Chap 39 Infectious-Communicable Diseases

Chapter 39
Infectious and Communicable Diseases
Copyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Objectives
Identify public health principles related to infectious diseases Describe the chain of elements needed for an infectious disease to occur Explain how internal and external barriers affect susceptibility to infection Distinguish between four periods of infectious diseases:
Latent, incubation, communicability, disease

Objectives
Describe mode of transmission, pathophysiology, prehospital considerations, and PPE for:
HIV Hepatitis TB Meningococcal meningitis Pneumonia SARS
Objectives
Describe transmission, pathophysiology, and signs and symptoms of:
Rabies Tetanus Selected childhood viral illnesses Influenza Mononucleosis Sexually transmitted diseases
Objectives
Identify signs, symptoms, and prehospital considerations related to lice and scabies Outline reporting for exposure to infectious disease Discuss the paramedics role in preventing disease transmission
Scenario
You recognize the address before the dispatcher tells you to stage until police arrive. The patient has attempted suicide several times, and you remember hearing she has hepatitis B and C. When police signal you to approach, you find your patient in the basement in a puddle of blood, vomit, and feces. She is unconscious, breathing 8 times per minute, and still bleeding from an apparent razor wound to the brachial artery area. Your partner begins to manage her airway and breathing while you control the bleeding and call for a pumper to assist with her care.
Discussion
What personal protective measures should you take:

Before this call? During this call?
Can you assume your information regarding her disease status is true?
How can these diseases be transmitted?

What should you do if think youve had an exposure to her blood?
Infectious disease
Illness caused by specific microorganism
Communicable disease
Infectious disease transmitted from one person to another
Public health principles CDC classification of infectious disease

Airborne Bloodborne
Agency responsibility relative to infectious agent exposure Personal responsibilities
Body Substance Isolation (BSI)
BSI is based on the premise that all exposures to body fluids, under any circumstances, are potentially infectious
Decontamination Methods
Cleaning, disinfection, and sterilization guidelines have been established by the CDC, OSHA, Environmental Protection Agency (EPA), and other agencies and organizations
Pathophysiology of Infectious Diseases
Depends on:
Virulence Degree of pathogenicity Number of infectious agents Dose Resistance of host Immune status Correct mode of entry
Chain of Elements
Pathogenic agent Reservoir Portal of exit from reservoir Environment conducive to transmission Portal of entry into new host Susceptibility of new host to infectious disease
Chain of Transmission for Infection

Transmission controlled by breaking any link in chain
Pathogenic Agent
Organism that can create pathological processes in a human host Classified according to:

Morphology Chemical composition Growth requirements Viability
Pathogenic Agents
Bacteria Viruses Fungi Protozoa
Helminths
Worms, including tapeworms, roundworms

Pathogenic Agent
Establishment of an infectious disease depends on:

Ability to invade and reproduce in host Mode in which it does so Speed of reproduction Ability to produce toxin Extent of tissue damage caused Potency Ability to induce immune response in host
Reservoir
Environment in which pathogen lives and reproduces in Life cycle of infectious agent depends on:

Demographics of host Genetic factors Therapeutic interventions
Portal of Exit
How pathogenic agent leaves one host to invade another
Depends on agent and may involve: GU tract Intestinal tract Oral cavity Respiratory tract Open lesion Wound through which blood escapes
Transmission/Portal of Entry
Determined by portal of exit Direct transmission
Physical contact between source and victim
Indirect transmission
Organism survives without human host
Portal of entry
How pathogenic agent enters new host
Host Susceptibility
Influenced by immune response and by:
Human characteristics General health status Immune status Geographical and environmental conditions Cultural behaviors Sexual behaviors
Human Response to Infection
External barriers

Flora Skin GI system Upper respiratory tract Genitourinary tract
First Line of Defense: External Barriers
Human Response to Infection
Internal barriers
Protect against pathogenic agents when external lines of defense are breached Include: Inflammatory response Immune response
Inflammatory Response
Inflammation
Local reaction to cellular injury
Generally protective and beneficial
Can destroy body tissue if sustained or directed toward host's own antigens
Three stages
Cellular response to injury Vascular response to injury Phagocytosis
Second Line of Defense: Inflammatory Response
Immune Response
White blood cells are backbone of immune system Humoral immunity component

Time-consuming response Specialized white blood cells (B cells) differentiate into antibodies
Immune Response
Cell-mediated immunity

Time-consuming response T cells coordinate other components of immune system to deal with foreign material Helper T cells Suppressor T cells Killer T cells Inflammatory T cells
Cellular and Humoral Immunity
Immune Response
Effector cells with no specialized function

Monocytes Neutrophils Eosinophils Basophils Natural killer cells
Reticuloendothelial System (RES)
Immune cells in spleen, lymph nodes, liver, bone marrow, lungs, and intestines Works with lymphatic system
Disposes of garbage material that results from immune system attack of intruders
Mature B and T cells are stored until immune system is activated by intruders
Complement System
Recognizes and kills invaders on first sight Doesnt take time to mobilize specialized responses, such as the humoral and cellmediated components of white blood cells
Stages of Infectious Disease
Latent period Incubation period Communicability period Disease period
HIV
Blood and serum-derived body fluids
Semen, vaginal, or cervical secretions
Directly transmitted person to person
Anal or vaginal intercourse Across placenta Contact with infected blood or body fluids on mucous membranes or open wounds
HIV
HIV is indirectly transmitted by:
Transfusion with contaminated blood or blood products Transplanted tissues and organs Contaminated needles or syringes
HIV Risk Factors
High-risk sexual behavior IV drug abuse Transfusion recipient between 1978 and 1985 Coagulation disorders requiring blood products Infant born of HIV-positive mother Other factors
HIV
Retroviral infection Alters cell function to produce virus
Host cell ruptures, releasing virus

Interferes with immune function
HIV Complications

Pulmonary TB Pneumonia Pneumocystis carinii pneumonia Kaposis sarcoma Wasting syndrome HIV dementia Sensory neuropathy Toxoplasmosis
HIVCategories
Acute Retroviral infection

2-4 wks after exposure Fever, adenopathy, sore throat Seroconversion 6-12 wks
Early symptomatic HIV

Localized infections, skin lesions Prolonged fever, diarrhea
Late symptomatic HIV
Severe opportunistic infections

Kaposis Sarcoma of the Heel and Lateral Foot
Kaposis Sarcoma of the Distal Leg and Ankle
HIVPPE
Universal precautions
Standard precautions
Increased risk if exposure to:
Large quantity of blood Device visibly contaminated with blood Deep penetration injury Terminal source patient
HIVPEP
Immediate notification If indicated, PEP drugs may include:
Nucleotide reverse transcriptase inhibitors Nonnucleotide reverse transcriptase inhibitors Protease inhibitors Fusion inhibitors
HIV test postexposure
Immediate, 2-3 wks, 3 and 6 mo, 1 yr

HIVPsychological Response
May feel anger related to:

Pain Early death Social rejection Prejudice
Hepatitis
Viral disease Produces pathological changes in liver
Three main hepatitis viruses

Hepatitis A (viral hepatitis) Hepatitis B (serum hepatitis) Hepatitis C (non-A/non-B hepatitis)
Hepatitis
Hepatitis non-ABC is a fourth class of hepatitis Caused by infection with hepatitis D virus and newer hepatitis viruses
E and G
Hepatitis A Virus (HAV)
Most common Contracted by ingesting food or drink contaminated with HAV Shed in feces Small number have liver failure Does not lead to:
Chronic liver disease Carrier state
Hepatitis A Virus (HAV)
Vaccine available Immune globulin
Provides temporary immunity
Good hand washing best defense against spread
Hepatitis B Virus (HBV)
Virus in blood and bloody secretions Affects liver Can cause chronic cirrhosis Lasts <6 mos
Carrier state may last years
Signs and symptoms
Flulike Or liver necrosis/death
Hepatitis B Virus (HBV)
Complications include:

Coagulation defects Impaired protein production Impaired bilirubin elimination Pancreatitis Hepatic cancer
Hepatitis B Virus (HBV) Exposure
Percutaneous inoculation Indirect
Skin cuts, tattoos/piercings
Mucosal surfaces
Eyes, mouth Transplacental
Intercourse Transfer by inanimate objects

Hepatitis B VirusPrevention
Universal precautions Vaccination preexposure
Postexposure if no antibodies

Vaccination Immune globulin
Hepatitis C Virus (HCV)
Similar to HBV Infected transfusions pre-1992 Most frequent infection from needle stick injury
85% become chronic carriers
Complications
Chronic hepatitis Cirrhosis Liver cancer
No vaccine No postexposure prophylaxis currently recommended
New guidelines from CDC pending
Transmission similar to HBV
Not easily spread through sex
Signs and symptoms

Most asymptomatic May be similar to HBV
HepatitisSigns and Symptoms
Flulike illness Jaundice, dark urine First week of symptoms most infectious 2-3 mos. after infection
Anorexia, nausea, vomiting Fever, joint pain, rashes 1% get liver failure and die
Prehospital Management
Universal precautions Maintain fluid status Prevent shock Appropriate disposal of wastes
Tuberculosis (TB)
8 million cases/year High-risk groups

Immigrants from highly infected area Correctional facilities, homeless shelters, hospitals, nursing homes
Tuberculosis (TB)
Chronic pulmonary disease Inhalation
Tubercle bacilli
Transmitted by coughing, sneezing

Or direct contact with sputum Rarely, skin or ingestion
Tuberculosis (TB)
Produces inflammatory lesions
Most often in lung Can produce cavities
May be dormant for years

High-risk groups
Young and old Immunocompromised

TuberculosisSigns and Symptoms
Cough Fever Night sweats Weight loss Fatigue Hemoptysis

TuberculosisComplications
Pericardial effusions Disk deterioration Chronic arthritis of one joint Subacute meningitis Brain granulomas Systemic distribution in blood
TuberculosisTesting
PPD skin test annually More often if:
High incidence of TB After exposure
If positive:
CXR Acid-fast bacilli sputum culture

TuberculosisPPE
Surgical mask on patient
Nonrebreather if oxygen needed
N-95 HEPA respirator on paramedics Ventilation in ambulance not on recirculate Disinfection of ambulance with tuberculocidal germicidal after care
HEPA Respirator
Tuberculosis Treatment
If PPD test positive:

CXR Possible treatment with INH If >35 years of age Or if high risk conditions met Must avoid alcohol during treatment
Meningitis
Inflammation of membranes around spinal cord and brain
Bacteria, virus, other microorganism
Neisseria meningitidis Airborne spread Usually involves prolonged contact Viral meningitis usually less severe
MeningitisSigns and Symptoms
Infants

Irritability Poor feeding or vomiting High-pitched cry Full fontanelle
MeningitisChildren and Adults

Malaise Low-grade fever Projectile vomiting Petechial rash Headache Stiff neck
Brudzinskis sign Kernigs sign Convulsions Coma Can progress rapidly
MeningitisPrevention
Vaccines for:

Hib Some strains of N. meningitidis S. pneumoniae
MeningitisPrehospital Care
Universal precautions Mask paramedics and patient Manage airway and breathing Support circulation
Rapid transport for diagnosis
Antibiotics urgent if bacterial

Bacterial Endocarditis
Inflammation of heart and one or more valves Causes by bacteria in blood stream Risk factors:
IV drug use Dental surgery Central venous line History of heart valve problems
20% mortality Variable onset

Bacterial Endocarditis
Signs and symptoms

Flulike Night sweats Red painless spots on palms and soles Heart murmur Dyspnea and chest pain
Diagnosis by blood cultures Treatment
Symptomatic in prehospital setting Antibiotics in hospital
Pneumonia
Acute inflammatory process of respiratory bronchioles and alveoli
Causes: Bacterial, viral, fungal

Affects lungs
Possibly CNS and throat
Airborne transmission
Pneumonia
Signs and symptoms

Chills, high fever, dyspnea Chest pain with respiration Tachypnea, chest retractions Congestion Productive cough
Pneumonia
Susceptibility increased by:
Preexisting pulmonary disease Smoking Aspiration Extremes of age Diseases compromising immune function
PneumoniaManagement
Universal precautions Airway support Oxygen and ventilation IV fluids Cardiac monitor Transport for:
Antibiotics, analgesics, expectorants

Tetanus
Serious, sometimes fatal disease of CNS Wound infection with spores of bacterium Clostridium tetani Affects nerves that control muscles
Rare in U.S. due to immunization

TetanusSigns and Symptoms
Muscle tetany Trismus Painful contractions in neck
Move to trunk
Abdominal rigidity Painful spasms of face Respiratory failure

TetanusPrehospital Care
Support vital functions
Aggressive airway management

Benzodiazepines
IV fluids
Magnesium sulfate Narcotics Antidysrhythmics
Tetanus Immunization
Begin as child Booster routinely every 10 yrs Booster at 5 yrs for a dirty wound Tetanus immune globulin after exposure if immunizations not current
Rabies (Hydrophobia)
Viral infection of nervous system Animal-human transmission by saliva
Through bite or scratch
Incubation 9 days to 7 years
Symptoms
Low-grade fever, headache Loss of appetite Hyperactivity, disorientation Seizures Intense thirst; drinking causes spasms Paralysis of eye and facial muscles Death from respiratory failure 2-6 days
After exposure
Wound care Human rabies immune globulin Rabies vaccine Tetanus prophylaxis Animal evaluation
Hantavirus

Hemorrhagic fever Virus carried by rodents Inhalation of material contaminated with rodent urine or feces Fever, malaise Respiratory distress in several days GI upset, capillary hemorrhage Kidney failure, hypotension Care is supportive
Viral Diseases of Childhood
Rubella (German measles) Rubeola (red measles or hard measles)
Mumps (parotitis)
Chickenpox (varicella) Pertussis (whooping cough)
Rubella
Virus Febrile Highly communicable

Direct contact with secretions Droplet spray Inanimate objects Maternal-fetal
Diffuse, punctate, macular rash
Rubella
Congenital rubella syndrome

90% of infants infected in first trimester Multiple congenital abnormalities Critical for paramedics to check immune status Receive vaccination if not immune Protects patients and paramedics families
Acquired Rubella (German Measles) in an 11-Month-Old Infant
Rubeola
Highly communicable viral disease
Measles virus
Fever, conjunctivitis, cough, bronchitis Red, maculopapular rash
Spreads from head to torso to feet
Complications
Bacterial Panencephalitis
Immunization
Rubeola (Measles) Rash on 3rd Day
Mumps
Mumps virus Edema of salivary glands
Transmitted by saliva droplets

May spread to glands or nervous tissue
Submaxillary Mumps in an Infant
Chickenpox
Varicella-zoster virus
Droplet contact (usually respiratory)

Highly communicable
Low-grade fever, malaise

Skin rash
Maculopapular for a few hours Vesicular for 3-4 days Forms scabs
Chickenpox
Rash appears on trunk, then extremities Treatment is symptomatic
Complications

Bacterial infections Aseptic meningitis Mononucleosis Reye syndrome

Chickenpox
Virus stays latent in body May reactivate during stress Shingles

Lesions along single sensory nerve group Can cause chickenpox if contact with lesions
Chickenpox vaccine available Varicella immune globulin

Chickenpox Skin Lesions
Pertussis
Mainly affects infants and young children Direct contact with infected droplets Inflammation of respiratory tract Cough

Becomes paroxysmal in 1-2 wks Violent whoop Lasts 1-2 months
Vaccine
Other Viral Diseases
Influenza Severe acute respiratory syndrome (SARS) Mononucleosis Herpes simplex type 1
Influenza
Respiratory infection
Influenza viruses A, B, C
Droplet spread Chills, fever, headache Muscle aches, anorexia, fatigue Upper respiratory infection, cough Secondary bacterial infections possible
High-risk groups
Influenza
Vaccines
Temporary, limited protection Repeat annually
Antivirals FluMist

Nasal spray Live vaccine

Mononucleosis
Causative agents

Epstein-Barr virus Cytomegalovirus
Oropharyngeal and salivary spread Slow onset and long duration
Mononucleosis
Fever, sore throat, mucus Lymphadenopathy Splenomegaly
Risk of rupture
10% have rash
Looks like bruises
Severe Acute Respiratory Syndrome (SARS)
Emerged in 2003 Coronavirus Spread
Airborne droplets Contact
Fever, cough Respiratory failure, death in some

SARS
No vaccine 80% improve without care Strict quarantine to prevent spread Transport with minimum number of people in vehicle
Notify receiving facility if SARS suspected
SARS
Infection control guidelines Pre-Hospital Emergency Medical Care and Ground Transport of Suspected Severe Acute Respiratory Syndrome Patients
CDC NASEMSD
Sexually Transmitted Diseases
Diseases transmitted sexually

May not have genital manifestations Agents causing STDs include: Bacteria, viruses, protozoa, fungi, and ectoparasites Can produce multiple disease syndromes Patients with one STD often have multiple STDs
Syphilis

Systemic disease Primary lesion Secondary skin eruption Long latency periods Late disabling lesions of skin, bone, CNS, CV Transmission
Direct contact with lesions Sex Blood transfusion/needle sticks Congenital

Syphilis
Primary stage Secondary stage Latency Treatable with antibiotics No vaccine available
Primary Syphilis Chancre on the Labia
Gonorrhea
Neisseria gonorrhoeae
Bacterium
Transmission

Exudate from infected tissue Congenital
Dysuria, urgency, frequency Purulent urethral discharge No vaccine

Chlamydia
Chlamydia trachomatis Sexually transmitted Nonspecific urethritis Leading cause of preventable blindness Penile or vaginal discharge Treated with antibiotics
Herpes Virus Infections
Four types
Herpes simplex virus (HSV) STD Cytomegalovirus Mononucleosis, hepatitis, and severe systemic disease
in immunosuppressed host

Epstein-Barr virus Mononucleosis Varicella-zoster virus Chickenpox and shingles
Herpes Simplex Virus
HSV-1 and HSV-2
Both can infect any body area

HSV-1 usually infects above the waist
HSV-2 often genital herpes

No immunization Transmission by contact with lesion Painful vesicular lesions
Lice and Scabies
Potential health hazards for emergency care providers
Potential vectors of communicable skin disease and systemic illness
Lice

Small, wingless insects Ectoparasites Pubic or body louse Eggs hatch in 7-10 days Produce red macule and itching Treatment

Eradicate nits Treat body, clothes, bedding
Scabies

Mite Parasite Bites concentrated around hands and feet Passed by intimate contact Contact with infested clothes or bedding Severe itching at night Secondary infection possible Treat as for lice
Pubic (Crab) Louse
Male Human Head Louse
Reporting an Exposure
Report suspected exposures to designated officer
Significant exposure is eye, mouth, mucous membrane, nonintact skin, parenteral contact with blood, blood products, bloody body fluids, or other potentially infectious materials
Whom to report to Medical evaluation and follow-up
Steps involved
Written report and confidentiality

Dont Go to Work if You
Have diarrhea Have a draining wound or any type of wet lesion; wait until lesion is crusted and dry Are jaundiced
Have mononucleosis
Dont Go to Work
If you have not been treated for lice or scabies Until you have been taking antibiotics for 24 hrs for strep throat If you have a cold and you must go to work, wear a surgical mask to protect your patients
Preventing Disease Transmission
Current immunization status
MMR Hepatitis B, A (if appropriate) DPT Polio Chickenpox Influenza (seasonally) Rabies, if appropriate to your occupational/recreational risk
Approach with caution Control scene Observe BSI:

Wear gloves If chance of splash: Protective eyewear or face shield If large volumes of blood possible: Gown If possible TB patient: Particulate mask Wash hands
Dont treat patients differently because there is a possibility of an infectious process Dont avoid doing things for your patients if you think they have a communicable disease
After calls, disinfect equipment and patient compartment with a disinfectant that kills M. tuberculosis
Also kill hepatitis viruses Any soap kills HIV High-level disinfection on laryngoscope blades
After call with lice, scabies, ticks, or other insect vectors:

Spray stretcher and patient compartment with insecticide Wipe off/mop up insecticide residue Bag linen separately Ensure it is not taken home; wash separately Report exposure to designated officer
Conclusion
Emergencies involving infectious and communicable diseases are common in the prehospital setting and can pose a significant health risk to EMS providers.
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Chapter 39

Infectious and Communicable Diseases

Latent, incubation, communicability, disease

Describe mode of transmission, pathophysiology, prehospital considerations, and PPE for:

HIV Hepatitis TB Meningococcal meningitis Pneumonia SARS

Describe transmission, pathophysiology, and signs and symptoms of:

What personal protective measures should you take:

Before this call? During this call?

How can these diseases be transmitted?

Infectious and Communicable Diseases

Illness caused by specific microorganism

Infectious disease transmitted from one person to another

Infectious and Communicable Diseases

Public health principles CDC classification of infectious disease

Agency responsibility relative to infectious agent exposure Personal responsibilities

Body Substance Isolation (BSI)

Pathophysiology of Infectious Diseases

Chain of Transmission for Infection

Morphology Chemical composition Growth requirements Viability

Bacteria Viruses Fungi Protozoa

Worms, including tapeworms, roundworms

Establishment of an infectious disease depends on:

Demographics of host Genetic factors Therapeutic interventions

How pathogenic agent leaves one host to invade another

Determined by portal of exit Direct transmission

Physical contact between source and victim

Organism survives without human host

How pathogenic agent enters new host

Influenced by immune response and by:

Human Response to Infection

Flora Skin GI system Upper respiratory tract Genitourinary tract

First Line of Defense: External Barriers

Human Response to Infection

Local reaction to cellular injury

Generally protective and beneficial

Cellular response to injury Vascular response to injury Phagocytosis

Second Line of Defense: Inflammatory Response

Cellular and Humoral Immunity

Effector cells with no specialized function

Monocytes Neutrophils Eosinophils Basophils Natural killer cells

Reticuloendothelial System (RES)

Stages of Infectious Disease

Latent period Incubation period Communicability period Disease period

Blood and serum-derived body fluids

Semen, vaginal, or cervical secretions

Directly transmitted person to person

HIV is indirectly transmitted by:

HIV Risk Factors

Retroviral infection Alters cell function to produce virus

Host cell ruptures, releasing virus

Acute Retroviral infection

Early symptomatic HIV

Localized infections, skin lesions Prolonged fever, diarrhea

Late symptomatic HIV

Severe opportunistic infections

Kaposis Sarcoma of the Heel and Lateral Foot

Kaposis Sarcoma of the Distal Leg and Ankle

Increased risk if exposure to:

Immediate notification If indicated, PEP drugs may include:

HIV test postexposure

Immediate, 2-3 wks, 3 and 6 mo, 1 yr

May feel anger related to:

Pain Early death Social rejection Prejudice

Viral disease Produces pathological changes in liver