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Transcript
CHA P TE R 34 Communicable Diseases Russell MacDonald Vimal Scott Kapoor INTRODUCTION Paramedics are typically the first healthcare personnel to encounter sudden illnesses or other healthcare emergencies in the community setting. Responding to these emergencies puts paramedic personnel at risk because the type, extent, and severity of this illness are not yet known. The Occupational Safety and Health Administration (OSHA) identifies there are more than 1.2 million community-based first response personnel, including law enforcement, fire, and EMS personnel, who are at risk for infectious exposure.1 This large number highlights the need to protect these personnel against such exposures. Although infectious and communicable disease preparation may not have been a priority in some EMS agencies, the 2003 severe acute respiratory syndrome (SARS) outbreaks made it a priority. Emergency medical personnel responding to patients at the onset of the SARS outbreaks in Toronto2 and Taipei3 were exposed to, or contracted, SARS in significant numbers, and one paramedic died due to SARS. More importantly, the loss of paramedic availability for work due to exposure, illness, and quarantine impacted the ability to maintain staffing during the outbreak and highlighted the need for EMS systems to adequately prepare and protect the workforce from potential exposure.4 This chapter addresses communicable and infectious disease in a manner relevant to EMS agencies and their personnel and is divided in two parts. The first is paramedic and patient centered, describing the basics of communicable disease transmission and prevention, general approach to the patient with a suspected infectious or communicable disease, and specific disease conditions outlined by presenting complaint. The second is service- and communityoriented, describing the EMS agency’s role and planning for healthcare emergencies related to infectious disease, EMS interactions with public health agencies, and special considerations for EMS agencies in epidemics or pandemics. Occupational health and safety is an important component of infection control and prevention of communicable disease in EMS. This includes aspects of routine EMS operations such as immunization of personnel, hand hygiene, personal protective equipment (PPE), sharps safety, and cleaning of equipment and disinfection. The reader is referred to a Chapter 10, Occupational Injury Prevention and Management, in Volume 4 dedicated to this subject. PART 1: PARAMEDIC AND PATIENT Communicable Disease Transmission and Prevention OSHA defines an occupational exposure as “a reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious material that may result from the performance of the employee’s duties.”1 Infection control practices are designed to prevent exposure to blood or potentially infectious material, including cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, amniotic fluid, peritoneal fluid, and any other body fluid, secretion, or tissue. 332 1_C_34_332-359.indd 332 12/8/08 3:01:06 PM Universal precautions is the term formerly used to describe aspects of the methods used to prevent exposure, but this term is no longer used by healthcare workers. The more favored terms are routine practices and additional precautions. These terms indicate that the same basic, minimum level of precaution is taken for all patients. Infection is defined by the Association for Professionals in Infection Control and Epidemiology5 as an invasion and multiplication of microorganisms in or on body tissue causing cellular damage through the production of toxins, multiplication, or competition with host metabolism. Infectious agents capable of causing disease include bacteria, viruses, fungi and molds, parasites, and prions. These five types of microorganisms can be differentiated by their appearance on microscopic examination, reproductive cycle, chemical structure, growth requirements, and other detailed criteria. Although bacteria and viruses are the most common causes of illness in the developed world, parasites are more prevalent in other settings. Numerous factors are directly related to the ability of a microorganism to cause an infection. The dose is the amount of viable organism received during an exposure. Infection occurs when there is a large enough number to overwhelm the body’s own defenses. Virulence refers to the ability of a microorganism to cause infection, and pathogenicity refers to the severity of infection. Additional factors determine the likelihood of transmission. Incubation and communicability period are the intervals between when the organism enters the body and when symptoms appear, and the time during which the infected individual can spread the disease to others, respectively. The host status and resistance refer to the host’s ability to fight infection, which can be influenced by immune function and immunization status, nutritional state, and presence of comorbid illness. (See Figure 34.1.) An infectious disease results from the invasion of a host by disease-producing organisms, such as bacteria, viruses, fungi, or parasites. A communicable (or contagious) disease is one that can be transmitted from one person to another. Not all infectious diseases are communicable. For example, malaria is a serious infectious disease transmitted to the human blood stream by a mosquito bite, but malaria is infectious, not communicable. On the other hand, chicken pox is an infectious disease that is also highly communicable because it can be easily transmitted from one person to another. The mode of transmission is the mechanism by which an agent is transferred to the host. Modes of transmission include contact transmission (direct, indirect, or droplet), airborne, vectorborne, or common vehicle (e.g., food, equipment). Contact transmission is the most common mode of transmission in the EMS setting and can be effectively prevented using routine practices. Direct contact transmission occurs when there is direct contact between an infected or colonized individual and a susceptible host. Transmission may occur, for example, by biting, kissing, or sexual Causative agent virulence dose pathogenicity Modes of transmission direct indirect droplet airborne vectorborne bloodborne foodborne Susceptible host host resistance Portal of entry into the body FIGURE 34.1 CHAPTER 34 1_C_34_332-359.indd 333 Communicable Diseases 333 12/8/08 3:01:06 PM contact. Indirect contact occurs when there is passive transfer of infectious agent to a susceptible host through a contaminated intermediate object. This can occur if contaminated hands, equipment, or surfaces are not washed between patient contacts. Examples of diseases transmitted by direct or indirect contact include human immunodeficiency virus (HIV), hepatitis, methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), Clostridium difficile, and Norwalk virus. Droplet transmission is a form of contact transmission requiring special attention. It refers to large droplets generated from the respiratory tract of a patient when he or she coughs or sneezes or during invasive airway procedures (intubation, suctioning). These droplets are propelled and may be deposited on the mucous membranes of the susceptible host. The droplets may also settle in the immediate environment, and the infectious agents remain viable for prolonged periods of time, later transmitted by indirect contact. Examples of diseases transmitted by droplet transmission include meningitis, influenza, rhinovirus, respiratory syncytial virus (RSV), and SARS. Airborne transmission refers to the spread of infectious agents to susceptible hosts by the airborne route. Infectious agents are contained in very small droplets that can remain suspended in the air for prolonged periods of time. These agents disperse widely by air currents and can be inhaled by susceptible hosts located at some distance from the source. Examples of diseases transmitted by airborne transmission include measles (rubeola), varicella (chicken pox), and tuberculosis (TB). Vectorborne transmission refers to the spread of infectious agents by means of an insect or animal (the “vector”). Examples of vectorborne illness include rabies, in which the infected animal is the vector, and West Nile Virus or malaria, in which infected mosquitos are the vectors. Transmission of vectorborne illness does not occur between emergency personnel and their patients. Common vehicle transmission refers to the spread of infectious agents by a single contaminated source to multiple hosts. This can result in large outbreaks of disease. Examples of this type of transmission include contaminated water sources (Escherichia coli), contaminated food (Salmonella), or contaminated medication, medical equipment, or IV solutions. 334 1_C_34_332-359.indd 334 SECTION C General Approach and Patient Assessment The risk of communicable disease is not as apparent as other physical risks, such as road traffic, power lines, firearms, or chemical agents. Paramedics and other public service agencies must use the same level of suspicion and precaution when approaching a patient before the risk of communicable disease is known. The use of routine practices, as a minimum, is necessary for every patient encounter to mitigate this risk. The risk assessment begins with information from an EMS dispatch or communication center before making patient contact. Call-taking procedures must include basic screening information to identify potential communicable disease threats and provide this information to all responding personnel. The screening information can identify patients with symptoms of fever, chills, cough, shortness of breath, or diarrhea. The call-taking can also identify if the patient location, such nursing home, group home, or other institutional setting, poses a potential risk to the responding personnel. This information helps responding personnel determine what precautions are necessary before they arrive. When patient contact is made, personnel can identify the patient at risk for harboring a communicable disease. A rapid history and physical examination can raise suspicion for a communicable disease. The following screening questions help assess if the patient has a communicable disease: • Do you have a new or worsening cough or shortness of breath? • Do you have a fever? • Have you had shakes or chills in the past 24 hours? • Have you had an abnormal temperature (⬎38° C)? • Have you taken medication for fever? A screening physical examination will also identify obvious signs or symptoms of a communicable disease. They may include any new symptom of infection (e.g., fever, headache, muscle ache, cough, sputum, weight loss, and exposure history), as well as any physical signs such as rash, diarrhea, skin lesions, or draining wounds. All personnel must take appropriate precautions when a patient presents with any signs or symptoms suspected to be due to an infectious or communicable Individual Chief Complaint Protocols 12/8/08 3:01:06 PM disease. All EMS and first responder agencies must provide appropriate training that enables personnel to identify at-risk patients and how to use appropriate use of PPE. Specific Disease Conditions by Presenting or Chief Complaint Respiratory Infections Respiratory infections may be suspected when there are symptoms that classically include any combination of cough, sneeze, shortness of breath, fever, chills, or shakes. Infections above the epiglottis are classified as upper respiratory tract infections, whereas those below the epiglottis are classified as lower respiratory tract infections. Upper respiratory infections may be suspected when patients present with “cold” symptoms such as rhinorrhea, sneezing, lacrimation, or coryza. More localized and possibly more serious upper respiratory may present with symptoms such as throat pain, fever, odynophagia, dysphagia, drooling, stridor, or muffled voice. Lower respiratory infections typically present with fever, shortness of breath, pleural pain, cough, sputum, and generalized symptoms such as chills, rigors, myalgia, arthralgia, malaise, and headache. More atypical symptoms of respiratory infection may be found in children, the elderly, and the immunocompromised. Children with respiratory infection may present with gastrointestinal symptoms such as nausea, vomiting, abdominal pain, and diarrhea.6,7 The elderly and the immunocompromised may not develop a fever in the presence of a respiratory infection. Respiratory infections are spread when people cough or sneeze and the aerosolized respiratory secretions directly come in contact with the mouth, nose, or eyes of another person. Because microorganisms in droplets can survive outside the body, indirect transmission can also occur when hands, objects, or surfaces become soiled with respiratory discharges. When respiratory infections are suspected in patients, EMS providers should use droplet precautions and apply them to a patient. Febrile Respiratory Illness Febrile respiratory illness should be suspected when a patient presents with any combination of fever, new or worse cough, and shortness of breath. It should be emphasized that the elderly and immunocompro- mised may not have a febrile response to a respiratory infection. Cough Pneumonia In addition to cough, shortness of breath, and fever, patients with pneumonia may also present with additional symptoms of tachypnea, increased work of breathing, chest or upper abdominal pain, and cough productive of phlegm, sputum, or blood. Generalized systemic symptoms such as myalgia, arthralgia, malaise, and headache may also be present. Gastrointestinal symptoms such as nausea, vomiting, and diarrhea may be associated with pneumonia.8 Evidence indicates that the signs and symptoms traditionally associated with pneumonia are actually not predictive of pneumonia, whereas diarrhea, dry cough, and fever are more predictive of pneumonia. In elderly patients, the diagnosis of pneumonia is more difficult because both respiratory and nonrespiratory symptoms are less commonly reported by this patient group.9 Infectious agents that typically cause pneumonia include Streptococcus pneumoniae, Mycoplasma pneumoniae, Chlamydia trachomatis, C. pneumoniae, Pneumocystis carinii, and Haemophilus influenzae.10 The incubation period from initial contact with the microorganism to development of symptoms is generally not well known for these organisms. For S. pneumoniae, it may be 1 to 3 days and for M. pneumoniae may range from 6 to 32 days. P. carinii may appear 1 to 2 months after initial contact for those who are immunosuppressed. S. pneumoniae can be transmitted up to 48 hours after treatment is initiated. However, M. pneumoniae can be transmissible for up to 20 days, and the organism may remain in the respiratory tract for up to 13 weeks post-treatment. For the other organisms, the time period when they are transmissible is unknown.11 Pertussis Pertussis should be in the differential diagnosis of a patient presenting with chronic cough. Pertussis presents in three stages: first, a catarrhal stage lasting 1 to 2 weeks, followed by a paroxysmal stage lasting 1 to 6 weeks, and finally ending with a convalescent stage lasting 2 to 3 weeks. In the first stage, pertussis is virtually indistinguishable from any other respiratory illness because it is characterized by runny CHAPTER 34 1_C_34_332-359.indd 335 Communicable Diseases 335 12/8/08 3:01:07 PM nose, sneezing, low-grade fever, and a mild cough. The EMS provider may suspect pertussis in the second, paroxysmal, stage, when the patient has bursts of rapid coughs. The cough usually ends with a long high-pitched inspiratory effort described as a whoop, or it may end with vomiting. The third stage is the period of recovery, in which the cough becomes less paroxysmal. In adolescents, adults, and the vaccinated, pertussis is milder, and hence may be indistinguishable from other respiratory illnesses, even in the paroxysmal stage. Pertussis is caused by the Bordetella pertussis bacterium and transmitted by the respiratory route with airborne droplets. Hence, respiratory and contact precautions should be undertaken with known or suspected cases of pertussis. Unfortunately, routine precautions are not always sufficient because pertussis is most infectious during the nonspecific catarrhal period and the first two weeks of the paroxysmal phase. The time from infection to the development of symptoms is usually 7 to 10 days.12 Complications from pertussis most often occur in young infants. The major complication and most common cause of pertussis-related death is bacterial pneumonia. From 2001 to 2003, among the 56 pertussis-related deaths reported in the United States, 51 (96%) were among infants younger than 6 months of age.13 With the introduction of routine pertussis vaccination, pertussis had declined from about 140 cases per 100,000 in the 1940s to about 1 per 100,000 in the 1980s. However, since the 1980s pertussis rates have been steadily increasing. In 2002 in the United States, there were 3 cases per 100,000. The majority of cases were in children under 6 months of age, the age group most at risk of pertussis-related complications.13 Children in the United States are routinely vaccinated for pertussis in a four-dose schedule, starting at age 2 months. Because these groups are often the source of infection in infants, an adolescent and adult vaccine was licensed in the United States in 2005. Pertussis is treated with macrolide antibiotics: erythromycin, clarithromycin, or azithromycin. Treatment ameliorates the illness and decreases the communicability period. Cases of pertussis treated with antibiotics should also be isolated for 5 days after antibiotic therapy has started to prevent further transmission. If exposed to a patient with pertussis, the immunization status of the contact should be assessed. In the event that the contact is not immunized, a 7-day course with macrolide antibiotics should be considered. Also, 336 1_C_34_332-359.indd 336 SECTION C regardless of immunization status, if the contact is a child under age 1 or a pregnant woman in the last 3 weeks of pregnancy, or if the person exposed has contact with infants or pregnant women in the last 3 weeks of pregnancy, macrolide antibiotic prophylaxis should be offered.14 Influenza Influenza classically presents with the abrupt onset of fever, usually 38° C to 40° C, sore throat, nonproductive cough, myalgias, headache, and chills. Unfortunately, only about half of infected persons develop the “classic” symptoms of influenza infection.15–17 Among those presenting with classic symptoms, studies have attempted to identify the signs and symptoms most predictive of influenza. Unfortunately, these clinical decision rules are no better than clinician judgment alone.18 Influenza is caused by a virus with three subtypes: influenza A, B, and C. Influenza A causes more severe disease and is mainly responsible for pandemics. Influenza A has different subtypes determined by surface antigens hemagglutinin and neuraminidase. Influenza B causes milder disease and mainly affects children. Influenza C rarely causes human illness and has not been associated with epidemics.19 Influenza transmission occurs primarily through airborne spread when a person coughs or sneezes, but it may also occur through direct contact of surfaces contaminated with respiratory secretions. Hand washing and shielding coughs and sneezes help prevent spread. Influenza is transmissible from 1 day before symptom onset to about 5 days after symptoms begin and may last up to 10 days in children. Time from infection to development of symptoms is 1 to 4 days.20 Influenza has been responsible for at least 31 pandemics in history. The most lethal “Spanish flu” pandemic of 1918–1919 is estimated to have caused 40 million deaths globally, with 700,000 of those deaths occurring in the United States in a single year. In this pandemic, deaths occurred mainly in healthy 20- to 40-year olds, which differs from the usual young children and elderly pattern of mortality and morbidity in the seasonal outbreaks of influenza. Individuals at high risk of influenza complications include young children, people over age 65, the immunosuppressed, and those suffering from chronic medical conditions. Complications of influenza include pneumonia, either the more common secondary bacterial pneumonia or the rare primary influenza viral pneumonia; Reye syndrome in children taking Individual Chief Complaint Protocols 12/8/08 3:01:07 PM aspirin; myocarditis, encephalitis, and death. Death occurs in about 1 per 1000 cases of influenza, mainly in persons older than age 65. Studies estimate about 36,000 influenza-related deaths annually from 1990 to 1999 in the United States.21 Influenza vaccine is the principal means of preventing influenza morbidity and mortality. The vaccine changes yearly based on the antigenic and genetic composition of circulating strains of influenza A and B found in January to March, when influenza reaches its peak activity. When the vaccine strain is similar to the circulating strain, influenza vaccine is effective in protecting 70% to 90% of vaccinees younger than age 65 from illness. Among those aged 65 and older, the vaccine is 30% to 40% effective in preventing illness, 50% to 60% effective in preventing hospitalization, and up to 80% effective in preventing death. EMS providers should be immunized annually, typically in October. Four antiviral drugs are available for preventing and treating influenza in the United States. Amantadine and rimantadine belong to a class of drugs known as adamantanes, which are active against influenza A; oseltamivir and zanamivir belong to the class of neuraminidase inhibitors active against influenza A and B. When used for prevention of influenza, they can be 70% to 90% effective. When used for treatment, antivirals can reduce influenza illness duration by 1 day and attenuate the severity of illness. Antiviral agents should be used as an adjunct to vaccination, but they should not replace vaccination. The Centers for Disease Control and Prevention (CDC) recommends influenza antivirals for individuals who have not as yet been vaccinated at the time of exposure, or who have a contraindication to vaccination and are also at high risk of influenza complications. Also, if an influenza outbreak is caused by a variant strain of influenza not controlled by vaccination, chemoprophylaxis should be considered for healthcare providers caring for patients at high risk of influenza complications, regardless of their vaccination status. Since the 2005–2006 influenza season, a high proportion of influenza A viruses were resistant to the adamantanes. As a result, the CDC has recently recommended against the use of adamantanes for treatment and prophylaxis of influenza. The neuraminidase inhibitors continue to be recommended as a second-line of defense against influenza. For prophylaxis, the neuraminidase inhibitors should be taken daily until the exposure no longer exists or until immunity from vaccination develops, which can take about 2 weeks. For treatment, these antivirals should be started as soon as influenza symptoms develop, but no later than 48 hours after symptoms start, and treatment should continue for 5 days. In the setting of an influenza outbreak, EMS systems may opt to restrict duties for EMS providers who are not immunized or who have not yet received prophylactic antiviral therapy in attempts to prevent spread of the outbreak.19 Avian Influenza Influenza A virus infects humans and also can be found naturally in birds. Wild birds carry a type of influenza A virus, called avian influenza virus, in their intestines and usually do not get sick from the virus. However, avian influenza virus can make domesticated birds, including chickens, turkeys, and ducks, quite ill and lead to death. The avian influenza virus is chiefly found in birds, but infection in humans from contact with infected poultry has been reported since 1996. A particular subtype of avian influenza A virus, H5N1, is highly contagious and deadly among birds. In 1997 in Hong Kong, an outbreak of avian influenza H5N1 occurred not only in poultry, but also in 18 humans, 6 of whom died. In subsequent infections of avian influenza H5N1 in humans, more than half of those infected with the virus have died. In contrast to seasonal influenza, most cases of avian influenza H5N1 have occurred in young adults and healthy children who have come in contact with poultry infected with, or surfaces contaminated with, H5N1 virus. As of the end of 2007, there were 346 documented human infections with influenza H5N1 and 213 deaths (62%). Although transmission of avian influenza H5N1 from human to human is rare, inefficient, and unsustained, there is concern that the H5N1 virus could adapt and acquire the ability for sustained transmission in the human population. If the H5N1 virus could gain the ability to transmit easily from person to person, a global influenza pandemic could occur. No vaccine for H5N1 currently exists, but vaccine development is underway. The H5N1 virus is resistant to the adamantanes but likely sensitive to the neuraminidase inhibitors.22 Tuberculosis TB is caused by the Mycobacterium tuberculosis complex. The majority of active TB is pulmonary (70%), whereas the remainder is extrapulmonary (30%). Patients with active pulmonary TB will typically present with cough, scant amounts of nonpurulent sputum, and possibly hemoptysis. Systemic signs such as weight loss, loss of appetite, chills, night sweats, fever, CHAPTER 34 1_C_34_332-359.indd 337 Communicable Diseases 337 12/8/08 3:01:07 PM and fatigue may also be present. Clinically, the EMS provider will be unable to distinguish pulmonary TB from other respiratory illness; however, certain risk factors may alert the EMS provider to the possibility of tuberculosis. These risk factors are immigration from a high-prevalence country, homelessness, exposure to active pulmonary TB, silicosis, HIV infection, chronic renal failure, and cancer, transplantation, or any other immunosuppressed state.23,24 Active pulmonary TB is transmitted via droplet nuclei from people with pulmonary tuberculosis during coughing, sneezing, speaking, or singing. Procedures such as intubation or bronchoscopies are considered high risk for the transmission of TB. Respiratory secretions on a surface lose the potential for infection. About 21% to 23% of individuals in close contact with persons with infectious TB become infected through inhalation of aerosolized bacilli. The probability of infection is related to duration of exposure, distance from the case, concentration of bacilli in droplets, ventilation in the room, and the susceptibility of the host exposed. Effective medical therapy eliminates communicability within 2 to 4 weeks of starting treatment.25 If infected with TB, an individual may develop active TB with symptoms or latent TB, which is asymptomatic. Time from infection to active symptoms or positive TB skin test is about 2 to 10 weeks. The risk of developing active TB is greatest in the first 2 years after infection. Latent TB may last a lifetime, with the risk that it may later progress to active TB. About 10% of patients with latent TB will progress to active TB in their lifetime. If transporting a patient who is known or suspected of having TB, respiratory precautions should be undertaken by the EMS provider, in particular, a submicron mask. Patients should cover their mouths when coughing or sneezing or wear surgical masks. In the event of suspected exposure to a patient with active pulmonary TB, the EMS provider should report the case and the exposure to the EMS system or public health authority. Close contacts should be monitored for the development of active TB symptoms. Two tuberculin skin tests should be performed, based on public health recommendations, on those closely exposed to patients with active TB.26 Because the incubation period after contact ranges from 2 to 10 weeks, the first test is typically done as soon as possible after exposure, and the second test typically is performed 8 to 12 weeks after the exposure. If the EMS provider or contact develops either active TB with symptoms 338 1_C_34_332-359.indd 338 SECTION C or latent asymptomatic TB, as diagnosed with a new positive TB skin test, treatment should be sought. Treatment for latent TB is typically isoniazid (INH) for 6 to 9 months.2 This single-drug regimen is 65% to 80% effective. For active TB, a four-drug regimen (isoniazid, rifampin, pyrazinamide, and ethambutol) is typically used for 2 months. This is followed by INH and rifampin for an additional 4 months. Several forms of multidrug-resistant (MDR)-TB and extensively-drug-resistant (XDR)-TB have been identified.27 These forms require an aggressive, multidrug regimens for prolonged periods of time and are dependent on the organism’s patterns of drug sensitivity and resistance for determination of the success of treatment. In all cases, a physician skilled in management of TB must initiate and monitor treatment and provide suitable follow-up. Public health officials must also be notified.28 Severe Acute Respiratory Syndrome It is difficult to distinguish SARS from other respiratory infections because patients present with symptoms similar to other febrile respiratory illnesses.29 On initial presentation, reliance on respiratory symptoms alone is not sufficient to distinguish SARS from nonSARS respiratory illness.30 Fever is the most common and earliest symptom of SARS, often accompanied by headache, malaise, or myalgia.31 In patients with SARS, high fever, diarrhea, and vomiting were more common as compared with other patients with other respiratory illnesses.32 Cough occurred later in the course of disease, and patients were less likely to have rhinorrhea or sore throat as compared with other lower respiratory tract illness.33 Because clinical features alone cannot reliably distinguish SARS from other respiratory illnesses, knowledge of contacts is essential.34 Contact with known SARS patients, contact with SARS-affected areas, or linkage to a cluster of pneumonia cases should be obtained in the history.35 SARS was first recognized in 2003, after outbreaks occurred in Toronto (Canada),36 Singapore, Vietnam, Taiwan, and China. The illness is caused by a coronavirus. The incubation period ranges from 3 to 10 days, averaging 4 to 5 days from contact to symptom onset. About 11% of those who develop SARS eventually die, usually due to respiratory failure. The risk of mortality is highly dependent on the patient’s age and presence of comorbid illnesses. The case fatality rate is less than 1% for SARS patients under age 24 and up to 50% for those age 65 and greater or those with comorbid illness.37 Individual Chief Complaint Protocols 12/8/08 3:01:07 PM The coronavirus is found in respiratory secretions, urine, and fecal matter. Transmission is via droplets spread from respiratory secretions, with high-risk transmission during intubation and procedures that aerosolize respiratory secretions. Transmission can also occur from fecal or urine contamination of surfaces. There have been no confirmed cases of transmission from asymptomatic cases. Preliminary studies show that transmission likely occurs after the development of symptoms, with the peak infectious period being 7 to 10 days after symptom onset, and declining to a low level after day 23 from onset of symptoms.38 If SARS is suspected, EMS providers must use all routine practices and additional precautions.39 EMS systems may also elect to limit or avoid any procedures that may increase risk to EMS personnel. These include tracheal intubation, deep suctioning, use of noninvasive ventilatory support (continuous positive airway pressure, bilevel positive airway pressure), administration of nebulized medication, and any other procedure that may aerosolize respiratory secretions. During the SARS outbreaks in Toronto, EMS medical direction modified medical directives such that paramedics did not intubate patients or deliver nebulized therapy in the prehospital setting.40 Finally, EMS personnel and systems must also notify the receiving facility of a patient suspected of SARS, permitting staff to have appropriate PPE in place and a suitable isolation room prepared for the patient.41,42 Rash Methicillin-Resistant Staphylococcus Aureus Skin infections with onset in the community or hospital may be caused S. aureus. S. aureus is a bacterium that normally secretes beta-lactamases rendering them resistant to antibiotics such as ampicillin and amoxicillin. Methicillin, a type of beta-lactam antibiotic, developed in 1959, is not broken down by these bacterial beta-lactamase enzymes. However, in the 1960s, infections of S. aureus were found to be resistant to methicillin and other beta-lactam antibiotics, resulting in the emergence of MRSA.43 In addition to common skin and soft tissue infections, MRSA may less commonly cause severe and invasive infections such as necrotizing pneumonia, sepsis, and musculoskeletal infections such as osteomyelitis and necrotizing fasciitis. MRSA skin infections typically present as necrotic skin lesions and are often confused with spider bites. The severity of MRSA skin infections may range from mild to severe. Unfortunately, there are no reliable clinical or risk factor criteria to distinguish MRSA skin and soft tissue infections from those caused by other infectious agents.44 Initially, MRSA infections were found in patients in healthcare facilities (healthcare-associated MRSA [HA-MRSA]). However, community-acquired MRSA (CA-MRSA) infections are increasingly identified in people who did not have the traditional risk factors of those with HA-MRSA, specifically contact with healthcare facilities. These community-acquired strains are new MRSA strains, different from those that cause HA-MRSA. Regardless, both HA-MRSA and CA-MRSA can mimic infections caused by less resistant bacteria, but they are more difficult to treat.45 Transmission of MRSA is mainly through hand contact from infected skin lesions, such as abscesses or boils. About 1% of the healthy population is also colonized with MRSA, mainly in the anterior nares, but also in the pharynx, axilla, rectum, and perineum. Therefore, autoinfection may also be a route of infection. The transmissible period lasts as long as skin lesions continue to drain or as long as the carrier state remains. Newborns, the elderly, and the immunosuppressed are most susceptible. Transmission of infection is prevented by routine precautions. Draining wounds should be covered with clean, dry bandages. Contaminated surfaces should be cleaned with disinfectants effective against S. aureus, such as a solution of dilute bleach or quaternary ammonium compounds. One study has showed that EMS ambulances may have a significant degree of MRSA contamination, highlighting the need for proper cleaning and decontamination of all equipment and the vehicle itself after every patient transport.46 There are no data to support the routine use of decolonization of MRSA with antiseptic agents or nasal mucopirocin. Decolonization may be considered in select circumstances, when a person has multiple recurrent infections of MRSA, or there is ongoing transmission in a well-defined group of close contacts. Little data are available on effective decolonization agents, but topical chlorhexidine gluconate or diluted bleach (3.4 g of bleach diluted in 3.8 L of water) is suggested.47 In those with skin or soft tissue infections, any drainage should be cultured. Abscesses should be incised and drained. Antibiotic therapy may be considered if there are signs of cellulitis, systemic illness, associated immunosuppression, extremes of age, facial infection, or failure of initial incision and drainage.The choice of therapy should be dictated by local susceptibility patterns. Clindamycin, doxycycline, and trimethoprim-sulfamethoxazole (TMP-SMX) are con- CHAPTER 34 1_C_34_332-359.indd 339 Communicable Diseases 339 12/8/08 3:01:08 PM siderations for treatment of CA-MRSA skin and soft tissue infections. HA-MRSA may be resistant to many more classes of antibiotics, and vancomycin or linezolid may be necessary.48 Measles Measles is a viral disease that initially presents with a 2- to 4-day prodrome of fever, cough, runny nose, and possibly conjunctivitis. In the prodrome stage, the EMS provider will be unable to clinically distinguish measles from any other viral upper respiratory illness. A measles rash follows, beginning on the hairline, then involving the face and neck, and over 3 days, proceeding downward and outward to the hands and feet. The rash produces discrete red maculopapular (flat and raised) lesions initially, which may become confluent. Initially, the lesions blanch, and after 3 to 4 days they become nonblanchable spots, which appear within 1 to 2 days before or after the maculopapular rash. Koplik spots, punctate blue-white spots on the red buccal mucosa of the mouth, are pathognomonic for measles and would alert the EMS provider to the presence of measles.49,50 Measles has a 0.2% mortality rate, mainly due to pneumonia in children in developing countries. Cases of measles have declined dramatically since the introduction of live attenuated virus vaccine in 1963, with a record low of 34 cases in 2004. Sporadic outbreaks occur in populations that refuse vaccination. Children in United States are routinely vaccinated with two doses of measles vaccine (MMR) at ages 12 to 15 months and ages 4 to 6 years. Measles is transmitted by aerosol or droplet spread and is communicable from 4 days before appearance of the rash to 4 days after rash appearance. EMS providers will likely encounter the patient in the transmissible stage and should use routine practices to prevent spread of disease. The incubation period is approximately 10 days. Those who have not been immunized or have never acquired measles (born after 1957) are susceptible to infection if exposed. If susceptible and exposed, immunoglobulin should be given to children under age 1, pregnant women, and the immunocompromised within 6 days of exposure. For other susceptible persons, live measles vaccine may prevent disease if given within 72 hours of exposure. There is no treatment for measles, but vitamin A supplementation should be considered to prevent ocular complications.51,52 Rubella Rubella is a viral disease with a prodrome that precedes the rash. Clinical diagnosis alone is unreliable. The pro- 340 1_C_34_332-359.indd 340 SECTION C drome consists of fever, upper respiratory symptoms, and prominent lymphadenopathy, lasts 1 to 5 days, and is mostly present in older children and adults. During the prodrome, rubella is clinically indistinguishable from any other viral upper respiratory tract infection. A maculopapular rash, appearing 14 to 17 days after exposure and lasting 3 days, typically follows the prodrome. Like measles, the rash starts on the face and progresses downward. In contrast to a measles rash, the rash due to rubella is fainter, does not coalesce, and is more prominent after a hot shower or bath. Associated symptoms may include arthralgias or conjunctivitis. Confirmation of rubella infection is by laboratory diagnosis of virus or antibody.53 Rubella is transmitted from respiratory secretions via airborne transmission or droplet spread, with an incubation period of 14 to 17 days. Even though rubella is most contagious when the rash is present, it may be transmitted by subclinical or asymptomatic cases of rubella and up to 7 days before the onset of rash. Life-threatening complications of rubella include encephalitis and hemorrhage, but these are uncommon. The main objective of immunization is to prevent congenital rubella syndrome (CRS), the main complication of rubella. CRS occurs when a pregnant woman in early gestation, mainly in the first trimester, is exposed to rubella. CRS may lead to fetal death, premature delivery, and congenital defects including deafness and ocular, cardiac, and neurologic abnormalities. There is no specific treatment for rubella, only preventative vaccination. Rubella immunization is part of the routine childhood vaccinations, administered as a live vaccine along with measles and mumps as MMR. Infants born to mothers immune to rubella are protected for 6 to 9 months from transplacental maternal antibodies.54 If exposed to patients later diagnosed with rubella, immunity of the contact should be assessed. Subsequent immunization of the nonimmunized contact would not prevent infection or illness. In adults, rubella is generally a mild febrile disease, and control measures are aimed at preventing spread to nonimmunized pregnant women. In the case of spread, patients suspected of having rubella should be isolated with routine precautions. Pregnant women contacts should be investigated for immunity. In case of infection with rubella in nonimmune pregnant women in early pregnancy, counseling should be provided with consideration for abortion. Immunoglobulin in early pregnancy may also be given to modify or suppress Individual Chief Complaint Protocols 12/8/08 3:01:08 PM symptoms, but there have been cases of CRS despite immunoglobulin therapy.55–57 Varicella Like measles and rubella, varicella starts with a prodrome that subsequently leads to a rash. In children, the prodrome of fever and malaise may be absent. Unlike measles and rubella, varicella infection, or chicken pox, can be clinically diagnosed by the EMS provider based on a more pathognomonic rash. The pruritic rash progresses from macules to papules and then to vesicles that later crust over. The vesicles are unilocular and collapsible, in contrast to the multilocular and noncollapsible vesicles of smallpox. Lesions start on the scalp, progress to the trunk, and later move to the extremities.58 Varicella virus infection leading to chicken pox typically lasts 3 to 4 days, with an incubation period of 14 to 16 days. Transmission is by airborne droplets from the respiratory tract or by inhalation of aerosolized vesicular fluid from skin lesions. Chickenpox is transmissible 1 to 2 days before the onset of rash until all papules become crusted.59 Complications in children include secondary bacterial skin infections, pneumonia, and dehydration. Nonimmunized adults may have more severe complications, including encephalitis, transverse myelitis, hemorrhagic varicella, and even death. In the United States, only 5% of the reported cases of varicella are from adults, whereas 35% of the mortality occurs in adults. The case fatality rate is 1 per 100,000 cases in children aged 1 to 14, but 25.2 per 100,000 cases in adults aged 30 to 49 years of age. Maternal varicella 5 days before to 48 hours after delivery may result in neonatal infection and subsequent mortality as high as 30%. Varicella infection in the mother at 20 weeks of gestation can lead to congenital varicella syndrome, which includes skin scarring, extremity atrophy, and eye and neurologic abnormalities. Since the licensure of varicella vaccine in 1995 in the United States, cases of chickenpox have declined by 83% to 94% by 2004. Varicella vaccine is recommended for all children without contraindication at 12 to 18 months of age and is administered as one dose. Adults and adolescents age 13 years and older who do not have evidence of immunity should receive two doses of varicella vaccine. Cases of chicken pox should be excluded from public places until the vesicles become dry. In the hospital, strict isolation measures should be undertaken to avoid contact with susceptible immunocom- promised persons. Articles soiled by discharges from the nose and throat should be disinfected. If exposed to chickenpox, contacts should assess their susceptibility based on their immune status. If previously infected or vaccinated, contacts are immune. Susceptible nonimmune contacts have three choices to prevent infection: vaccination, varicella zoster immunoglobulin, or antiviral drugs. Varicella vaccine can prevent illness or attenuate severity if used within 3 days of contact. Vaccine is recommended in susceptible individuals. Varicella zoster immunoglobulin (VZIG) is recommended for newborns, the immunocompromised, and pregnant women and can also modify severity or prevent illness if given within 96 hours of exposure. Antiviral drugs such as acyclovir, if used within 24 hours of onset of rash, can reduce the severity of disease. These are not recommended for routine postexposure prophylaxis, but they can be considered in persons aged older than 13 years and the immunocompromised.60,61 Bites Bites require treatment for the physical injury itself and treatment for the infectious disease exposure due to the bite. Infection rates from bites mainly depend on the animal that has caused the bite and the site of injury.62 Cat bites can have an infection rate of up to 50%, whereas about 10% of dog bites become infected. Bites on the face, scalp, hand, wrist, foot, or joints have the highest rate of infection. Hands are the most common site of human, dog, and cat bites. Bite infections may cause cellulitis, osteomyelitis, abscess, septic arthritis, or even septicemia. In addition to antibiotic therapy, bites may also require treatment with rabies prophylaxis, tetanus prophylaxis, HIV prophylaxis, and hepatitis B prophylaxis. Prophylactic antibiotic treatment for bites depends on the specific infectious agents most commonly associated with the particular animal. Finally, EMS personnel should also be aware of the risk of transmission of hepatitis C due to human bites.63 Animal Bites Bites by dogs and cats account for 95% of animal bites. In up to 75% of infected cat bites and 50% of infected dog bites, the causal infectious agent is Pasteurella species. This bacterium can produce an infection in as short as 12 hours. P. canis is the most common organism in infected dog bites, whereas P. multicoda is most common in cat bites. Other common organisms from infected cat and dog bites include Streptococci, Staphylococci, Fusobacterium, and Bacterioides.62 CHAPTER 34 1_C_34_332-359.indd 341 Communicable Diseases 341 12/8/08 3:01:08 PM Preventing infection due to bites should begin with copious high-pressure irrigation with sterile saline solution. Prophylactic antibiotics are advised for hand bites from cats or dogs and high-risk bites including any cat bite, deep dog bite punctures, and bites in immunocompromised individuals. Amoxicillinclavulanic acid or cefuroxime, each for 5 days, provides appropriate broad-spectrum activity. In penicillin-allergic patients, either azithromycin alone or clindamycin with levofloxacin can be given.64,65 Human Bites After dog and cat bites, humans are the next most common cause of bites. Streptococci species and Eikenella corrodens are the most common pathogens in infected human bites. Clenched-fist injuries, resulting from a flexed knuckle of a fist striking human teeth, are common and serious causes of human bite injuries. This type of injury often leads to serious deep infections because the patient usually offers an alternative mechanism for the hand injury, resulting in delayed antibiotic therapy. Human bites can also transmit HIV, hepatitis B, and hepatitis C.66 Prophylactic antibiotics should be provided for all human bites that penetrate deeper than the epidermal layer, as well as bites to the hands, feet, or skin overlying joints or cartilaginous structures. Amoxicillinclavulanic acid for 5 days is recommended as prophylactic therapy for human bites. In penicillin-allergic patients, a combination of clindamycin and a fluoroquinolone is a suggested regimen. Postexposure prophylaxis (PEP) for HIV and hepatitis B should be considered for human bites according to a risk evaluation of the source. Patients should also be educated on the risk of transmission of hepatitis C.67 Rabies Rabies is caused by rabies virus, a rhabdovirus of the genus Lyssavirus, and may be transmitted by an animal bite. There is no treatment for rabies once it develops, and it has a mortality rate approaching 100%. The time from infection to development of disease is usually 3 to 8 weeks, and death is typically due to respiratory paralysis. To determine the risk of rabies transmission, knowledge is needed on the type of animal inflicting the bite, geographic location of the incident, the vaccination status of the animal and person, whether the bite was provoked or unprovoked, and whether the animal can be captured and tested.68 Patients receiving bites by animals suspected of having rabies should be given PEP. For nonimmune in- 342 1_C_34_332-359.indd 342 SECTION C dividuals, prophylaxis consists of one dose of human rabies immunoglobulin, half given into the bite site, accompanied by a five-dose series of rabies vaccine on days 0, 3, 7, 14, and 28. PEP should always occur in consultation with local public health officials.69 In the United States in 2006, 92% of rabid animals were wild, and 8% were domestic. Among wild animals, rabies was most frequently found in raccoons, followed by bats, skunks, and foxes. Among domestic animals, cats were the most common cause of rabies, followed by dogs and cattle. Squirrels, guinea pigs, hamsters, chipmunks, gerbils, mice, rats, rabbits, and hares very rarely have rabies. In the United States, there have been two to three cases of human rabies each year for the last 10 years. Most were due to contact with bats, likely because bites from bats are superficial and not easily noticed. In the United States, Canada, and Western Europe, dogs account for less than 5% of animal rabies, whereas in most developing countries, dogs account for more than 90% of cases of animal rabies. Rabies immunization is not routinely recommended for the general population in North America, unless the person is engaged in activities that place him or her at high risk of acquiring rabies. These include rabies lab workers and veterinarians. Most agencies recommend that domestic dogs, cats, ferrets, and livestock be vaccinated against rabies. Routine rabies immunization for EMS personnel is not recommended. Abnormal behavior in an animal or an unprovoked bite is more likely to indicate that a bite was from a rabid animal. This increases the risk of rabies transmission, and PEP should be offered. If a dog, cat, or ferret that caused a bite can be captured, it should be confined and observed for 10 days for the development of rabies symptoms. If rabies develops, the bitten individual should receive rabies PEP. For any bites from bats, raccoons, skunks, or foxes, PEP should be offered regardless of whether the animal is captured or not.70,71 Tetanus Bites are at risk of being infected with C. tetani because they are puncture wounds and/or contaminated with saliva. Live C. tetani organisms are not present in the oral flora or humans or animals, but their resilient spores are ubiquitous in the environment, soil, and feces. Crushed, devitalized tissue produced by bites favors the production of tetanus.72,73 Tetanus is an often fatal disease caused by the exotoxin of C. tetani. The incubation period ranges Individual Chief Complaint Protocols 12/8/08 3:01:09 PM from 3 to 21 days, during which time the spores transform into live bacteria which then produce an exotoxin. Clinically, the exotoxin leads to convulsive spasms of the skeletal muscles and generalized rigidity, mainly involving the jaw and neck. Patients with any form of bites should receive prophylaxis with 0.5 ml of tetanus toxoid intramuscularly if they have not been immunized within the past 5 years. Those who have not completed a primary immunization series, or have an unknown immunization history should also receive tetanus immunoglobulin.74 Meningitis Meningitis refers to inflammation of the meninges covering the brain. It can be caused by infectious and noninfectious causes. Noninfectious causes include drugs, vaccines, systemic disease such as collagen vascular disorders, and malignancy. Infectious causes include viruses, bacteria, fungi, parasites, and rickettsiae.75 Meningitis is typically classified as bacterial meningitis versus aseptic meningitis. Aseptic meningitis refers to meningitis with cerebrospinal fluid absent of microorganisms on Gram stain and/or routine culture. The most common cause of aseptic meningitis is viral agents.76,77 Viral meningitis is generally less severe, and requires supportive measures with no specific treatment. Bacterial meningitis, on the other hand, has a case fatality rate of 13% to 37%, and as high as 80% in the elderly, despite appropriate antibiotic therapy. In addition, up to 20% of survivors of bacterial meningitis have permanent sequelae such as brain damage, hearing loss, or limb loss.78,79 Bacterial meningitis should be suspected when the patient presents with at least two of the four following symptoms: headache, fever, neck stiffness, or altered mental status. However, the EMS provider should be aware that only one of these symptoms may be present in the patient with bacterial meningitis.80 Focal neurologic symptoms, such as extremity pain or temperature changes, may be early signs. Although a petechial rash is classically associated with bacterial meningitis, only 11% to 23% of patients with bacterial meningitis actually have a rash.81 In the absence of diagnostic tests such as lumbar puncture, EMS personnel are unable to use clinical signs and symptoms alone to distinguish bacterial from aseptic meningitis.82–84 Considering the rapid onset of symptoms and high morbidity and mortality with untreated bacterial meningitis, all patients with suspected meningitis should be treated as bacterial meningitis until proven otherwise. Neisseria meningitidis and S. pneumoniae currently account for 80% to 85% of adult community-acquired meningitis. Less common causes include staphylococci, group B streptococci, and Listeria. S. pneumoniae is a more common cause of meningitis, and mortality is also higher (30%) as compared to the mortality rate of meningitis caused by N. meningitidis (7%). Since the introduction of routine childhood vaccination with H. influenzae type b, this is no longer a leading cause of meningitis.85–87 Transmission is by droplet spread from respiratory secretions. Therefore, respiratory and contact precautions should be undertaken when transporting patients suspected of meningitis. The time from transmission to the development of symptoms is about 2 to 10 days for N. meningitidis and about 1 to 4 days for S. pneumoniae. Empiric treatment of adult bacterial meningitis is vancomycin plus a third-generation cephalosporin, such as cefotaxime. In neonates, those over age 50, and those with altered immune status or alcoholism, ampicillin is added to cover L. monocytogenes. Treatment may last 14 to 21 days depending on the infectious agent. In addition to treating the patient, EMS personnel exposed or in close contact with patients with meningitis may require prophylactic therapy. This is particularly important for personnel exposed to the patient’s oral or respiratory secretions. Exposed personnel should contact their EMS agency or local public health agency immediately. Public health will likely provide prophylactic treatment with ciprofloxacin, ceftriaxone, or rifampin to prevent infection due to close contact.88 Diarrhea Diarrhea is practically defined by increased frequency, increased volume, and decreased consistency of stools. A strict definition is greater than three stools in a 24 hour period, with the stools being liquid enough to adopt the shape of the container in which they are placed. Acute diarrhea lasts up to 2 to 3 weeks, with chronic diarrhea lasting longer. Infectious diarrhea is commonly associated with nausea, vomiting, fever, abdominal cramps, and intestinal gas-related complaints. Diarrhea may be infectious or noninfectious in origin, and the provider should attempt to rule out noninfectious causes because most noninfectious causes are true diarrheal emergencies (e.g., mesenteric ischemia, gastrointestinal bleed, and bowel obstruction). CHAPTER 34 1_C_34_332-359.indd 343 Communicable Diseases 343 12/8/08 3:01:09 PM Infectious diarrhea may be caused by viruses, bacteria, protozoa, or helminthes. The diarrhea may be caused by the organisms themselves or the toxins they produce. Gastrointestinal infections are typically spread by contaminated water, contaminated food, contaminated environments, direct contact among humans, and hand-to-mouth transmission. The differential diagnosis can be narrowed by selectively testing stool specimens for bacterial culture, ova, parasites, C. difficile toxin, and viral enzyme-linked immunosorbent assay (ELISA) tests. These tests are not available in the prehospital setting, but history may identify prior testing results and the likely offending agent.89 To prevent spread of infection, EMS providers and systems must ensure routine practices and additional precautions are in place. In addition, equipment and transport vehicles must be thoroughly cleaned and decontaminated when transport involves a patient suspected of having infectious diarrhea. Therapy that can be initiated by EMS providers includes isotonic fluid replacement and management of hypovolemia and sepsis. Antibiotic therapy and antimotility therapy should only be considered once a thorough assessment has been conducted in the hospital setting because there are certain diarrheal conditions in which such therapy may be inappropriate. Acute infectious diarrhea may be bloody or watery, with bloody diarrhea signifying inflammatory destruction of the intestinal mucosa. Whether the diarrhea is watery or bloody provides clues as to the cause of the diarrhea and the consequent sequelae: In watery diarrhea, the main concern is dehydration, whereas in bloody diarrhea, the main concern is intestinal damage and sepsis.89 The most common causes of diarrhea are viruses, accounting for 50% to 75% of cases. As compared with bacterial diarrhea, viral diarrhea typically has less high fever and watery stools, whereas bacterial diarrhea typically has bloody stools with less severe abdominal pain. Among the viral causes of diarrhea, rotavirus90 and the noroviruses91 (Norwalk and Norwalk-like viruses) account for 50% of viral gastroenteritis. Adenoviruses are the second most common cause of acute viral gastroenteritis. Rotavirus diarrhea is the most common cause of viral diarrhea in children and usually occurs in children between 6 and 24 months of age because most individuals have antibodies by age 3. History and physical examination alone cannot clinically distinguish rotavirus from other enteric viral infections because rotavirus infection presents 344 1_C_34_332-359.indd 344 SECTION C with watery diarrhea, vomiting, fever, and abdominal pain. It is usually diagnosed from rotavirus antigen in stools. In addition to transmission by the contact and the fecal-oral route, respiratory spread may also occur with rotavirus. The incubation period is 24 to 72 hours, with the period of communicability being up to 8 days from the start of the watery diarrhea. Two rotavirus vaccines are available for children, RotaRix and Rotateq; Rotateq is licensed for use in the United States. In 1999, RotaShield was withdrawn from the market after being associated with intussusception. Diarrhea by norovirus causes signs and symptoms clinically indistinguishable from rotavirus: nausea, vomiting, diarrhea, and abdominal pain also occur with norovirus infection. In children, vomiting is more prevalent, whereas in adults, diarrhea is more common. Diagnosis is made by nucleic acid hybridization assays and reverse transcriptase-polymerase chain reaction (RT-PCR). The incubation period is 12 to 48 hours, and illness lasts for a shorter time than rotavirus diarrhea, 12 hours to 3 days. The period of communicability is unknown, lasting up to 7 days. Transmission routes are similar to rotavirus, including airborne transmission. There is currently no vaccine for norovirus infections.91 Bacterial diarrhea typically includes bloody diarrhea, as opposed to watery diarrhea; however, not all bacterial diarrhea is bloody. Bloody diarrhea is often referred to as dysentery. It is important to note that bloody diarrhea may not necessarily be due to infectious causes, and other causes of bloody diarrhea should be considered, such as mesenteric ischemia or other non-infectious conditions producing gastrointestinal bleeding. Common causes of bacterial diarrhea are Salmonella, Shigella, Yersinia, E. coli, and Campylobacter.92,93 E. coli are classified by their O, H, and K antigens and also by their virulence properties.94 E. coli 0157:H7 is the main serotype that causes bloody diarrhea through secretion of a potent shiga-like cytotoxin. This serotype was responsible for a large outbreak of bloody diarrhea in the United States in 1982. This bloody diarrhea is notable for the absence of fever and the subsequent 5% to 15% rate of development of hemolytic uremic syndrome (HUS), manifesting as pallor, jaundice, scleral icterus, dark urine, purpura, mucosal bleeding, dyspnea, and chest pain. The death rate of infections that lead to HUS is 3% to 5% even with intensive care unit treatment. E. coli 0157:H7 is found in healthy cattle and is spread to humans from undercooked beef, raw milk, and produce. Individual Chief Complaint Protocols 12/8/08 3:01:09 PM The incubation period is typically 3 to 4 days, and the period of communicability can be up to 3 weeks in children. Antibiotics and antimotility agents are not recommended for this infection. Treatment is directed at HUS, which may require dialysis, steroids, or plasma therapy in the intensive care unit setting. C. difficile is a bacterium that can cause a spectrum ranging from mild watery diarrhea to severe colitis, which may progress to perforation of the colon and sepsis.95–97 This infection is increasing in prevalence and frequently associated with healthcare settings.95 More than 90% occur after or during antibiotic therapy. C. difficile is also the most common cause of bacterial diarrhea in persons with HIV in the United States. The EMS provider may only suspect diarrhea associated with C. difficile based on the risk factors because it is clinically indistinguishable from any other watery diarrhea based on signs and symptoms. Diagnosis is confirmed by enzyme immunoassays of stool samples. EMS providers should notify transfer and receiving facilities that a patient has disease associated with C. difficile, if known. Treatment is cessation of existing antibiotic therapy if possible, rehydration, avoidance of antimotility agents, and therapy with oral metronidazole or vancomycin for 10 days.98 Jaundice Hepatitis A Hepatitis A can cause acute disease or asymptomatic infection but not chronic infection.99 Whereas more than 70% of older children and adults are symptomatic, in children younger than 6 years, 70% of infections are asymptomatic. Symptomatic illness is characterized by fever, jaundice, and dark urine, in addition to malaise, anorexia, and nausea. Jaundice is the most common symptom. Unfortunately, the clinical signs and symptoms of hepatitis A are indistinguishable from other types of acute viral hepatitis. Diagnosis is usually made by immunoglobulin detection in blood: anti-hepatitis A immunoglobulin M in the acute phase, and anti-hepatitis A immunoglobulin G after 6 months. Hepatitis A infection rarely progresses to fulminant hepatitis A, which can lead to death. In 2005, 0.6% of patients with hepatitis A progressed to fulminant hepatitis and died. Age and underlying chronic liver disease are risk factors for progression to fulminant hepatitis. Also in 2005, the proportion of persons hospitalized with hepatitis A increased with age from 20% among children aged less than 5 years to 47% among persons aged greater than 60 years. Hepatitis A is transmitted by the fecal-oral route from consumption of contaminated food or water. Rarely, hepatitis A can be transmitted by blood transfusion, particularly clotting factor concentrates. In the United States between 1990 and 2000, 45% of hepatitis A patients could not identify a risk factor for their infection. The time from infection to the presentation of symptoms, if any, is on average 28 days. Hepatitis A is most transmissible from feces 1 to 2 weeks before the onset of illness to about 1 week after the onset of jaundice. If an EMS provider comes in contact with a patient suspected of having hepatitis A, routine practices and additional precautions can prevent spread of infection. Hepatitis A infection is prevented with vaccination administered in two doses 6 to 18 months apart. In 2005, the Advisory Committee on Immunization Practices (ACIP) recommended that all children aged 12 to 23 months of age receive the hepatitis A vaccination. International travelers, men who have sex with men, persons with clotting factor disorders, and those with chronic liver disease should also be immunized. Hepatitis A vaccination is not routinely recommended for healthcare workers. Unvaccinated persons who have been exposed to hepatitis A may be candidates for postexposure antihepatitis A immunoglobulin. This has been shown to be 85% effective in preventing hepatitis A infection if given within 2 weeks of exposure. Potential candidates include persons who have had household or sexual contact with a person with hepatitis A, persons who have shared illegal drugs with a person with hepatitis A, food handlers working with another food handler diagnosed with hepatitis A, patrons of an infectious food handler if the food handler had diarrhea or poor hygiene, and staff and attendees at a child care center where a hepatitis A case has been diagnosed. Vaccination should supplement immunoglobulin administration in PEP but not replace it.100–102 Hepatitis B Hepatitis B infection can cause acute disease, chronic disease, or be asymptomatic.103 Like hepatitis A, symptoms present more in adults than children, and symptoms are not specific for hepatitis B. Even about 50% of adults with acute infection are asymptomatic. When symptoms occur, they are divided into phases: prodromal, icteric phase, and convalescent phases. In the 3- to 10-day prodromal phase, nonspecific symptoms of malaise, weakness, and anorexia are the most CHAPTER 34 1_C_34_332-359.indd 345 Communicable Diseases 345 12/8/08 3:01:09 PM common symptoms, but also low-grade fever, arthritis, rash, vague abdominal discomfort, nausea, and vomiting may occur. The icteric phase lasts 1 to 3 weeks and is characterized by jaundice, dark urine, and light stools starting 1 to 2 days before the onset of jaundice. In convalescence, jaundice disappears, whereas malaise and fatigue may persist for weeks. Definitive diagnosis of hepatitis B is by serologic testing. Most acute hepatitis B infection results in complete recovery, but in 1% to 2% of patients fulminant hepatitis infection occurs, with a 63% to 93% case fatality rate. About 10% of acute infections progress to chronic infection, which leads to premature death from cirrhosis or liver cancer in 25% of cases. In the United States, an estimated 46,000 new hepatitis B infections occurred in 2006. Hepatitis B is transmitted by percutaneous or mucosal exposure to infected blood or blood products. Transmission can also occur from saliva, semen, vaginal secretions, and cerebrospinal, pleural, peritoneal, pericardial, amniotic, or synovial fluid. Transmission to EMS workers can occur not only from needlesticks or other sharp injuries but also through cutaneous scratches or abrasions. The hepatitis B virus can exist for at least 7 days outside the body on inanimate surfaces, and infection can occur by touching skin lesions or mucous membranes with any contaminated equipment. This is particularly important in the EMS setting and emphasizes the need for adherence to routine practices and additional precautions and proper cleaning and decontamination of equipment and vehicle surfaces. If the hepatitis B HBs-antigen is present in the blood of a source, then the source is communicable for hepatitis B. If infected, the incubation period is on average 60 to 90 days. Hepatitis B vaccination is recommended for all infants at birth, age 1 to 2 months, and at age 6 to 18 months. For unvaccinated adults, a three-dose schedule is recommended for those at increased risk of hepatitis B infection, which includes healthcare workers. If percutaneous or mucous membrane exposure occurs to blood that may contain hepatitis B, PEP with hepatitis B immunoglobulin may be considered. Before doing so, the vaccination status of the exposed person with hepatitis B should be assessed. If vaccinated, the exposed person should have an assessment of protective antibody levels to hepatitis B because about 5% of vaccinees may not respond to the hepatitis B vaccine. If available, the source blood should also be assessed for the presence of HBs-antigen, which signi- 346 1_C_34_332-359.indd 346 SECTION C fies infection with hepatitis B and communicability. If an individual is exposed to HBsAg-positive fluid and is nonimmunized or lacks protective antibody levels, hepatitis B immunoglobulin should be given within 24 hours, and hepatitis B vaccination also should be started.104–106 Hepatitis C About 60% to 80% of persons infected with hepatitis C are initially asymptomatic. Among the 15% to 30% who become symptomatic, clinical signs and symptoms are similar to those of other acute viral hepatitis illnesses and include jaundice, fatigue, dark urine, abdominal pain, anorexia, and nausea. Diagnosis of hepatitis C is by serologic testing.107 Unlike the other viral hepatitis infections, in up to 85% of hepatitis C infections, persistent infection develops. Among those with chronic infection, 70% develop chronic liver disease, and 1% to 5% of those die prematurely from their chronic liver disease. It is estimated that 19,000 new hepatitis C infections occurred in the United States in 2006, and 3.2 million U.S. Americans are chronically infected with hepatitis C. Hepatitis C is transmitted by mucosal or percutaneous exposure to infectious blood or blood-derived body fluids. Sexual contact can lead to transmission but is a far less efficient route of transmission. The period of transmission may persist in infected persons indefinitely. If infected, the incubation period is on average 6 to 9 weeks, and it may take up to 20 years before the onset of liver disease. There is no vaccine available to prevent hepatitis C, and PEP with hepatitis C immunoglobulin has not been shown be effective. EMS providers must rely on routine practices and additional precautions to prevent occupational and nosocomial transmissions. Disposable injection equipment should not be reused and should be properly disposed of, and reusable injection equipment should be appropriately sterilized before reuse.108,109 Biologic Weapons Anthrax The symptoms of anthrax are determined by the route of transmission of the bacterium that causes anthrax, Bacillus anthracis. There are three forms of anthrax: cutaneous, gastrointestinal, and inhalational.110,111 Cutaneous anthrax presents as a small, painless, pruritic papule, which progresses to an enlarging vesicle in 1 to 2 days. The vesicle ruptures and erodes, leaving a necrotic ulcer that later gets covered with a black, pain- Individual Chief Complaint Protocols 12/8/08 3:01:10 PM less eschar. Pathognomonic features of anthrax include the presence of an eschar, lack of pain, and edema out of proportion to the size of the lesion. Associated symptoms include swelling of adjacent lymph nodes, fever, malaise, and headache. Cutaneous anthrax is caused by B. anthracis entering a cut or abrasion in exposed areas of the body such as the face, neck, arms, and hands. The incubation period of cutaneous anthrax is 1 to 12 days. The case fatality rate can be as high as 20% without antibiotic therapy, but lowers to 1% with therapy. Gastrointestinal anthrax presents with more nonspecific symptoms. Two forms exist: oropharyngeal and intestinal. Oropharyngeal anthrax starts with edematous lesions at the base of the tongue or tonsils that progress to necrotic ulcers with a pseudomembrane. Sore throat, fever, cervical adenopathy, and profound oropharynx edema are associated symptoms. This form of anthrax initially presents with fever, nausea, vomiting, and abdominal pain and tenderness that may progress to hematemesis, bloody diarrhea, and abdominal swelling from hemorrhagic ascites. Gastrointestinal anthrax is caused by consumption of meat contaminated with anthrax. The incubation period for intestinal anthrax is believed to be 1 to 7 days. The case fatality rate of gastrointestinal anthrax is estimated to be 25% to 60%. Inhalational anthrax initially causes nonspecific symptoms that mimic influenza. These early symptoms are low-grade fever, nonproductive cough, malaise, and myalgias. Two to 3 days later, the patient rapidly progresses to severe dyspnea, profuse sweating, high fever, cyanosis, and shock. Hemorrhagic meningitis occurs in up to half of patients. It is critical that the EMS provider attempt to distinguish any influenza-like illness from anthrax because of the narrow window opportunity for successful treatment. Nasal congestion and rhinorrhea are not common with inhalational anthrax but more common with influenza-like illness. Further, shortness of breath is more common in inhalational anthrax and less common in influenza-like illness. Although not typically available to EMS providers, the chest x-ray demonstrates mediastinal widening or pleural effusion. These findings are the most accurate predictors of inhalational anthrax. Inhalational anthrax can be caused by inhalation of anthrax spores, commonly seen following intentional release of aerosolized anthrax, or from the processing of materials from infected animals, such as goat hair. The incubation period for inhalational anthrax is usually 1 to 7 days but can be as long as 43 days. Case fatality rate of inhalational anthrax can be as high as 97% without antibiotics and up to 75% with antibiotics. Human-to-human transmission of any form of anthrax is rare. A vaccine for anthrax is licensed in the United States and is administered in a six-dose schedule with annual boosters thereafter. Vaccination is not currently recommended for emergency first responders or medical personnel; however, it may be indicated for certain military personnel. In cases of deliberate use of anthrax as a biologic weapon, first responders should wear a full face respirator with high efficiency particulate arresting (HEPA) filters or a self-contained breathing apparatus, gloves, and splash protection. If clothing is contaminated, it should be removed and placed in plastic bags. Soap and copious amounts of water should be used to decontaminate skin, and bleach should be applied for 10 to 15 minutes in a 1:10 dilution if there is gross contamination. If exposure to aerosolized anthrax occurs, PEP with ciprofloxacin or doxycycline should begin and continue for 60 days. Vaccination given in three doses for PEP should also be administered because of the persistence of anthrax spores in the lungs. Quarantine is not appropriate for persons exposed to anthrax because they are not contagious. Patients suspected of being infected with anthrax and requiring hospitalization should be immediately started on IV antibiotics such as ciprofloxacin and one other active drug. Other active drugs include doxycycline, rifampin, vancomycin, penicillin, ampicillin, chloramphenicol, imipenem, and clindamycin. Treatment should continue for 60 days or longer.112–114 Botulism Botulism is caused by a neurotoxin produced by C. botulinum, which ultimately leads to a flaccid paralysis. Four clinical forms of botulism exist, and the presenting form is based on the site of toxin production: foodborne, wound, intestinal, and inhalational.115 In foodborne botulism, early symptoms are nonspecific gastrointestinal ones, and they include nausea, vomiting, and diarrhea. This may progress to blurred vision, double vision, dry mouth, and difficulty in swallowing, breathing, and speaking. Descending muscle paralysis occurs, starting with the shoulders and progressing to upper arms, lower arms, thighs, and then calves. Respiratory muscle paralysis ultimately leads to death. Foodborne botulism is caused by the ingestion of C. botulinum toxin present in contaminated food, including deliberate contamination when the toxin is used as a biologic weapon. The incubation CHAPTER 34 1_C_34_332-359.indd 347 Communicable Diseases 347 12/8/08 3:01:10 PM period is usually 12 to 36 hours. The case fatality rate in the United States is 5% to 10%. Intestinal botulism is rare and occurs mainly in infants. It causes a striking loss of head control, constipation, loss of appetite, weakness, and an altered cry. Intestinal botulism occurs with ingestion of botulism spores, rather than ingestion of toxin. Spores, which may come from honey, food, and dust, germinate in the colon. The incubation period is unknown. It is estimated to cause 5% of deaths of sudden infant death syndrome. The case fatality rate of hospitalized cases is less than 1%. Wound botulism causes the same symptoms as foodborne botulism. The incubation period is up to 2 weeks. Like intestinal botulism, this is a rare disease, caused by spores entering an open wound from soil or gravel. Inhalational botulism would be the most common form in the case of use of botulinum toxin as a biologic weapon. Symptoms would the same as foodborne botulism, but the incubation period may be longer. No reported cases of person-to-person transmission of botulism have been identified. Therefore, EMS providers do not require any special equipment to manage a patient with suspected or known botulism infection. Supportive care is advised in all cases, including volume replacement. In the case of consumption of food suspected of being contaminated with botulism, treatment may include gastric lavage or whole bowel irrigation. In the case of suspected aerosol exposure to the toxin, clothing should be removed and placed in plastic bags, and the exposed person should shower thoroughly. Treatment for botulism is botulinum antitoxin, given after blood is collected to determine the specific antitoxin needed. Antitoxin use should be considered and administered within 1 to 2 days of exposure. Patients should be transported immediately to a center with an intensive care unit. In intestinal botulism in infants, equine botulinum antitoxin should not be used. In the United States, an investigational human derived botulinal immunoglobulin is available for infant intestinal botulism from the California Department of Health Services.116–118 Plague Plague is caused by the bacterium Yersinia pestis. Initial signs and symptoms may be non-specific and include fever, chills, sore throat, malaise, and headache. Tender, swollen, warm, and suppurative lymph nodes, mainly in the inguinal area, often follow. This swollen 348 1_C_34_332-359.indd 348 SECTION C lymph node is called a bubo, hence the term, bubonic plague. Patients infected with the plague often progress to septicemia, meningitis, pneumonia, or shock. When plague progresses to the lungs, leading to pneumonic plague, person-to-person transfer may occur from infective respiratory droplets that are expelled with coughing. The exposed contact subsequently develops primary plague pneumonia. Untreated plague has a case fatality rate of 50% to 90%. If treated, the death rate is 15%. Plague is transmitted to humans by bites, scratches, respiratory droplets, or by direct skin contact. Bites from infected rat fleas are the most frequent source of transmission, but bites or scratches from cats may also transmit plague. Airborne droplets from the respiratory tract of cats or humans infected with pneumonic plague are another source of transmission. In case of deliberate use as a biologic weapon, plague bacilli would be transmitted via the aerosolized airborne droplets. Direct contact with tissue or body fluids of a plague-infected sick or dead animal can lead to transmission to humans through a break in the skin. The incubation period is 2 to 6 days for bubonic plague. For primary pneumonic plague, the incubation period is shorter, typically 1 to 4 days.119,120 Prevention of infection is by controlling exposure to infected fleas. In addition, environmental flea and rodent control can be effective means to prevent occurrence of disease and subsequent transmission. A vaccine for bubonic plague exists, but a vaccine for pneumonic plague does not. The vaccine is administered in a three-dose schedule with booster doses every 6 months. Commercial plague vaccine is no longer available in the United States. For patients with pneumonic plague, strict isolation is indicated with precautions against airborne spread until 48 hours after start of antibiotic therapy. Antibiotic therapy for bubonic or pneumonic plague is effective if started within 8 to 18 hours of onset of symptoms. First-line antibiotics are streptomycin or gentamicin. Chloramphenicol is used to treat plague meningitis. Close contacts of patients infected with pneumonic plague should be provided with chemoprophylaxis with tetracycline or chloramphenicol for 1 week after exposure ends. Close contacts include EMS and other medical personnel, household contacts, and face-toface contacts. Contacts should also be placed under surveillance for 7 days. If contacts refuse antibiotics, they should remain in strict isolation for 7 days. Articles soiled with sputum or purulent discharges should be disinfected. Individual Chief Complaint Protocols 12/8/08 3:01:12 PM Y. pestis could be used as a potential biologic weapon disseminated through aerosol spread and leading to pneumonic plague. Many patients presenting with fever, cough, and particularly hemoptysis in a fulminant course with a high case fatality rate should raise suspicion to clinicians for deliberate use as a biologic weapon.121–123 Smallpox Two clinical forms of smallpox have been identified: variola major and variola minor. Variola major is the more severe form of disease with a case fatality rate of greater than 30%, whereas variola minor is the less severe form with a case fatality rate less than 1%. All smallpox begins with a prodrome that lasts 2 to 4 days. The prodrome starts abruptly and consists of fever, headache, nausea, vomiting, muscle pain, headache, and malaise. Variola major has four principal clinical presentations: ordinary, modified, flat, and hemorrhagic. Ordinary is the most common, occurring in 90% of cases. Modified is mild. Flat and hemorrhagic forms are uncommon but usually severe and fatal.124 In ordinary smallpox, after the prodrome, mucous membrane lesions (an enanthem) in the mouth begin. This consists of red spots on the tongue, oral, and pharyngeal mucosa that enlarge and ulcerate quickly. Subsequently, a skin rash (an exanthem) develops, beginning as macules on the face. The exanthem progresses from the proximal extremities to the distal extremities and trunk within 24 hours. The macules progress to papules, vesicles, pustules, and then crusts. Crusts later separate, leaving depigmented skin and pitted scars. The case fatality rate for ordinary smallpox is about 30%. Modified smallpox occurs in previously vaccinated persons. During the prodrome fever is absent, and the illness is less severe. The skin rash is more superficial and progresses quickly, and lesions are less numerous. This form is more easily confused with chicken pox. Flat smallpox has a more severe prodrome with an exanthem that is softer and flatter and contains little fluid. Most cases are fatal. The enanthem is more extensive, and fever remains elevated throughout the course of illness rather than remaining restricted to the prodromal period. Hemorrhagic smallpox consists of a more severe and prolonged prodrome along with extensive bleeding into the skin, mucous membranes, and gastrointestinal tract. The skin rash remains flat and does not progress beyond the vesicular stage. Hemorrhagic smallpox is usually abruptly fatal between the fifth and seventh days of illness. Case fatality for hemorrhagic and flat smallpox is greater than 90%. Variola minor produces a rash like ordinary smallpox, but patients experience much less severe systemic reactions. Transmission of smallpox is via inhalation of the virus from airborne droplets or fine particle aerosols originating from the oral, pharyngeal, or nasal mucosa of an infected person. This usually occurs from direct face-to-face contact within a distance of 6 feet. Transmission could also occur from physical contact with an infected person or with contaminated articles through skin inoculation. Transmission from dried skin crusts is uncommon. Smallpox is not transmissible during the incubation period. It becomes transmissible with the first appearance of rash and remains transmissible until the disappearance of all scabs, which is about 3 weeks. The average incubation period of smallpox is 12 days, but it ranges from 7- to 19 days. EMS personnel should be able to identify the rash caused by smallpox and should try to distinguish it from other less virulent diseases, particularly chicken pox. It is important to identify smallpox because its presence indicates a medical and public health emergency. Differentiation can be made through the prodrome and the rash. In smallpox, patients have a severe febrile prodrome, whereas chicken pox produces a short, mild prodrome or even no prodrome. In smallpox, the rash consists of deep, hard, well, circumscribed lesions at the same stage of development, whereas in chicken pox, the lesions are superficial, not well circumscribed, and at different stages of development. In addition to chicken pox, other conditions may be confused with smallpox, such as herpes, impetigo, contact dermatitis, erythema multiforme, and scabies. Further information to differentiate these illnesses from smallpox is available from the CDC at www. bt.cdc.gov/agent/smallpox/. The last two cases of smallpox were identified in 1978, and in 1980, the World Health Organization (WHO) declared smallpox officially eradicated from the planet. However, two sources of smallpox virus remain in storage and for research purposes, one in the United States and one in Russia. Any new suspected cases of smallpox would be a medical and public health emergency. Therefore, strict respiratory and contact isolation of confirmed or suspected smallpox cases must be undertaken. No antiviral drug CHAPTER 34 1_C_34_332-359.indd 349 Communicable Diseases 349 12/8/08 3:01:12 PM is approved for the treatment of smallpox, but cidofovir may be useful as a therapeutic agent and could be used off label under an investigational new drug protocol. Contacts of suspected or confirmed smallpox cases should be wearing N95 fit-tested masks, and they should use routine PPE practices and additional precautions. All bedding and clothing should be autoclaved or laundered in hot water with bleach. Contacts include first responders, laundry handlers, housekeepers, and lab personnel. Smallpox vaccine is administered as one dose, and success of vaccination is determined by a major reaction at the inoculation site. The use of smallpox vaccine as a childhood immunization was discontinued in 1972. In nonemergency situations, vaccination is recommended for public health, hospital, and other personnel who may need to respond to a smallpox case or outbreak. In an emergency situation, such as the intentional release of variola virus in a bioterrorist event, vaccination would be recommended for those exposed to initial release, contacts of confirmed or suspected cases, and those involved in direct care or transportation of confirmed or suspected cases. A number of uncommon but serious adverse reactions, precautions, and contraindications to smallpox vaccine exist, and these should be carefully reviewed before administration of the vaccine. These matters are well addressed at the CDC web site, www.bt.cdc.gov/ agent/smallpox/. Vaccinia immunoglobulin is available for IV administration for the treatment of adverse reactions to smallpox vaccine. Smallpox vaccine can be used for PEP in exposed contacts. If administered less than 7 days after exposure, contacts generally experience the mild, modified type of smallpox if the disease were to occur.125,126 Tularemia Tularemia is caused by the bacterium Francisella tularensis, and its various clinical manifestations are related to the route of introduction. All forms have a sudden onset of nonspecific influenza-like symptoms, including high fever, cough, sore throat, chills, headache, and generalized body aches. Sometimes, nausea, vomiting, and diarrhea may also occur. All forms may lead to sepsis, pneumonia, and meningitis. The clinical forms include ulceroglandular, glandular, oculoglandular, septic, oropharyngeal, and pneumonic.128 Ulceroglandular tularemia is the most common form. It begins at the skin site of the bite of a tick or 350 1_C_34_332-359.indd 350 SECTION C fly. A papule appears that becomes pustular, later ulcerates, and finally develops into an eschar. Regional lymph nodes become swollen, painful, and tender, and they may suppurate and discharge purulent material. Glandular tularemia has no skin involvement, only regional lymphadenopathy similar to that which occurs with ulceroglandular disease. Oculoglandular tularemia is caused by the bacillus entering the eye, and conjunctival ulceration is followed by regional lymphadenopathy of the cervical and preauricular nodes. Septic tularemia begins with nonspecific symptoms of fever, nausea, vomiting, and abdominal pain, eventually leading to confusion, coma, multisystem organ failure, and septic shock. Oropharyngeal tularemia is caused by consumption of contaminated water or food, leading to exudative pharyngitis, which may be accompanied by oral ulceration. Abdominal pain, diarrhea, and vomiting may accompany this type. Regional lymphadenopathy occurs affecting the cervical and retropharyngeal nodes. Pneumonic tularemia may be caused not only by inhalation of an infective aerosol from soil, grain, or hay but also due to deliberate use of an infective aerosol as a bioterrorist attack. The clinical presentation may be cough, pleuritic pain, and occasionally dyspnea. Chest x-ray findings include bronchopneumonia and hilar lymphadenopathy. Despite the lungs as the primary route of entry, it is not uncommon for tularemic pneumonia to present as nonspecific systemic signs without respiratory symptoms, often with a normal chest-x-ray. Tularemia is transmitted through the skin, mucous membranes, lungs, and gastrointestinal tract. The bacteria may be transmitted through the skin by bites, and it may be transmitted to the oropharyngeal mucosa and conjunctiva by contaminated water or by contaminated blood or tissue while handling carcasses of infected animals. Through the gastrointestinal tract, it is transmitted by ingestion of insufficiently cooked meat of infected animals or by consumption of contaminated water. Finally, tularemia can be transmitted to the lungs by inhalation of particles of contaminated soil, by handling contaminated furs, or by deliberate aerosolization of the bacterium as a biologic weapon. The incubation period is usually 3 to 5 days but can range from 1 to 14 days. No documented person-to-person transmission of tularemia has been found, even for pneumonic tularemia. Routine precautions are adequate when transporting and caring for patients. Vehicles and equipment, Individual Chief Complaint Protocols 12/8/08 3:01:12 PM however, must be thoroughly cleaned and decontaminated after patient transport. Although a vaccine for tularemia exists, no commercial production is as yet active, and its availability is under review by the Food and Drug Administration. Streptomycin is the drug of choice for treatment of tularemia, with ciprofloxacin as an excellent alternative. Gentamicin and tetracycline are alternatives, but the diseases may show high relapse rates when these agents are administered. Treatment should be maintained for 14 to 21 days. In a mass casualty situation doxycycline or ciprofloxacin for 14 days are the preferred choices for prophylaxis and should be started as soon as possible after exposure.128,129 Viral Hemorrhagic Fevers Viral hemorrhagic fevers are caused by different distinct families of viruses and lead to similar clinical syndromes. In the case of bioterrorist attack, it is essential that first responders be able to recognize the illness associated with the intentional release of the biologic agent. In hemorrhagic fever the initial signs and symptoms are non-specific and include high fever, headache, muscle aches, and severe fatigue. Associated gastrointestinal symptoms of nausea, vomiting, diarrhea, and abdominal pain may appear. Respiratory symptoms of cough and sore throat may also occur. About 5 days after the onset of illness, a truncal maculopapular rash develops in most patients. As the disease progresses, bleeding commonly occurs from internal organs, the mouth, eyes, ears, and from under the skin. Skin manifestations include petechiae and ecchymosis. Shock, coma, seizures, and kidney failure may occur in severe cases. Viral hemorrhagic fevers are caused by four families of viruses: arenaviruses, bunyaviruses, flaviviruses, and filoviruses. Diseases caused by these agents include Ebola hemorrhagic fever, Hantavirus pulmonary syndrome, Lassa fever, Marburg hemorrhagic fever, hemorrhagic fever with renal syndrome, and Crimean-Congo hemorrhagic fever.130 Initial transmission occurs when humans have direct contact with infected animals, mainly rodents, or are bitten by a mosquito or tick vector. Once a person has become infected, some viruses can be transmitted from person to person, mainly by close contact with infected people, but also indirectly by objects contaminated with infected body fluids. Transmission of viral hemorrhagic fever mainly occurs in the latter stage of illness when the patient suffers vomiting, diarrhea, shock, and hemorrhage. In the case of Ebola virus, reports of transmission within a few days of the onset of fever have been made. The incubation period ranges from 2 days to 3 weeks, and no transmission has been documented during the incubation period. No vaccine or treatment is yet available for most of the agents causing viral hemorrhagic fever, although vaccines are available for yellow fever and Argentine hemorrhagic fever. Ribavirin or convalescent plasma has been used for treatment with some success. Prevention is the best method of control. To prevent infection, contact with rodents and bites from ticks and mosquitos should be prevented. Person-toperson transmission can be prevented by strict adherence to routine PPE practices and additional precautions. In addition, patients with known or suspected viral hemorrhagic fever must be isolated. Although this may be difficult in the EMS setting, the transporting vehicle can serve to isolate the patient from the scene and while in transit. If EMS personnel are exposed to viral hemorrhagic fever, they should be placed under surveillance for fever. Surveillance should occur twice daily for at least 3 weeks after exposure. In case of development of temperature above 38.3°C, patients should be hospitalized immediately with strict isolation. WHO and CDC have prepared an infection control manual specific to viral hemorrhagic fever management and control, with detailed and comprehensive strategies to prevent spread and protect healthcare workers during an outbreak.131–134 PART 2: EMS AND THE COMMUNITY IT SERVES This section describes the role and planning for healthcare emergencies due to infectious disease, EMS interactions with public health agencies, and special considerations for EMS agencies in epidemics or pandemics. EMS agencies have a responsibility in the healthcare sector that exceeds merely emergency response. The report “EMS Agenda for the Future” identifies EMS at the intersection of the health care, public health, and public safety sectors. As a key stakeholder in community health and often the public’s first point of contact with the healthcare system during an emergency, EMS systems must be proactive in protecting their personnel against infectious and CHAPTER 34 1_C_34_332-359.indd 351 Communicable Diseases 351 12/8/08 3:01:13 PM communicable disease. EMS systems must be able to maintain this essential service during a disease outbreak and act as one of the first barriers to disease spread within the health care system as a whole. and any requisite training in a timely manner. Finally, the EMS agency’s plan must include methods to coordinate the release of factual, consistent information to the media and other public sources as required. EMS Planning EMS Surveillance and Mitigation Each and every EMS agency must explore its existing infectious disease outbreak or pandemic operational plans and procedures. The plans and procedures must be up to date and include a number of essential elements to be useful and functional during a true outbreak or pandemic. The plans must include the EMS agency’s role in preparing for, mitigating, and responding to a healthcare emergency. EMS agencies should consult with, develop, and coordinate their plans in conjunction with other local, regional, and national agencies and governments to ensure the EMS roles and responsibilities are well defined and understood by all stakeholders. The agency’s leadership and authority must also be delineated within the plan and be consistent with local, regional, and national plans to avoid conflict during the actual emergency. If not already in place, the EMS agency should adopt an incident command process or other similar system used by other public service agencies. Each EMS agency should also develop and participate in training exercises that will prepare the agency and its personnel for their role in local, regional, and national infectious disease emergencies. These exercises allow each agency to exercise its plans and procedures and determine how it functions together with those from other public service and healthcare agencies. The exercises also allow individual EMS providers to better understand their respective roles during an emergency. Most importantly, exercises allow EMS leaders and personnel to develop a personal relationship with others within the public service and healthcare systems that can enhance communication during an actual emergency. Effective communication and dissemination of information is typically a major obstacle during any healthcare emergency or disaster. To avoid ineffective or erroneous communication between stakeholders, plans must include a defined process to gather, update, and disseminate factual information to all relevant stakeholders. In the EMS setting, this must include clinical standards, treatment protocols, and any procedures specific to that emergency. The plan must also include just-in-time training methods to ensure all EMS leadership and providers receive this information EMS agencies and their providers are often the first point of contact between the public and the healthcare system during an emergency. This contact may be the first opportunity to identify a potential threat and mitigate that risk. During the SARS outbreaks in Toronto and Taipei, EMS providers were among the first healthcare workers infected with the virus.2,3 Interfacility patient transport by EMS agencies was also identified as a cause of further spread of SARS between hospitals.2,36 To mitigate the risk to providers and the healthcare system, EMS agencies must quickly adopt and implement a multitude of surveillance, screening, and mitigation strategies to prevent further disease spread. During the SARS outbreaks in Toronto, all EMS personnel were screened, and a surveillance system monitored all potentially exposed personnel.4 A series of work and home quarantine measures were also implemented to prevent depletion of the EMS workforce and ensure a level of sufficient staff to maintain emergency response capabilities. In addition, call-taking procedures were modified to screen all calls to an EMS dispatch center for any sign of communicable or infectious disease. Responding personnel would be advised of any call that screened positive. Finally, a provincial government developed and deployed an innovative EMS command, control, and tracking system to mitigate the risk of iatrogenic spread of SARS among healthcare facilities, healthcare workers, and patients due to interfacility patient transfers.135 All EMS agencies should have plans to provide providerand agency-level strategies for surveillance, screening, and mitigation to protect both their personnel and the public at large. Local and regional EMS agencies should identify the roles that they play in ongoing disease surveillance to quickly identify and mitigate the risk of disease once it occurs. Potential roles for EMS include real-time monitoring and analysis of patterns in call volume, call type, presenting complaint, location, and any other disease-specific factors for which data are routinely available at EMS dispatch centers. These data, when used alone or in conjunction with other healthcare data, can help identify variations from nor- 352 1_C_34_332-359.indd 352 SECTION C Individual Chief Complaint Protocols 12/8/08 3:01:13 PM mal or expected patterns in community health-seeking behavior. These temporal and spatial fluctuations may be the first evidence of a potential threat to community health. EMS agencies can also play a collaborative role in a multiagency, multijurisdictional initiative to identify persons or groups at risk based on location and points of contact with the healthcare system. This can help public health and other authorities identify and track patients at risk of exposure and prevent further spread of disease. Continuity of EMS Operations EMS agencies should include, in their preparedness plans, a contingency to allow EMS to maintain its ability to respond to routine emergencies while meeting the needs of a major infectious disease outbreak. EMS will likely experience an increased demand for service while facing potential loss of trained personnel due to illness and absenteeism. In addition, the agency may face increased emergency department (ED) diversions or offload delays and a shortage of equipment and supplies. Both limit the agency’s ability to maintain adequate resources to meet its existing service mandate. Finally, it is likely that a healthcare emergency due to infectious disease will be ongoing and of many weeks duration, placing a prolonged strain on EMS operations, personnel, and resources. EMS should take into account the prolonged nature of this potential emergency when planning. Local, regional, and national EMS organizations should have a plan to shift personnel between jurisdictions and augment any inadequate numbers in EMS workforce. An adequate supply of essential equipment, supplies, and services must be available should the supply chain be interrupted during an emergency. Finally, an effective, reliable communication system and set of protocols must be available to EMS, public service, and healthcare agencies to ensure all stakeholders receive timely information and are aware of diversion and capacities at local and regional levels. Legal Authority It is not typically possible for routine EMS policies and procedures to take into account any possible situation or scenario. This is particularly true in the setting of a healthcare emergency or disaster. The emergency plans developed by EMS agencies should include approved policies and procedures that enable agencies to devi- ate from routine procedures to respond to a disaster or similar situation. The plans should identify the legislative authority, administrative rules and regulations, and liability protection to support the role of EMS providers during an infectious disease outbreak or other public health emergency. The legal authority should permit EMS agencies and their providers to modify established treatment procedures to respond to the evolving role of EMS during the emergency, while assuring appropriate medical direction, education, and quality assurance measures are in place. The plans should also include authority and ability to move and license EMS assets, such as vehicles and personnel, if restrictions in movement of the general public are in place. Clinical Standards and Protocols EMS standards and treatment protocols may require rapid and repeated modification during an infectious disease outbreak as more information on the outbreak becomes available. Each EMS agency must have physician medical direction to provide oversight and input regarding these modifications and rapid dissemination and training methods to ensure providers are appropriately informed and prepared to deal with the outbreak. Medical directors and EMS agencies should also have methods to communicate with other healthcare agencies to ensure new EMS standards and protocols are consistent with those in other healthcare sectors. The office of the medical examiner or coroner should be contacted to help identify protocols and processes to manage facilities and outpatient facilities, and determine the need for EMS-based treat-and-release protocols that do not require patient transport to a healthcare facility in the setting of unusual circumstances such as mass gatherings, outbreaks, or other instances where health-seeking behaviour may increase. Protecting EMS Workforce Well-Being EMS is a key component of any critical infrastructure, and EMS personnel would experience additional workplace stress during an outbreak or other related healthcare emergency. The EMS agency must have in place strategies to protect the EMS workplace and their families to maintain EMS operations during an outbreak. CHAPTER 34 1_C_34_332-359.indd 353 Communicable Diseases 353 12/8/08 3:01:13 PM EMS agencies must ensure that all EMS personnel use routine PPE practices and additional precautions (when indicated) and ensure the necessary infrastructure is in place to promote safe working practices to mitigate the risk of disease. Finally, EMS agencies must make available, at all times, an adequate amount of appropriate protective equipment and related supplies designed to prevent disease. Where risk mitigation programs exist, EMS agencies must ensure that EMS personnel receive priority access to these programs. In the event of a vaccine- or medication-preventable outbreak, EMS agencies must have an established plan to provide vaccination or appropriate prophylactic medication to all EMS personnel in a timely manner. In the event of potential contact with an infectious disease, EMS agencies must have mechanisms in place to determine if isolation or quarantine are necessary and provide suitable resources for this. Finally, EMS personnel and their families must have available the necessary support services, including counseling and mental health, both during and after an infectious disease outbreak. CLI NI C A L VIGNE T T E The regional EMS communications center receives a call from a young boy. He states “I came home and found my mother on the floor! She is confused! Please help!” The EMS call-taker asks, “Are you close to her?” “Yes” he replies. “Is she breathing?” “Yes, he replies.” The call-taker tells the boy, “Alright, help is on the way” and forwards the call information to the vehicle dispatcher. The call-taker continues his call-taking. “Does she have a fever, cough, or any other sign of illness?” The boy replies, “She feels very hot! She has been sick since coming back from a trip.” The call-taker refers to the pre-arrival instructions and his infection control protocol. “Is anyone else in the home sick?” “Yes, my father and sister are also sick with a cough and diarrhea.” The call-taker advises the dispatcher to notify the first responders and EMS crew to use personal protective equipment to ensure they are protected against infectious disease. The first responders and EMS crew arrive at the same time. The EMS crew advises the first responders to remain outside the home until they assess the scene and the patient. Both paramedics put on mask, gloves, and gown before making patient contact. In keeping with their infection control protocol, they bring only limited equipment into the house. They find the patient lying on the floor, eyes closed, and not responding to questions. Her respirations appear labored. A fecal odor permeates the room. Paramedics take the patient’s vital signs: pulse 130/minute and regular, respirations 32/minute and labored, blood pressure 102/80 mmHg, SpO2 86%, 354 1_C_34_332-359.indd 354 SECTION C and temperature of 40.4 degrees Celsius. Auscultation of the chest shows wheezes throughout with prolonged expiration. They find no rash or other lesions on the skin. While one paramedic delivers high-flow oxygen by a mask specially designed to prevent respiratory droplet spread, his partner establishes an intravenous line and initiates a crystalloid bolus. The first responders are asking the paramedics if they should enter the home and assist in packaging the patient for transport. The paramedics replies “No, stay outside but bring our stretcher to the door and have everyone move away from the building” in order to prevent unnecessary exposure of other providers to the patient. As they prepare the patient for transport, paramedics contact EMS dispatch to determine a receiving hospital. The closest hospital is a community hospital less than 5 minutes from the home. Regional EMS protocols indicate patients with infectious or communicable disease should be transported to one of the designated regional hospitals equipped with infection control facilities unless the patient has an immediate threat to life requiring emergent intervention not available in the field. EMS dispatch advises the crew to bypass the local hospital and transport to the regional hospital. The EMS dispatch also notifies the receiving facility of the patient, advising them to prepare staff to receive the patient. Finally, EMS dispatchers follow regional protocols and notify the public health authorities of an infectious disease affecting several people in the same location, and Individual Chief Complaint Protocols 12/8/08 3:01:13 PM dispatches additional EMS resources to assess the other family members. The paramedics transfer the patient to the stretcher and load her into the ambulance. In keeping with protocol, the first responders do not assist the paramedics. En route, the paramedics contact the receiving facility. “We have a 38 year old female who just returned from China with fever, cough, and confusion. She has is tachycardic and hypovolemic, altered level of consciousness, and increased work of breathing. We are not intubating her due to an active respiratory disease. Our ETA is 8 minutes. Please prepare your infection control room and for possible intubation.” The transport to hospital is uneventful. Paramedics arrive, unload the patient, and are directed through a separate entrance to a dedicated resuscitation room equipped with negative pressure ventilation. Emergency department staff are wearing full PPE and prepare to intubate the patient. The paramedics return to their ambulance. They contact EMS communications and inform the dispatcher they are not available until their vehicle and equipment is properly decontaminated. 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