitis– PerihepatitisPerihepatitis

GonorrheaGonorrheaGonorrheaGonorrhea Signs/SymptomsSigns/Symptoms

– MalesMales» DysuriaDysuria» Mucopurulent urethral dischargeMucopurulent urethral discharge» Can progress to epidydymitis or prostatitisCan progress to epidydymitis or prostatitis

– FemalesFemales» May be asymptomatic May be asymptomatic

– dysuria and purulent vaginal discharge may occurdysuria and purulent vaginal discharge may occur

» Lower abdominal painLower abdominal pain» Can progress to PID: fever, lower abd pain, Can progress to PID: fever, lower abd pain,

abnormal menstrual bleedingabnormal menstrual bleeding


Females are at increased risk forFemales are at increased risk for– sterilitysterility

– ectopic pregnancyectopic pregnancy

– abscesses of fallopian tubes, ovaries or peritoneumabscesses of fallopian tubes, ovaries or peritoneum

– peritonitisperitonitis Males & FemalesMales & Females

– septic arthritis can occur resulting in fever, pain, septic arthritis can occur resulting in fever, pain, joint swelling, joint deteriorationjoint swelling, joint deterioration


Treatment & Preventive CareTreatment & Preventive Care– BSIBSI

– HandwashingHandwashing

– Antibiotics for treatment of infectionAntibiotics for treatment of infection


ChlamydiaChlamydiaChlamydiaChlamydia Bacterial trachomatisBacterial trachomatis Most common STD in U.S.Most common STD in U.S. TransmissionTransmission

– Sexual contactSexual contact

– Contact with exudates, including childbirthContact with exudates, including childbirth Affects eyes, genital area and associated organsAffects eyes, genital area and associated organs Estimated that up to 25% of men may be Estimated that up to 25% of men may be

carrierscarriers

ChlamydiaChlamydiaChlamydiaChlamydia

Signs and SymptomsSigns and Symptoms– Similar to gonorrheaSimilar to gonorrhea

– Conjunctivitis (leading cause of preventable Conjunctivitis (leading cause of preventable blindness in world)blindness in world)

– Infant pneumoniaInfant pneumonia May result in infertilityMay result in infertility

ChlamydiaChlamydiaChlamydiaChlamydia



– Antibiotics for treatment of infectionAntibiotics for treatment of infection


SyphilisSyphilisSyphilisSyphilis

Produced by spirochete - Produced by spirochete - Treponema pallidumTreponema pallidum Transmitted by Transmitted by

– Sexual contactSexual contact– From mother to fetusFrom mother to fetus– Direct contact withDirect contact with

» exudates from moist, early, obvious or concealed lesions of exudates from moist, early, obvious or concealed lesions of skin and mucous membranes, or semen, blood, saliva, skin and mucous membranes, or semen, blood, saliva, vaginal dischargesvaginal discharges

– blood transfusion or needlestick (low risk)blood transfusion or needlestick (low risk)

30% of exposures result in infection30% of exposures result in infection


Primary stagePrimary stage– ChancreChancre

» At site of entryAt site of entry

» Painless ulcerPainless ulcer

– Regional Regional lymphadenopathylymphadenopathy

– Lasts 4 to 8 weeksLasts 4 to 8 weeks

SyphilisSyphilisSyphilisSyphilis Secondary stageSecondary stage

– Bacteremia stage ~6 Bacteremia stage ~6 weeks after chance weeks after chance healedhealed

– Skin lesions, rashesSkin lesions, rashes

– Fever, headache, nausea, Fever, headache, nausea, malaisemalaise

– Begin at 6 to 12 weeksBegin at 6 to 12 weeks

– Peak at 3 to 4 monthsPeak at 3 to 4 months

– Lesions may reappear Lesions may reappear for up to 1 yearfor up to 1 year


Latent stageLatent stage– Begins at about 1 yearBegins at about 1 year

– May last from 3 years to rest of patient’s lifeMay last from 3 years to rest of patient’s life

– Early latent phase: < 2 yearsEarly latent phase: < 2 years

– Late latent phase: > 2 yearsLate latent phase: > 2 years

– 1/3 of untreated patients develop tertiary syphilis 1/3 of untreated patients develop tertiary syphilis within 3 to 25 year; others remain asymptomaticwithin 3 to 25 year; others remain asymptomatic

– 25% may relapse and secondary symptoms develop 25% may relapse and secondary symptoms develop againagain

SyphilisSyphilisSyphilisSyphilis Tertiary stageTertiary stage

– Lesions of skin, bone, Lesions of skin, bone, viscera (gummas)viscera (gummas)

» painless w/sharp borderspainless w/sharp borders» bone w/deep, gnawing painbone w/deep, gnawing pain

– Cardiovascular syphilisCardiovascular syphilis» 10 yrs after 1º infection10 yrs after 1º infection» dissecting aneurysmdissecting aneurysm

– NeurosyphilisNeurosyphilis» meningitismeningitis» loss of reflexes, painloss of reflexes, pain» mental deteriorationmental deterioration

SyphilisSyphilisSyphilisSyphilis Treatment and Preventive CareTreatment and Preventive Care

– Avoid direct contact with skin lesionsAvoid direct contact with skin lesions

– Patients are contagious in primary, secondary, Patients are contagious in primary, secondary, possibly early latent stagepossibly early latent stage

– Tertiary stage is not contagiousTertiary stage is not contagious

Herpes simplexHerpes simplexHerpes simplexHerpes simplex TypesTypes

– Type I: Cold sores, fever blisters,Type I: Cold sores, fever blisters,– Type II: Genital herpesType II: Genital herpes

Usually affect:Usually affect:– oropharynx, face, lipsoropharynx, face, lips– skin, fingers, topsskin, fingers, tops– CNS in infantsCNS in infants

Herpes simplexHerpes simplexHerpes simplexHerpes simplex

TransmissionTransmission– Saliva of carriersSaliva of carriers– Infection on hands, fingersInfection on hands, fingers

Herpes simplexHerpes simplexHerpes simplexHerpes simplex Signs and SymptomsSigns and Symptoms

– Cold sores, fever blisters (lips, Cold sores, fever blisters (lips, face, conjunctiva, oropharynx)face, conjunctiva, oropharynx)

– BurningBurning

– TendernessTenderness

– FeverFever

– LymphadenopathyLymphadenopathy

– Vesicular lesionsVesicular lesions

» Weep clear fluid, ulcerateWeep clear fluid, ulcerate Treated with acyclovir Treated with acyclovir

(Zovirax®)(Zovirax®)



» consider maskconsider mask– Lesions are highly contagiousLesions are highly contagious– Acyclovir (topical, IV or oral)Acyclovir (topical, IV or oral)

Genital HerpesGenital HerpesGenital HerpesGenital Herpes

Genital herpes in Genital herpes in female may transmit female may transmit to infant at birth if to infant at birth if open lesions presentopen lesions present

May be life May be life threatening for threatening for infantinfant

Genital HerpesGenital HerpesGenital HerpesGenital Herpes

Caused by herpes simplex virus type 2Caused by herpes simplex virus type 2 Affects tissues and structures associated with Affects tissues and structures associated with

intimate contact with infected personintimate contact with infected person TransmissionTransmission

– Usually through sexual activityUsually through sexual activity

Genital HerpesGenital HerpesGenital HerpesGenital Herpes Signs and SymptomsSigns and Symptoms

– MalesMales» lesions of the penis, anus, rectum and/or mouth lesions of the penis, anus, rectum and/or mouth

depending on sexual practicesdepending on sexual practices

– FemalesFemales

» lesions of the cervix, vulva, anus, rectum and lesions of the cervix, vulva, anus, rectum and mouth depending on sexual practicesmouth depending on sexual practices

» recurrent usually affects vulva, buttocks, legs, recurrent usually affects vulva, buttocks, legs, and perineal skinand perineal skin


Treatment & Preventive Treatment & Preventive CareCare– BSIBSI

– Wash handsWash hands

– Launder linens wellLaunder linens well

– AcyclovirAcyclovir

MeaslesMeaslesMeaslesMeasles Red measles, rubeola, hard Red measles, rubeola, hard

measlesmeasles ParamyxovirusParamyxovirus Affects respiratory, CNS, Affects respiratory, CNS,

pharynx, eyes, systemicpharynx, eyes, systemic TransmissionTransmission

– nasopharyngeal air dropletsnasopharyngeal air droplets

– direct contact with secretionsdirect contact with secretions

MeaslesMeaslesMeaslesMeasles SymptomsSymptoms

– begins with:begins with:» conjunctivitis, swelling of eyelids, photophobia, high fever, conjunctivitis, swelling of eyelids, photophobia, high fever,

hacking cough, malaisehacking cough, malaise

– 1 or 2 days before rash1 or 2 days before rash» small, red-based lesions with blue-white centers on buccal small, red-based lesions with blue-white centers on buccal

mucosa (Koplik’s spots)mucosa (Koplik’s spots)

– rash: red, maculopapular (slightly bumpy) rash: red, maculopapular (slightly bumpy) spreading from forehead to face, neck torso and feet spreading from forehead to face, neck torso and feet by the third dayby the third day

» usually lasts for 6 daysusually lasts for 6 days

MeaslesMeaslesMeaslesMeasles May progress to May progress to

pneumonia, eye pneumonia, eye damage or damage or myocarditismyocarditis

Most life-threatening Most life-threatening is sclerosing is sclerosing encephalopathyencephalopathy– slowly progressing slowly progressing

neurological disease neurological disease with deteriorating with deteriorating mental capacity and mental capacity and coordinationcoordination

MeaslesMeaslesMeaslesMeasles

Treatment & Preventive CareTreatment & Preventive Care– Body Substance Isolation, consider maskBody Substance Isolation, consider mask


– Immunization (MMR)Immunization (MMR)

MumpsMumpsMumpsMumps ParamyxovirusParamyxovirus Affects salivary glands and Affects salivary glands and

CNSCNS TransmisisonTransmisison

– Respiratory dropletsRespiratory droplets

– Direct contact with salivaDirect contact with saliva

– 12-25 day incubation period12-25 day incubation period

MumpsMumpsMumpsMumps

Signs and SymptomsSigns and Symptoms– FeverFever– SwellingSwelling– Tenderness of salivary glandsTenderness of salivary glands


ComplicationsComplications– Aseptic meningitisAseptic meningitis 15%15%

– OrchitisOrchitis 20-50% post-pubertal 20-50% post-pubertal malesmales

– PancreatitisPancreatitis 2-5%2-5%

– DeafnessDeafness 1 in 20,0001 in 20,000

– DeathDeath 1-3/10,0001-3/10,000


Treatment & Preventive CareTreatment & Preventive Care– EMS personnel should have established MMR EMS personnel should have established MMR

immunityimmunity

– BSI & HandwashingBSI & Handwashing

– Apply surgical mask to patientApply surgical mask to patient

– MMR Immunization MMR Immunization

Chicken PoxChicken PoxChicken PoxChicken Pox Varicella-zoster virus (VZV)Varicella-zoster virus (VZV) Primarily affects skinPrimarily affects skin Humans are the only source Humans are the only source

of infectionof infection TransmissionTransmission

– Person to personPerson to person

– through droplets from mucous through droplets from mucous membranes membranes

– direct contact with vesicle discharge direct contact with vesicle discharge (varicella or zoster) and through (varicella or zoster) and through respiratory secretionsrespiratory secretions

Chicken PoxChicken PoxChicken PoxChicken Pox Incubation: 10 to 21 days Incubation: 10 to 21 days

after contactafter contact Cases most contagious 2 Cases most contagious 2

days before the rash days before the rash appears, until 5 days after appears, until 5 days after new lesions stop eruptingnew lesions stop erupting

5,000 to 9,000 5,000 to 9,000 hospitalizations annuallyhospitalizations annually– 100 deaths100 deaths

Chicken PoxChicken PoxChicken PoxChicken Pox Signs and SymptomsSigns and Symptoms

– begins with respiratory sx, begins with respiratory sx, malaise and low-grade malaise and low-grade feverfever

– Itchy rash with vesicular Itchy rash with vesicular lesions that cover bodylesions that cover body

» worse on trunkworse on trunk More severe form in adultsMore severe form in adults

– May cause pneumonia, May cause pneumonia, disseminated infection in adultsdisseminated infection in adults

Chicken PoxChicken PoxChicken PoxChicken Pox

Treatment & Preventive CareTreatment & Preventive Care– BSI & HandwashingBSI & Handwashing

– Isolation of children from public places until lesions Isolation of children from public places until lesions are crusted and dryare crusted and dry

– antivirals to lessen symptoms mostly in adultsantivirals to lessen symptoms mostly in adults

– EMS workers w/o past exposure to chickenpox may EMS workers w/o past exposure to chickenpox may consider chickenpox vaccineconsider chickenpox vaccine

– Varicella zoster immune globulin recommended if Varicella zoster immune globulin recommended if pregnant and with a substantial exposurepregnant and with a substantial exposure


DiagnosisDiagnosis– Immunofluorescence of the vesicular fluidImmunofluorescence of the vesicular fluid

– Culture of the vesicular fluidCulture of the vesicular fluid

– PCR of any tissue of vesicular fluidPCR of any tissue of vesicular fluid




– antivirals to lessen symptoms mostly in adults antivirals to lessen symptoms mostly in adults

– EMS workers w/o past exposure to chickenpox may EMS workers w/o past exposure to chickenpox may consider chickenpox vaccineconsider chickenpox vaccine

– Varicella zoster immune globulin recommended if Varicella zoster immune globulin recommended if pregnant and with a substantial exposurepregnant and with a substantial exposure




– antivirals to lessen symptoms mostly in adults antivirals to lessen symptoms mostly in adults

» Acyclovir, vidarabine, famvir, foscarnetAcyclovir, vidarabine, famvir, foscarnet

» Acyclovir – drug of choice for childrenAcyclovir – drug of choice for children

» Acetaminophen may be used to control feverAcetaminophen may be used to control fever

» NO ASPIRINNO ASPIRIN


Treatment & Preventive CareTreatment & Preventive Care– Immunization Immunization

» MMRV (Measles, Mumps and Rubella Vaccine)MMRV (Measles, Mumps and Rubella Vaccine)

» EMS workers w/o past exposure to chickenpox EMS workers w/o past exposure to chickenpox may consider chickenpox vaccinemay consider chickenpox vaccine

» Varicella zoster immune globulin recommended Varicella zoster immune globulin recommended if pregnant and with a substantial exposureif pregnant and with a substantial exposure

Rotavirus Rotavirus Rotavirus Rotavirus

Rotavirus is the most common cause Rotavirus is the most common cause of severe diarrhea among infants of severe diarrhea among infants and young children.and young children.

It is a genus of double-stranded RNA It is a genus of double-stranded RNA virus in the family Reoviridae. virus in the family Reoviridae.

5 Species5 Species5 Species5 Species

Rotavirus A – most common species, causes Rotavirus A – most common species, causes more than 90% infection in humans.more than 90% infection in humans.

Rotavirus B – adult diarrhea rotavirus (ADRV)Rotavirus B – adult diarrhea rotavirus (ADRV) Rotavirus C - rare and cause of sporadic cases Rotavirus C - rare and cause of sporadic cases

of diarrhea in children.of diarrhea in children. Rotavirus DRotavirus D Rotavirus ERotavirus E

EtiologyEtiologyEtiologyEtiology

Invades the epithelium and damages Invades the epithelium and damages villi of the upper small intestinevilli of the upper small intestine

In severe cases involves the entire In severe cases involves the entire small bowel and colonsmall bowel and colon

Vomiting may last 3 to 4 daysVomiting may last 3 to 4 days Diarrhea may last 7 to 10 daysDiarrhea may last 7 to 10 days

EtiologyEtiologyEtiologyEtiology

Dehydration is common in childrenDehydration is common in children Primary infection with rotavirus in Primary infection with rotavirus in

infancy may cause moderate to infancy may cause moderate to severe disease but is less severe in severe disease but is less severe in later lifelater life

Epidemiology Epidemiology Epidemiology Epidemiology

Occurs both in developing and Occurs both in developing and developed countriesdeveloped countries

Peaks in the winter each yearPeaks in the winter each year Highest rate of illness occurs in Highest rate of illness occurs in

children 3-42 months of agechildren 3-42 months of age

Transmission Transmission Transmission Transmission

Fecal oral route is the major Fecal oral route is the major mechanism of transmission mechanism of transmission

Causes gastrointeritis (often called Causes gastrointeritis (often called “stomach flu” despite having no “stomach flu” despite having no relation to influenza)relation to influenza)

Clinical Manifestations Clinical Manifestations (Sx/Sx)(Sx/Sx)

Clinical Manifestations Clinical Manifestations (Sx/Sx)(Sx/Sx)

Low grade feverLow grade fever LethargyLethargy Abdominal PainAbdominal Pain Dehydration – prominent Dehydration – prominent Diarrhea (characterized by watery stools, with Diarrhea (characterized by watery stools, with

no blood or mucus)no blood or mucus) Stools may be odorless or foul-smellingStools may be odorless or foul-smelling Vomiting may be presentVomiting may be present

Diagnosis Diagnosis Diagnosis Diagnosis Complete Blood Count (CBC)Complete Blood Count (CBC) Basic Metabolic Panel (BMP) Test Basic Metabolic Panel (BMP) Test

(measures sugar, fluid, and electrolyte (measures sugar, fluid, and electrolyte levels in the blood)levels in the blood)

Urine Analysis for specific gravity as an Urine Analysis for specific gravity as an indicator of hydration statusindicator of hydration status

Stool specimensStool specimens Stool culturesStool cultures

Treatment Treatment Treatment Treatment

Correcting dehydration and Correcting dehydration and electrolyte deficitselectrolyte deficits

Most infectious causes of diarrhea in Most infectious causes of diarrhea in children are self-limited.children are self-limited.

Prevention Prevention Prevention Prevention Hand washingHand washing Diaper changing for childrenDiaper changing for children Water purificationWater purification Vaccines: Vaccines:

– Rota Teq – pentavalent RV5 (ages 2, 4, 6 Rota Teq – pentavalent RV5 (ages 2, 4, 6 months)months)

– Rotarix – RV1 (2 months and 4 months) Rotarix – RV1 (2 months and 4 months)

Hand Foot Mouth DiseaseHand Foot Mouth DiseaseHand Foot Mouth DiseaseHand Foot Mouth Disease

Enterovirus Family (includes Enterovirus Family (includes polioviruses, coxsackieviruses, and polioviruses, coxsackieviruses, and echoviruses)echoviruses)

Coxsackie Virus A16 – most Coxsackie Virus A16 – most common causecommon cause

Occasional – other strains of Occasional – other strains of coxsackievirus A and enterovirus 7coxsackievirus A and enterovirus 7

Signs and SymptomsSigns and SymptomsSigns and SymptomsSigns and Symptoms

Sores in mouth with associated Sores in mouth with associated blisters on hands and feetblisters on hands and feet

FeverFever Loss of appetite headacheLoss of appetite headache

Epidemiology Epidemiology Epidemiology Epidemiology

Can’t catch it from animalsCan’t catch it from animals Affects children ages 10 and underAffects children ages 10 and under Spread through hand contaminationSpread through hand contamination Incubation: 3-7 daysIncubation: 3-7 days

Prevention and TreatmentPrevention and TreatmentPrevention and TreatmentPrevention and Treatment

Supportive treatment: control fever’ Supportive treatment: control fever’ good hydrationgood hydration

No known cure or vaccineNo known cure or vaccine

ScabiesScabiesScabiesScabies Burrowing mitesBurrowing mites Affects skinAffects skin TransmissionTransmission

– direct skin to skin direct skin to skin contactcontact

– sexual contactsexual contact

– bedding in contact bedding in contact with infected person with infected person w/I past 24 hoursw/I past 24 hours

ScabiesScabiesScabiesScabies Sx/SxSx/Sx

– Intense itching, especially at nightIntense itching, especially at night

– Papules (bumps) with intense itching on hands, Papules (bumps) with intense itching on hands, fingers, wrists, axillae, genitalia, medial thighsfingers, wrists, axillae, genitalia, medial thighs

– MalesMales» lesions prominent around finger webs, anterior surfaces of lesions prominent around finger webs, anterior surfaces of

wrists and elbows, armpits, belt line, thighs and external wrists and elbows, armpits, belt line, thighs and external genitaliagenitalia

– FemalesFemales» lesions prominent on nipples, abdomen, lower portion of lesions prominent on nipples, abdomen, lower portion of

buttocksbuttocks

ScabiesScabiesScabiesScabies Treatment & Preventive CareTreatment & Preventive Care

– BSI when handling patient and beddingBSI when handling patient and bedding

– Treated with Kwell® or other similar agents based Treated with Kwell® or other similar agents based on patient ageon patient age

– No immunizationNo immunization

LiceLiceLiceLice Parasites that infest the Parasites that infest the

head, body and pubic head, body and pubic areaarea

A whole group of A whole group of people now who are people now who are professional “ Nit professional “ Nit pickers!” Not kiddingpickers!” Not kidding

LiceLiceLiceLice

Blood sucking insectsBlood sucking insects TypesTypes

– HeadHead– BodyBody– Pubic (crab)Pubic (crab)

Itching, white specks Itching, white specks (nits) on hair(nits) on hair

Lice: Pediculus HumanusLice: Pediculus HumanusLice: Pediculus HumanusLice: Pediculus Humanus Spread by close person to Spread by close person to

person contactperson contact Life cycle is NitLife cycle is Nit Nymph Nymph

Adult Adult Adult is the size of a Adult is the size of a

pinhead, is rusty color and pinhead, is rusty color and clings to hairclings to hair

LiceLiceLiceLice TransmissionTransmission

– Head and Body liceHead and Body lice

» direct contact with an infested person and objects direct contact with an infested person and objects used by themused by them

– Body liceBody lice

» indirect contact with the personal belongings, indirect contact with the personal belongings, especially shared clothing and headwear, of especially shared clothing and headwear, of infested personinfested person

– Crab liceCrab lice

» sexual contact with infested personsexual contact with infested person

– Fever does not favor transmission; leave febrile hostsFever does not favor transmission; leave febrile hosts

LiceLiceLiceLice Signs and SymptomsSigns and Symptoms

– itchingitching– location dependent upon infestationlocation dependent upon infestation– head licehead lice

» itching of hair, eyebrows, eyelashes, mustache itching of hair, eyebrows, eyelashes, mustache and beardsand beards

– body licebody lice» infestation of clothing especially along seams of infestation of clothing especially along seams of

inner clothing surfacesinner clothing surfaces

LiceLiceLiceLice

Treatment & Preventive CareTreatment & Preventive Care– BSI, Bag linen separatelyBSI, Bag linen separately

– Insecticide in ambulance effective for lice and mitesInsecticide in ambulance effective for lice and mites

– Personal treatment includes use of body/hair Personal treatment includes use of body/hair pediculicide repeated 7-10 days laterpediculicide repeated 7-10 days later

– Treatment: Treatment: Permethrin 1% creamPermethrin 1% cream rinserinse applied to applied to clean dry hair and left on for 10 min. Repeat in 1 wkclean dry hair and left on for 10 min. Repeat in 1 wk

TetanusTetanusTetanusTetanus ClostridiumClostridium tetanitetani AffectsAffects musculoskeletalmusculoskeletal systemsystem TransmissionTransmission

– Tetanus spores introduced into body through wounds or Tetanus spores introduced into body through wounds or disruptions in skindisruptions in skin

– Introduction of soil, street dust, animal or human fecesIntroduction of soil, street dust, animal or human feces

– Dose not require significant wound to result in infectionDose not require significant wound to result in infection

TetanusTetanusTetanusTetanus Sx/SxSx/Sx

» Muscular tetanyMuscular tetany

» Painful contractions of masseter (“lockjaw”) and Painful contractions of masseter (“lockjaw”) and neck muscles; later trunk musclesneck muscles; later trunk muscles

» Abdominal rigidity often first sign in pedsAbdominal rigidity often first sign in peds

» Facial contortion often noted (grotesque Facial contortion often noted (grotesque grinning)grinning)

» May lead to respiratory failureMay lead to respiratory failure

TetanusTetanusTetanusTetanus Treatment and Preventive CareTreatment and Preventive Care

– Temporary, passive immunity from tetanus immune Temporary, passive immunity from tetanus immune globulin or tetanus antitoxinglobulin or tetanus antitoxin

» usually administered at childhood as DPTusually administered at childhood as DPT

– Active tetanus immunization with a boosterActive tetanus immunization with a booster

» booster generally recommended every 10 years booster generally recommended every 10 years or following potential exposureor following potential exposure

» booster recommended every 5 years for high risk booster recommended every 5 years for high risk persons like EMS personnelpersons like EMS personnel

RabiesRabiesRabiesRabies LyssavirusLyssavirus Affects Nervous SystemAffects Nervous System TransmissionTransmission

– saliva containing virus transmitted after a bite or saliva containing virus transmitted after a bite or scratch from an infected animalscratch from an infected animal

– transmission person-to-person possible but has transmission person-to-person possible but has never been documentednever been documented

– Hawaii only area in US that is rabies freeHawaii only area in US that is rabies free

– In US, wildlife rabies common in: skunks, raccoons, In US, wildlife rabies common in: skunks, raccoons, bats, foxes, dogs, wolves, jackals, mongoose, and bats, foxes, dogs, wolves, jackals, mongoose, and coyotescoyotes

RabiesRabiesRabiesRabies Sx/SxSx/Sx

– Onset usually byOnset usually by» Sense of apprehensionSense of apprehension» HeadacheHeadache» FeverFever» MalaiseMalaise

– Progresses to weakness/paralysis, spasm of Progresses to weakness/paralysis, spasm of swallowing muscles (results in hydrophobia), swallowing muscles (results in hydrophobia), delirium and convulsionsdelirium and convulsions

– W/O intervention, lasts 2-6 daysW/O intervention, lasts 2-6 days– Death usually from respiratory failureDeath usually from respiratory failure

RabiesRabiesRabiesRabies

Treatment & Preventive CareTreatment & Preventive Care– Body Substance Isolation (BSI)Body Substance Isolation (BSI)

– Allow free bleeding and drainageAllow free bleeding and drainage

– Vigorously clean wound with soap and waterVigorously clean wound with soap and water

– Human Rabies immune globulinHuman Rabies immune globulin

– Tetanus prophylaxisTetanus prophylaxis

– Immunization with Human Diploid Cell Rabies Immunization with Human Diploid Cell Rabies vaccine or Rabies vaccine for higher risk personsvaccine or Rabies vaccine for higher risk persons

» animal care workers, animal shelter personnelanimal care workers, animal shelter personnel

Infection Control ProceduresInfection Control ProceduresInfection Control ProceduresInfection Control Procedures

Pre-ResponsePre-ResponsePre-ResponsePre-Response

Maintain personal healthMaintain personal health– Yearly general check-upYearly general check-up

– Nutrition/Alcohol, Drug UseNutrition/Alcohol, Drug Use VaccinationVaccination

– DPT, MMRDPT, MMR

– VaricellaVaricella

– Hepatitis B, consider Hepatitis AHepatitis B, consider Hepatitis A

– InfluenzaInfluenza PPD test for TB every 6-12 monthsPPD test for TB every 6-12 months

Pre-ResponsePre-ResponsePre-ResponsePre-Response

Work Area RestrictionsWork Area Restrictions– In areas where there is likelihood of exposure to In areas where there is likelihood of exposure to

blood or other infectious materials, do not eat, blood or other infectious materials, do not eat, drink, apply cosmetics or lip balm, smoke, or handle drink, apply cosmetics or lip balm, smoke, or handle contact lensescontact lenses

– This includes the driver’s compartment of the This includes the driver’s compartment of the ambulance unless it is isolated from the patient ambulance unless it is isolated from the patient compartmentcompartment

– Protect these items from exposure while being Protect these items from exposure while being stored in ambulance or on your personstored in ambulance or on your person

Pre-ResponsePre-ResponsePre-ResponsePre-Response Don’t go to work if you:Don’t go to work if you:

– have diarrheahave diarrhea

– have a draining wound or wet lesionhave a draining wound or wet lesion

– jaundicejaundice

– have mononucleosishave mononucleosis

– have lice/scabies and have not been treated with a have lice/scabies and have not been treated with a medication and/or shampoomedication and/or shampoo

– have been taking antibiotics for less than 24 hours have been taking antibiotics for less than 24 hours for a strep throatfor a strep throat

– have a cold (wear a mask if you have to go to work)have a cold (wear a mask if you have to go to work)

During ResponseDuring ResponseDuring ResponseDuring Response

Personal Protective EquipmentPersonal Protective Equipment– Gloves: whenever contact may occur with blood, Gloves: whenever contact may occur with blood,

other potentially infectious material, non-intact other potentially infectious material, non-intact skin, mucous membranesskin, mucous membranes

– Masks, goggles: whenever splashes, spray, splatter, Masks, goggles: whenever splashes, spray, splatter, or droplets of blood or other potentially infectious or droplets of blood or other potentially infectious materials can be anticipatedmaterials can be anticipated

» TB masks: HEPA or N95 respiratorsTB masks: HEPA or N95 respirators

– Caps, hoods, resistant shoe covers: whenever gross Caps, hoods, resistant shoe covers: whenever gross contamination can be anticipatedcontamination can be anticipated

During ResponseDuring ResponseDuring ResponseDuring Response

NeedlesNeedles– Contaminated sharps are not bent, recapped, Contaminated sharps are not bent, recapped,

removed, sheared, or brokenremoved, sheared, or broken

– Sharps are discarded in closeable, puncture-proof, Sharps are discarded in closeable, puncture-proof, leak-proof, labeled, color-coded containersleak-proof, labeled, color-coded containers

Post ResponsePost ResponsePost ResponsePost Response

Remove contaminated garments as soon as Remove contaminated garments as soon as feasiblefeasible

Dispose of all disposable equipment in Dispose of all disposable equipment in biohazard labeled receptaclesbiohazard labeled receptacles

Remove contaminated linens from vehicle, bag Remove contaminated linens from vehicle, bag for laundering following agency proceduresfor laundering following agency procedures


Wash Your Hands!!!Wash Your Hands!!!

Post ResponsePost ResponsePost ResponsePost Response Disinfect non-disposable equipment Disinfect non-disposable equipment

immediatelyimmediately– bactericidal against TB and hepatitisbactericidal against TB and hepatitis

Clean up all spills immediatelyClean up all spills immediately Scrub, disinfect ambulance daily or as needed Scrub, disinfect ambulance daily or as needed

after responseafter response

Wear gloves during all clean-upsWear gloves during all clean-ups

Consider wearing maskConsider wearing mask


Wash Your Hands Wash Your Hands Again!!!Again!!!

Post-ExposurePost-ExposurePost-ExposurePost-Exposure Exposure IncidentExposure Incident

– any specific eye, mouth, other mucous membrane, any specific eye, mouth, other mucous membrane, non-intact skin, parenteral contact with blood, blood non-intact skin, parenteral contact with blood, blood products, or other potentially infectious materialsproducts, or other potentially infectious materials

ReportingReporting– should be reported quicklyshould be reported quickly

– allows for immediate medical follow up and allows for immediate medical follow up and intervention as appropriateintervention as appropriate

– allows for evaluation of incident and allows for evaluation of incident and implementation of changes to prevent future implementation of changes to prevent future occurrencesoccurrences

Post-ExposurePost-ExposurePost-ExposurePost-Exposure ReportingReporting

– Ryan White act requires a designated person within Ryan White act requires a designated person within organization for reportingorganization for reporting

– Implements organization’s Exposure Control PlanImplements organization’s Exposure Control Plan Medical EvaluationMedical Evaluation

– Employer must provide free medical evaluation and Employer must provide free medical evaluation and treatment to exposed employeestreatment to exposed employees

» includes counseling regarding risks, sx/sx, includes counseling regarding risks, sx/sx, medication side effects, risk of developing diseasemedication side effects, risk of developing disease

Post-ExposurePost-ExposurePost-ExposurePost-Exposure EvaluationEvaluation

– Often involves blood testing of exposed employee Often involves blood testing of exposed employee (baseline)(baseline)

» PPD testing in case of TBPPD testing in case of TB

– Implement prophylactic regimens as appropriate Implement prophylactic regimens as appropriate after medical counselingafter medical counseling

– Follow up and repeat testingFollow up and repeat testing

Communicable disease

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