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EMS Blood Borne Pathogens and Other Dangers Dan O’Donnell Indiana University Emergency Mecicine 2/19/06 Goals Recognize infectious disease risks assumed by EMS personnel Understand post-exposure management of needlestick injuries, respiratory exposure, and contact exposure involving EMS personnel Review the Clarian policy on post-exposure HIV prophylaxis Why should we care Estimated 4.1 million Americans infected with HCV 3.2 million chronic infection Estimated 946,00 people in US with HIV/AIDS Estimated rate in Indiana 6.5 per 100,000 14,097 new cases of TB reported in the US in 2005 Source: www.cdc.gov Early Universal Precautions WEAR GLOVES It is A LOT Different Now You are called for unresposive person As you get vitals and begin to start an IV, the patient begins to seize and you stick yourself What information do you need? Do you need to get any shots? Can we draw blood on him? Infectious Diseases & EMS Hepatitis B Hepatitis C HIV/AIDS Tuberculosis Meningitis Terrorist Attacks New Case Called to the local dialysis center for chest pain As you they are unhooking his port some blood splashes onto your arm Patient is HBV + and HCV + What testing do you need? Hepatitis B Virus Blood-borne exposure Risk of infection after percutaneous exposure reported from 2-40% OSHA requires EMS employers to provide HBV vaccination series free of charge Vaccination given at 0, 1, 6 month intervals Follow-up testing at 1-3 months to ensure immunity Hepatitis B Virus Prevention is important Associated with 6-10% incidence of chronic liver disease and primary hepatocellular carcinoma HBV Prophylaxis for Needlestick Exposed EMT is unvaccinated If source patient not tested or unknown If source patient HBsAg negative initiate HBV vaccine series initiate HBV vaccine series If source patient HBsAg positive HBIG (0.06 ml/kg IM up to 10 ml) single dose and initiate HBV vaccine series HBV Prophylaxis for Needlestick Exposed EMS provider is previously vaccinated and known responder (anti-HBsAB >10 mIU/ml) Source patient not tested or unknown: no tx Source patient HBsAg negative: no tx Source patient HBsAg positive: test exposed and if titer >10 mIU/ml: no tx; if titer < 10 mIU/ml: HB vaccine booster dose HBV Prophylaxis for Needlestick Exposed EMT is previously vaccinated and is known non-responder Source patient not tested or unknown: if a highrisk source may treat as HBsAg + Source patient HBsAg negative: no tx Source patient HBsAg positive: HBIG two doses or HBIG one dose and HBV vaccine one dose HBV Prophylaxis for Needlestick Exposed EMT previously vaccinated but response unknown Source patient not tested or unknown: test EMT for anti-HBsAb and if adequate no tx, if inadequate, give one HB vaccine booster Source patient HBsAg negative: no tx Source patient HBsAg positive: test exposed, if inadequate HBIG x 1 & booster HBV Exposure and Work Duty Does not need to be removed from pt care Counsel to practice safe sex for 6 mos Document baseline and 6 mos HB titer If infected with acute HBV should wear gloves for invasive procedures or those involving mucous membrane contact until antigenemia resolves HB carriers: avoid invasive procedures Hepatitis C Virus Blood-borne exposure Risk of infection after percutaneous exposure reported from 3 - 10% No current vaccine Ig prophylaxis post-exposure no proven benefit and not currently recommended ? Role for alpha-interferon Hepatitis C Virus Prevention is important Causes chronic liver disease in up to 67% affected and associated with hepatocellular carcinoma HCV and Needlestick Injury Test source patient for HCV If source patient positive for HCV: Provider testing for hepatitis C antibody titer and LFTs at baseline and in 6 mos HCV Exposure and Work Duty Does not need to be removed from pt care Counseling regarding safe sex for 6 mos Same precautions with invasive procedures as with HBV Next Case Called for possible overdose Upon arrival find a 20ish male obtunded with needle sticking from arm You go to start an 18g IV and stick yourself His girlfriend is HIV+ but doesn’t know his status What do you do now? HIV/AIDS Blood-borne as well as other body fluids to lesser extent Risk of infection after percutaneous exposure reported from 0.2 - 0.5% No existing vaccine Prevention important for obvious reasons of currently incurable disease, devastating financial and emotional aspects, etc. HIV and Needlestick Increased risk deep injury viremic blood on device causing injury device used in pt vein or artery (hollow needle) source pt dies from AIDS within 60 days of exposure (assumes pt had high viral load) HIV and Mucous Membranes Risk approximate 0.1% For intact skin even <0.1% Increased risk high volume of blood high viral load of HIV prolonged contact membrane/skin integrity compromised extensive area of contact HIV Exposure Prophylaxis “A Walk Through the EMTC” Initial Clean affected area as promptly as possible with copious amounts of water or sailine and cleansing with soap or alcohol based products Notify EMS supervisor Taken from the 2007 Clarian Guidelines for EMS needlestick exposures Once You Get to the EMTC You will be immediately triaged to the fast track EMTC health care provider witll assess the exposure The provider will esnure the affected areas are clean as promptly as possible The OUCH nurse will be notified Then What? Blood draws 1st dose of emtricitabine and tenofovir, lopinavir/ritonavir CBC, CMP, b-HCG If very high risk this will be broadened You will be d/c with Emtricitabine Tenofovir kaletra The Next Day Occupational health will be responsible for drawing baseline Hepatits B, C and HIV lab work What About the Patient? The Clarain OUCH nurse will coordinate getting blood for Rapid HIV, HBV, HCV What if they refuse draws? The employer or the Indiana State Health department may petition the court Physical restraint may NEVER be used What if we are not going to EMTC? The staff physician or charge nurse will complete all steps HIV Exposure Prophylaxis Other drugs Zidovudine (AZT) Lamivudine (Epivir) Indinavir (Crixivan) All have shown to have great results at preventing seroconversion Issues in HIV Prophylaxis Current ZDV doses well tolerated Short term toxicity seen in higher doses includes GI symptoms, fatigue, headache Contraindicated in pregnancy/breastfeeding Toxicity of other antiretrovirals not well studied in HIV negative individuals In HIV +, 3TC can cause GI symptoms, pancreatitis Issues in HIV Prophylaxis IDV toxicity in HIV + individuals includes GI symptoms and with prolonged use, increased incidence of: hyperbilirubinemia kidney stones (<5%) Prophylaxis should be initiated ASAP, preferably within 1-2 hours post-exposure. No absolute cut-off for prophylaxis start HIV Exposure and Work Duty Does not need to be removed from pt care Counsel to practice safe sex for 6 mos Baseline and follow-up HIV testing at 6 weeks, 3 months, and 6 months For HIV positive EMTs, avoid invasive procedures Needle stick Prevention in EMS No needle recapping Avoid two handed techniques Needle less drug administration Proper and immediate disposal of needles Attention to task and patient behavior Communication with EMS driver Reassessment of need for IV, meds Next Case Called for Cough and Fever Find a homeless gentelman on the streets. Claims he has been coughing up blood for the past year progressively worsening Tuberculosis Airborne transmission in droplets < 5 micrometers in diameter Symptoms associated with active TB: persistent cough > 3 weeks bloody sputum night sweats weight loss fever Tuberculosis Exposure CXR most useful study for contemporaneous assessment of exposure risk Exposed EMT should have Mantoux skin test for TB at baseline and again in 12 weeks Mantoux Skin Test < 5mm: negative > 5mm and < 10 mm: negative UNLESS: HIV + or risk factors for HIV recent TB contact CXR shows fibrotic changes of TB >10 mm and < 15 mm: negative UNLESS: several risk factors for TB > 15 mm: positive Tuberculosis Prevention HEPA filter masks to filter particles 1 micrometer diameter or more Suspected patients wear surgical masks over mouth and nose Open windows of ambulance Air conditioning/heat on nonrecirculation mode Tuberculosis Treatment Refer to pulmonary/infectious disease consultants Multidrug resistent TB increasing Selection of antituberculosis meds based on local sensitivities and profiles Tuberculosis and Work Duty Does not need to be removed from pt care unless EMT has active disease If EMT has a prior history of treated TB needs to be counseled on symptoms of active TB Last Case Called to a local ECF for “Altered Mental Status” Find an 87 y/o female who has had fever 104 and headache Transport 2 days later the doc lets you know that she was diagnosed with meningitis What do you do? Bacterial Meningitis Neisseria meningitidis Haemophilus influenzae Streptococcus pneumoniae Who needs prophylaxis Meningitis Exposure Prophylaxis Neisseria meningitidis if contact with oral secretions, intubation, suctioning rifampin 10 mg/kg/dose max 600mg BID x 2d ciprofloxacin 500mg single dose Haemophilus influenzae same exposures as with n. meningitidis rifampin 600mg qd x 4 days Meningitis Exposure Prophylaxis Streptococcus pneumoniae no specific post-exposure prophylaxis recommended All meningitis exposures counsel exposed providers on signs and symptoms of meningitis Meningitis and Work Duty Does not need to be removed from pt care unless signs and symptoms of meningitis develops Summary Universal precautions at all times Practice good needle safety Be aware of the HIV post-exposure prophylaxis Remember respiratory isoloation as part of universal precautions When in doubt…ask!