The issue of infectious (communicable) disease in the fire service has been well established as a very serious concern. IAFF members are exposed every day to potentially life threatening disease including MRSA, HIV, pertussis and many more. The 2011 NFPA Injury Report informs that there were over 11,000 exposures to communicable diseases during the reporting period. This amounts to 1 exposure for every 1,500 EMS runs. In the U.S., 27 states have made infectious diseases a presumptive illness for fire fighters and emergency medical providers.

This webpage offers basic information about common infectious diseases that can affect the health and safety of IAFF members and their family members. For each disease the symptoms, prevention and transmission methods and treatment options are discussed so that IAFF members can protect themselves in the workplace. Please feel free to use this information as a supplement to your annual OSHA required bloodborne pathogen refresher training.

Infectious disease is an area of rapidly changing conditions. Some of the controversies that may arise in the next several years are the issue of baseline screening for hepatitis B and C, mandatory testing for HIV, and whether to regulate exposures for non-bloodborne pathogens such as tuberculosis. While this webpage discusses some of these issues, this continues to be an evolving field.


IAFF Infection Control Policy

The issue of infectious (communicable) disease in the fire service continues to take on an urgent meaning with fire fighter’s risks of contracting AIDS, hepatitis, pertussis and MRSA. However, the range of diseases that may affect fire fighters, EMTs and paramedics goes well beyond this list. The IAFF Death and Injury Survey reports that 1 out of every 50 fire fighters is exposed to a communicable disease annually.

  • 5% exposed to hepatitis B
  • 10.2% exposed to hepatitis C
  • 8.6% exposed to human immunodeficiency virus
  • 0.3% exposed to hepatitis A
  • 29.8% exposed to tuberculosis
  • 10.6% exposed to meningitis
  • 16.1% exposed to blood/bodily fluids
  • 19.4% exposed to some other communicable disease

Overview

This program is intended to support the provisions of the IAFF Executive Board policy on infectious diseases. Every attempt has been made to substantiate, support, and provide recommendations for our locals to establish similar policies within their departments for the health and welfare of our fellow brothers and sisters.

Officially Designated Physicians

The policy has been updated by the IAFF due to current concern regarding the risk of transmission of HIV, hepatitis C, and other infectious diseases to emergency response personnel. Therefore, the Executive Board developed and adopted the following position statement and recommended guidelines to address this issue:

The IAFF Executive Board supports the Fire Service Joint Labor Management-Wellness Fitness Initiative and NFPA 1500, Standard on Fire Department Occupational Safety and Health Program, as it relates to fire department medical programs (Chapter 10). Specifically, the IAFF supports NFPA 1500, Section 10.6.1, which states:

“The fire department shall have an officially designated physician who shall be responsible for guiding, directing, and advising the members with regard to their health and fitness for various duties.”

Limitations on Duty

The IAFF Executive Board believes a policy that specifies limitations on HIV-infected fire fighters, EMTs or paramedics is necessary. If there is clear evidence that such workers pose a significant risk of transmitting infection through an inability to meet basic infection control standards or guidelines, appropriate limitations of duty should be instituted.

Through the Fire Service Joint Labor Management Wellness-Fitness Initiative and NFPA 1500, fire departments are responsible for evaluating the health status of all fire fighters, EMTs, and paramedics and their ability to perform assigned duties.

The fire department must establish procedures for the evaluation of work limitations for employees with an infectious disease who in the course of performing their duties demonstrate evidence of functional impairment or inability to adhere to standard infection control practices or who present an excessive risk of infection to patients or fire department members. The fire department physician must evaluate fire fighter, EMT and paramedic job duties to determine job limitations, if any, in the event of an individual’s contraction of an infectious disease. The evaluation should include an assessment of any factors that may compromise the performance of job duties, as well as a review of scientifically and medically accepted infection control practices. Factors include illness or presence of exudative or weeping lesions that may interfere significantly with the fire fighters’, EMTs’ and paramedics’ ability to perform their jobs and provide quality care. Both physical and mental competencies are also to be considered. Additionally, the fire department physician should review the immunologic status of the fire fighter, EMT and paramedic and susceptibility to infectious diseases.

The fire department physician must assist with developing policies addressing limited duty assignment for non-infectious personnel where there is a greater potential for that individual to contract an infectious disease. Fire fighters, EMTs and paramedics with extensive skin lesions or severe dermatitis on hands, arms, head, face, or neck must be evaluated to determine whether they should engage in direct patient contact, handle patient care equipment, or handle medical waste until such time that they are healed.

Infection Control Programs

The IAFF also demands that all fire departments adopt NFPA 1581, Standard on Fire Department Infection Control Program. The standard requires departments to develop policy guidelines for the prevention of transmission of bloodborne pathogens and other infectious diseases during fire fighter, EMT, and paramedic response activities as well as guidelines for improving infection control practices. The fire department must be responsible for providing barrier protection equipment (gloves, protective garments, etc.), safer needle devices, supplies, proper disinfection facilities, and appropriate training.

Basic Elements of an Exposure Control Plan

  • Written policy for protecting employees from bloodborne pathogens exposures
  • Designated individual responsible for administering the plan
  • Employee exposure determination (a list of job classifications where employees may be exposed)
  • Hepatitis B virus vaccination provisions
  • Employee training (initial and annual training)
  • Methods for control of bloodborne pathogens
    • Universal precautions
    • Engineering controls (for example, safety devices and sharps containers)
    • Work practice controls (for example, sharps handling and disposal, hand washing, cleanup)
    • Personal protective equipment (for example, disposable gloves or face shields)
    • Housekeeping
  • Post-exposure reporting, evaluation, counseling, and follow-up procedures
  • Procedures for evaluating circumstances surrounding an exposure incident
  • Recordkeeping, including sharps injury logs, training records, and annual plan updates
  • Source: http://www.cdc.gov/niosh/docs/2008-115/

Personnel Training

Fire departments must implement annual training for all fire department personnel in universal blood and body fluid precautions, barrier techniques, safer needle devices, and other scientifically accepted infection control policies. Such training also should provide information on infectious disease risk factors and the contagiousness and transmission of infectious disease as well as information on the availability and merits of voluntary, confidential or anonymous counseling and testing as a personal health measure for fire department personnel. Training materials must include information on exposure to infectious diseases and reproductive health.

Infectious diseases, also known as communicable or contagious diseases, are illnesses caused by “harmful microorganisms, including bacteria, viruses, fungi and parasites.” (La Dou) Occupational infectious diseases are these same illnesses that result from a person’s exposure to these microorganisms while he or she is at work/on the job. Occupationally contracted contagious diseases are considered compensable through the workers’ compensation system, just like any other job-related disease.

While working, fire fighters are often exposed to many different kinds of people in many different, uncontrolled settings. They often respond to emergencies involving victims who have been injured and are actively bleeding. They often do not know the health status of their victims, including what sorts of infectious diseases they may have. These victims may require rescue from a difficult to access accident scene, such as a motor vehicle accident or poorly accessible building. There may be broken glass or other sharp objects at the scene that are poorly visualized, and the lighting at the scene may be minimal. In addition, if a victim is bleeding profusely, and needs to be extricated quickly to save his/her life, the emergency provider may act in haste, with disregard for his or her own safety.

Fire fighters also may be involved in emergency medical treatment at the scene, including intravenous line insertion and blood drawing, and during these procedures, may accidentally expose themselves to infectious disease from those they are trying to help. Exposures to blood, body fluids, open wounds, aerosols from coughing, sneezing, talking, and even intact skin can allow the microorganisms to enter the body and cause illness. All of these factors combine to place the fire fighter at increased risk of contracting a contagious bloodborne disease.


The Chain of Infection

Overview

For an infection to occur, a certain sequence of events must take place. This sequence of events is often referred to as the chain of infection. This chain is made up of sections that link together to form the infectious process. The chain must include a:

  • Pathogen
  • Mode of Transmission
  • Route of Exposure
  • Susceptible Host (such as the human body)

What is a pathogen?

The first link in the chain of infection is the pathogen. A pathogen is anything that causes a disease. Pathogens include:

  • Bacterium – A group of microscopic organisms that are capable of reproducing on their own, causing human disease by direct invasion of body tissues. Bacteria often produce toxins that poison the cells they have invaded. Numerous bacteria also live in harmony with the body and are necessary for human existence, such as bacteria that aid in digestion in the gut. Important bacterial diseases include “strep” tonsillitis, pneumonia, and meningitis. (example: bacterial meningitis or strep throat)
  • Virus – A group of microbes that are incapable of reproducing on their own, and must invade a host cell in order to use its genetic machinery for reproduction. Viruses are smaller than bacteria, and are responsible for the most common human diseases, the common cold and the “flu” (influenza). Viruses are also responsible for more serious diseases such as AIDS, hepatitis B, and hepatitis C. (example: hepatitis A, hepatitis B, and hepatitis C)
  • Fungus – A single-celled or multicellular organism that can be true pathogens that cause infections in healthy persons or they can be opportunistic pathogens that cause infections only in immunocompromised persons. (example: athlete’s foot)

We come in contact with pathogens every day. Most of the time our body’s immune system destroys them before they can cause harm.

  • We are considered Exposed when we have been in contact with a pathogen.
  • We are considered Infected when a pathogen has entered the body and resulted in disease.

Whether an exposure results in infection depends on three factors:

  • Dose – the amount of organisms that enter your body.
  • Virulence – the strength of the organism.
  • Host resistance – the ability of your immune system to fight infection.

What are the modes of transmission?
Exposure occurs through either direct or indirect contact.

  • Direct transmission occurs when a pathogen (an agent that causes disease, esp. a living microorganism such as a bacterium or fungus) is transmitted directly from an infected individual to you. For example, you could become infected with HBV (Hepatitis B Virus) if you had an open wound that was exposed to a patient’s HBV infected blood.
  • Indirect transmission occurs when an inanimate object serves as a temporary reservoir for the infectious agent. For example, you could become infected with HBV if you come in contact with equipment that has dried infectious blood on it.

It is important to note that many diseases do not manifest themselves immediately. Therefore, it can often be difficult to track the source of an exposure.

Many of the symptoms of some diseases can be quite similar to the flu. Therefore, if flu-like symptoms do not subside in a normal amount of time with normal treatment methods, you may need to have blood tests performed to rule out other possible causes.

What are the routes of exposure?
Pathogens can enter the body through four primary routes:

  • Inhalation
  • Contact with blood or other body fluids
  • Ingestion
  • Fecal-oral (ingestion of something that has been contaminated with the feces of an infected person)
  • An intermediate carrier (vector such as a tick or another animal or soil)

What is a susceptible host?

A susceptible host is a person who is vulnerable to getting an infection. Certain groups of people are more vulnerable than other groups. For example, children, the elderly and immunocompromised (patients with weaker immune systems) patients are more vulnerable to getting infections than people who have a normal immune systems.

Preventing the Spread of Infection

The Centers for Disease Control and Prevention recommends using Standard Precautions (formerly called Universal Precautions) when caring for people. Standard Precautions is defined as treating all blood, body fluids, not intact skin, and mucous membranes as if they were infected with an infectious disease. A simple way to remember Standard Precautions is that all bodily fluids except sweat should be treated as if they were infected with an infectious agent. Under Standard Precautions, “body fluids” include saliva, sputum (fluid coughed up), urine, feces, semen, vaginal secretions, and pus or other wound drainage. The use of Standard Precautions is the only way to safely perform your job.


Hand Hygiene

The single most effective way to prevent the spread of infection is hand washing. Hands should be washed before and after patient contact. Wash hands during patient care as hands can become soiled. Wash hands with soap and water immediately after removing gloves. Wearing gloves does not eliminate the necessity for hand washing. If soap and water are not available, antiseptic hand cleanser or towelettes may be used, wash hands with soap and water as soon as possible. Hands should be scrubbed a minimum of 10 to 15 seconds.

Hand Hygiene Guidelines:

Improved adherence to hand hygiene (i.e. hand washing or use of alcohol-based hand rubs) has been shown to terminate outbreaks in health care facilities, to reduce transmission of antimicrobial resistant organisms (e.g. Methicillin Resistant Staphylococcus Aureus) and reduce overall infection rates.

CDC is releasing guidelines to improve adherence to hand hygiene in health care settings. In addition to traditional hand washing with soap and water, CDC is recommending the use of alcohol-based hand rubs by health care personnel. Alcohol- based hand rubs significantly reduce the number of microorganisms on skin, are fast- acting and cause less skin irritation for patient care because they address some of the obstacles that health care professionals face when taking care of patients. When using an alcohol-based hand rub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry.

The use of gloves does not eliminate the need for hand hygiene. Likewise, the use of hygiene does not eliminate the need for gloves. Gloves reduce hand contamination by 70 to 80 percent, prevent cross-contamination and protect patients and health care personnel from infection. Hand rubs should be used before and after each patient just as gloves should be changed before and after each patient.


Personal Protective Equipment (PPE)

Gloves – Put on gloves before contact with non-intact skin or with blood or body substances. Change gloves between each patient procedure. Wear non-sterile, latex gloves when performing any clinical procedure that may expose the staff to the patient’s blood or other body substances. (e.g., with venipuncture and during perineal care) Sterile latex gloves are worn during certain clinical procedures that require sterile technique (e.g., during certain dressing changes or while inserting a urinary catheter). After each use, sterile and non-sterile latex gloves are discarded in a leak resistant waste receptacle, such as a plastic trash bag.
Gowns – Wear moisture-proof, disposable gowns if clothing may be contaminated with blood or other body substances. Remove personal protective equipment after use, and dispose of it according to department policy and procedure.
Masks – Disposable facemasks are worn whenever aerosolization or splattering of blood or other body substances may occur. Masks can also be used on a patient with an unknown respiratory disease to protect medical providers from the patient. Masks are not considered respiratory protection. Follow department procedure for disposal of mask.
Respirators – For patients with an unknown respiratory illness, use a NIOSH-approved P-100 disposable respirator as a minimum respiratory protection or a respirator with a higher level of respiratory protection. Additionally, disposable respirators must have seal enhancing elastomeric components (e.g. rubber or plastic respirator to face seals) and must be equipped with two or more adjustable suspension straps.
Goggles – Goggles or safety glasses with side shields are worn when aerosolization or splattering of blood or other body substances may occur to the eyes. Clean the goggles with soap and water after each use. If the goggles become cracked or heavily contaminated, discard them according to facility procedures.
Disposable CPR Masks – Use disposable CPR masks if they are required to provide artificial mouth- to-mouth resuscitation or mouth-to-stoma ventilation.

Handling Sharps

A needle-stick or a cut from a contaminated scalpel can lead to infection from hepatitis B virus (HBV) or human immunodeficiency virus (HIV), which causes acquired immune deficiency syndrome (AIDS). Few cases of AIDS have been documented from occupational exposure. The Occupational Safety and Health Administration (OSHA) standard covering blood-borne pathogens specifies measures to reduce these risks of infection.

Prompt Disposal: The best way to prevent cuts and sticks is to minimize contact with sharps. That prevention means disposing of them immediately after use. Puncture resistant containers must be available nearby to hold contaminated sharps – either for disposal or, for reusable sharps, later decontamination for reuse. Contaminated sharps must never be sheared or broken.

Recapping, bending, or removing needles is permissible only if there is no feasible alternative or if required for a specific medical procedure such as blood gas analysis. If recapping, bending or removal is necessary, the employees must use either a mechanical device or a hand-handed technique. If recapping is essential – for example, between multiple injections for the same patient – employees must avoid using both hands to recap. Employees might recap with a one-handed “scoop” technique, using the needle itself to pick up the cap and pushing cap and sharp together against a hard surface to reassure a tight fit. Alternatively, they might hold the cap with tongs or forceps to place it on the needle.

Sharps Containers: Containers for used sharps must be puncture-resistant. The sides and the bottom must be leak-proof. The container must be labeled or color-coded red to ensure that everyone knows the contents are hazardous. Containers for disposable sharps must have a lid, and they must be maintained upright to keep liquids and the sharps inside. Employees must never reach by hand into containers of contaminated sharps. Containers for reusable sharps could be equipped with wire basket liners for easy removal during reprocessing, or employees could use tongs or forceps to withdraw the contents. Reusable sharps disposal containers may not be opened, emptied, or cleaned manually. Containers need to be located as near to the area of use as feasible and safeguarded to ensure safety. The containers must be replaced routinely and not to be overfilled, which can increase the risk of needle sticks or cuts.


Additional Precautions

Along with the above recommendations regarding the use of Standard Precautions, hand washing, use of PPE and sharps handling, some more tips on preventing the spread of infection are provided below:

  • Don’t insist that your physician give antibiotics if you do not need them. Antibiotics have no effect on illnesses caused by viruses.
  • Take prescribed antibiotics exactly as instructed. Do not stop taking them without checking with your physician, even if the medicine makes you feel better or worse.
  • Keep your immunizations up to date.
  • Follow safe sexual practices.
  • Do not use I.V. drugs. If you do, do not share needles.
  • Don’t share personal items–such as razor blades, toothbrushes, comb, and hairbrushes–do not eat or drink from others’ plates or glasses.
  • Keep kitchen surfaces clean, especially when preparing meat, chicken, and fish.
  • Disinfect kitchen surfaces.
  • Keep hot foods hot and cold foods cold; avoid leaving food out for an extended period.
  • Remove gloves immediately when finished with procedure.
  • Immediately wash all skin surfaces that have been contaminated with blood and body fluids. Flush skin with running water for one minute.
  • Wear a disposal gown if you may come into contact with blood or body fluids (for example, emptying a urinary drainage bag). If your client has a contagious illness, you should wear a gown even if it is not likely you will come into contact with blood or body fluids.
  • Wear a mask and protective glasses if the possibility exists that you will come into contact with splashing blood or body fluids (for example, emptying a bed pan)
  • Wear gloves and use caution when handling razor blades, needles, and other sharp objects. Discard these objects carefully in a puncture-resistant, biohazard container.
  • Avoid nicks and cuts when shaving clients.
  • Carefully bag all contaminated supplies and disposes of them according to your agency’s policy

Recommendations for Emergency Responders

Get Vaccinated

Before the Run

  • Ensure that you have your PPE readily available (respirators, masks, medical gloves, face/eye protection, gowns or garments)

During the Run

  • Assume patients with respiratory symptoms are contagious
  • Don your PPE before entering the patient area
  • Strictly limit the number of crew members having direct patient contact
  • Put a mask on the patient
  • Create or promote good ventilation

After the Run

  • Properly dispose of/clean exposed PPE
  • Sanitize or wash your hands
  • Properly clean/disinfect reusable medical equipment
  • Decontaminate other equipment and vehicles
  • Do not continue to wear contaminated clothing, and do not take any contaminated items, including uniforms, home
  • Take care of your physical health (diet, rest)
  • If you are exposed, report it

And Finally

  • Do not go to work if you are sick

The potential exposure of firefighters to blood borne infectious diseases is similar, if not greater, to that of health care providers. Any and all occupational exposures to blood and body fluids should be approached as urgent medical concerns with life and death significance. Specific exposures of concern to first responders would include percutaneous (i.e., passage through the skin by puncture) and permucosal (blood splashed on the surfaces of mucous membranes) exposures to infected blood and body fluids. As such, it is prudent that fire fighters be familiar with the recommendations set by the Centers for Disease Control and Prevention.

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Potentially Life-Threatening Infectious Diseases for Fire Fighters and Paramedics

ANTHRAX

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What is it?

Anthrax is an infection of the skin, gastrointestinal tract or lungs caused by the bacteria Bacillus anthracis. This is a common infection of hoofed animals and historically posed a risk to farm workers, veterinarians, tannery and wool workers. Anthrax may also be used as a biological weapon.

How can you get it?

There are three types of anthrax with different modes of transmission:

  • Cutaneous anthrax
    • Occurs after anthrax spores touch a cut or scrape on the skin
    • The most common type of anthrax infection in animal workers
  • Inhalation anthrax
    • Occurs when anthrax spores are inhaled
    • The inhaled spores grow and release toxic substances causing disease
    • This form of the disease occurred in 2001 as a result of anthrax being mailed as a weapon
  • Gastrointestinal anthrax
    • Eating undercooked meat contaminated with anthrax

Anthrax in humans is generally not considered contagious. Cutaneous anthrax is rarely spread by contact with an ulcer by another person.

What are the symptoms?

The symptoms of anthrax will vary depending upon which type of the disease is present:

  • Cutaneous anthrax
    • Symptoms begin in 1 to 7 days and healing takes 2 to 4 weeks
    • Initially an itchy but painless sore develops on the skin
      • Sore forms a blister and eventually a black ulcer
    • Complications: 20% may die without treatment since the infection can spread to the blood. The death rate is < 1% with treatment
  • Inhalation anthrax
    • Symptoms begin in in 1 to 7 days but may take up to a month
    • Fever
    • Malaise
    • Headache
    • Cough
    • Shortness of breath and chest pain
    • Shock
    • Complications: death occurs in 75% even with treatment
  • Gastrointestinal anthrax
    • Symptoms begin 1-7 days after exposure
    • Fever
    • Abdominal pain
    • Diarrhea (sometimes bloody)
    • Sores in the mouth
    • Nausea and/or vomiting
    • Complications: Death occurs in > 50% of those who do not receive antibiotic treatment but is < 40% with treatment.

How do you prevent it?

Anthrax may be prevented through several methods:

  • Anthrax vaccine
    • Available to military personnel and those at increased risk of contracting anthrax
  • Post-exposure preventive antibiotics
    • These may be given to exposed individuals who have not yet developed symptoms
    • Antibiotics are effective against the bacteria but not against the toxins which cause the complications of the infection.
  • Use Universal Precautions
    • Nitrile or vinyl gloves will protect workers from cutaneous anthrax exposure
    • OSHA does not recommend respirators for the vast majority of workers. However, when effective protection from anthrax spores [is needed], the CDC recommends the use of NIOSH-approved respirators that are at least as protective as an N95 respirator
  • Emergency Responders response to a bio-attack incident
    http://www.osha.gov/dep/anthrax/matrix/index.html

    • Workplace Risk Pyramid
      • Red Zone = Authorities confirm or suspect presence of anthrax spores
        • PPE used should be proportional to the risk anticipated for the task workers will do
        • Use modified Level C protection for clean-up of a known anthrax release where the agent was dispersed from a letter or package
        • Use Level B protection where anthrax spores may have been dispersed with an aerosol-generating device
        • Use Level A protection for a release via an unknown dispersal method or an ongoing aerosol-generating device
      • Yellow Zone = Contamination with anthrax spores is possible
        • Voluntary use of PPE including impermeable gloves (nitrile or vinyl) and N95 or greater respiratory filter
      • Green Zone = Contamination with anthrax spores is unlikely
        • Prudent work practices

What should you do if you are exposed to the disease or get the disease?

You should contact your infection control officer and seek medical attention if you have been exposed or suspect exposure to anthrax or if you develop symptoms of anthrax. Anthrax can be treated with various antibiotics, including penicillin, doxycycline and ciprofloxacin.

DIPHTHERIA

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What is it?

Diphtheria is a respiratory tract illness caused by the bacteria Corynebacterium diphtheria. This infection is rare in the United States because of routine childhood immunizations but is present in other countries such as Latin America, Asia and the Soviet Union. This bacteria can also cause a skin infection.

How can you get it?

Diphtheria is transmitted through respiratory droplets. When patients infected with the virus cough or sneeze, they exhale droplets that can be inhaled by people nearby. Rarely, the infection is spread through contact with contaminated objects, food or infected skin lesions. Risk factors for transmission include lack of immunization and crowded environments.

What are the symptoms?

Diphtheria bacteria infect the nose and throat creating a gray covering (pseudomembrane) that may block the airway. These bacteria produce toxins that may spread from the throat into the bloodstream and lead to life threatening complications. Symptoms start between 2 and 5 days after exposure.

The signs and symptoms of diphtheria may include:

  • Sore throat (mild to severe)
  • Drainage from the nose (watery or bloody)
  • Breathing difficulties
  • Barking cough (similar to that seen with Croup)
  • Fever
  • Skin ulcers are rare but can occur
  • Painful swallowing
  • No symptoms at all in some patients

Complications from diphtheria depend on the person and recovery is typically a slow process. The illness may be mild in some or life threatening in others. Complications that are more serious include inflammation of the heart muscles, airway obstruction, temporary paralysis and kidney damage. Death occurs in 5-10% of patients with respiratory diphtheria infection.

How do you prevent it?

Diphtheria is a vaccine preventable disease. Diphtheria, tetanus and pertussis are combined in one vaccination for children. Adults should receive the tetanus and diphtheria booster every ten years.

In addition to vaccination , you can help prevent the spread of diphtheria by:

  • Preventing contamination and performing decontamination of surfaces
  • Using Droplet and Universal Precautions
    • Assume patients with respiratory symptoms are contagious and provide masks for symptomatic patients
    • Limit the number of crew members having direct patient contact
    • Hand hygiene (wash with soap and water or using an alcohol based hand rub)
    • Personal protective equipment (PPE) (gloves, gowns, goggles, and respiratory protection). IAFF recommends P100 respirators for all patients with respiratory symptoms such as cough
    • Proper handling and disposal of contaminated instruments/devices and clothing

What should you do if you believe you have been exposed?

  • Notify your infection control officer
  • See a health care provider who can look for the grey covering in the throat and perform a culture to identify the bacteria.

Post exposure prophylaxis for anyone who has encountered diphtheria includes immunization with the diphtheria toxoid or a booster if already vaccinated. Treatment of suspected diphtheria is with an antitoxin as well as antibiotics such as penicillin. Symptoms can be improved with oxygen, bed rest, IV fluids as needed and a breathing tube.

HEPATITIS A VIRUS

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What is it?

Hepatitis A (also known as Infectious Hepatitis) is a disease that affects the liver. Hepatitis describes a group of diseases that cause inflammation of the liver. Inflammation occurs when tissues of the body become injured or infected, which can cause problems with organ function.

Hepatitis A is the most common type of viral hepatitis, usually seen among children or young adults. It can be a problem for fire fighters, especially if their meals are prepared by an infected person or they are infected by contaminated materials at a fire, hazardous materials incident, USAR, or SCUBA.

Hepatitis A is caused by the Hepatitis A Virus (HAV), one member of a group of viruses that cause this kind of disease. Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV) are other important members of this virus family.

How can you get it?

Hepatitis A is transmitted person-to-person via the fecal-oral route (through contact with small amounts of an infected person’s stool, usually due to inadequate hand-washing).

You can get HAV by:

  • Eating contaminated food (prepared by someone who is infected with HAV that did not wash their hands after using the bathroom)
  • Drinking unclean water or washing food in untreated water
  • By coming into contact with items and surfaces contaminated with HAV
  • Through openings in the skin such as cuts or abrasions. These opening can be visible or so small that they aren’t visible to the naked eye.
  • Through close personal contact (such as living in a home with someone who has this disease) or sexual contact, especially among men who have sex with men
  • Bloodborne transmission of hepatitis A is rare
  • Salive transmission has not been demonstrated

Firefighters are at risk of being exposed to HAV. Some specific jobs (ex. HazMat, USAR, SCUBA) place firefighters at greater risk of coming into contact with contaminated water. First responder duties, especially disaster response, also increase the chance that a firefighter will come into contact with contaminated water.

What are the symptoms?

While adults become infected with HAV less often than children, adults are much more likely to suffer health problems related to HAV. Children under 6 often have no symptoms and can be a silent source of infection spread. More than 80% of adults will have some symptoms of HAV infection. The signs and symptoms of Hepatitis A may include:

  • jaundice
  • fatigue
  • abdominal pain, loss of appetite, nausea, vomiting, diarrhea
  • dark yellow urine
  • fever

It takes about 15-50 days to develop symptoms of hepatitis A after exposure. Symptoms typically last two weeks or longer. Most patients recover on their own, but there average time lost from work is five weeks. Some of those that are infected may have relapsing symptoms over a six to nine month period. One in five infected adults gets sick enough to be hospitalized. Unlike Hepatitis B (HBV) or Hepatitis C (HCV), HAV does not usually cause long term health problems such as chronic infection or chronic liver disease.

How do you prevent it?

Hepatitis A is a vaccine preventable disease. The HAV vaccine has been available since 1995 and is recommended for certain high risk line jobs in NFPA 1581, Fire Department Infection Control Programs. The HAV vaccine can prevent disease two ways, either given before exposure or within 2 weeks after known exposure. Hepatitis A vaccine is given with 2 injections, six months apart. A combined Hepatitis A and Hepatitis B vaccine is also available and requires a series of three injections, given with 0, 1, and 6 month intervals.

Anyone exposed to hepatitis A that has not previously vaccinated can receive a shot of immune globulin (IG) to prevent infection. Post exposure IG provides less than two months protection. For adults younger than 40, post-exposure HAV vaccination is generally a better option because it can provide long term protection in those not previously vaccinated. After age 40, the CDC recommends immune globulin therapy for HAV.

You can help prevent the spread of HAV by:

  • Getting vaccinated if you are in a high risk job (ex. HazMat, USAR, SCUBA)
  • Using Universal Precautions
    • Hand hygiene (wash with soap and water or using an alcohol based hand rub)
    • Personal protective equipment (PPE) (gloves, gowns, masks and goggles that offer mouth, nose and eye protection)
    • Proper handling and disposal of instruments/devices and clothing contaminated with blood or body fluids
  • Make sure all your children are vaccinated for HAV (age 12 months and older)

What should you do if you are exposed to the disease or get the disease?

You should see a doctor or health care professional immediately if you think you may have been exposed to Hepatitis A Virus. The healthcare provider may offer you Hepatitis A vaccine or immune globulin therapy.

HEPATITIS B VIRUS

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What is it?

Hepatitis B is an infectious disease that is responsible for an estimated 4,000 to 5,000 deaths each year in the United States due to chronic liver disease, cirrhosis and liver cancer.

Hepatitis B is caused by the Hepatitis B Virus (HBV), one member of a group of viruses that cause this kind of disease. Hepatitis A Virus (HAV) and Hepatitis C Virus (HCV) are other important members of this virus family.

Hepatitis B is a serious threat to all healthcare providers. Blood infected with the HBV is much more infectious than HIV infected blood. Additionally, HBV is more common in the US than HIV with a greater proportion of the population infected with hepatitis B then with HIV.

How can you get it?

Hepatitis B is transmitted via contact with the blood or body fluids of a person infected with HBV.
You can get HBV by:

  • Exposure to blood through a needle stick or cut from sharp instrument
  • Direct contact with blood or open sores of an infected patient
  • Sharing personal care items with an infected person (ex. razors, toothbrushes)
  • Injection Drug Use, Sexual Activity, Mother-to-Child

Several groups are noted to have a high risk of hepatitis B, including parenteral (IV) drug abusers, heterosexuals with multiple partners, homosexual men, clients and staff in institutions for the developmentally disabled, prisoners, and hemodialysis center patients.

What are the symptoms?

The majority (>70%) of adults with acute HBV will have symptoms. Small children, under age 5, may have no symptoms at all. Signs and symptoms of acute HBV may include:

  • jaundice, dark urine, light colored bowel movements
  • fatigue
  • abdominal pain, loss of appetite, nausea, vomiting
  • joint pain
  • fever

Symptoms of acute hepatitis B usually develop within 90 days after exposure. Symptoms typically last a few weeks, but can last as long as 6 months . Hepatitis B (HBV) can cause long term health problems such as chronic infection or chronic liver disease.

Persons infected with the hepatitis B virus run the risk of developing severe health complications, including cirrhosis, liver cancer, liver failure, and death. They can also become a hepatitis B carrier and transmit infection to their partner and children.

How do you prevent it?

Hepatitis B is a vaccine preventable disease. For an unvaccinated person, the risk of contracting hepatitis B from a single exposure ranges from 6-30%. People who have received the hepatitis B vaccine and have developed immunity to the virus are at virtually no risk for infection. Hepatitis B vaccine provides greater than 90% protection to infants, children, and adults who receive a complete series of 3 doses.

The HBV vaccine is recommended for all firefighters in NFPA 1581, Fire Department Infection Control Programs. The 1991 OSHA Bloodborne Pathogen Standard requires employers to make the hepatitis B vaccine available free of charge to all workers at risk.

Hepatitis B vaccine is usually given as a series of 3-4 shots over a six month time period. A combined Hepatitis A and Hepatitis B vaccine is also available and requires given a series of three injections, given with 0, 1, and 6 month intervals.
You can help prevent the spread of HBV by:

  • Getting vaccinated
  • Sharps Safety
    • Training and consistent use of safer needle techniques and devices
    • Proper sharp disposal
  • Using Universal Precautions
    • Hand hygiene (wash with soap and water or using an alcohol based hand rub)
    • Personal protective equipment (PPE) (gloves, gowns, masks and goggles that offer mouth, nose and eye protection)
    • Proper handling and disposal of instruments/devices and clothing contaminated with blood or body fluids

What should you do if you are exposed to the HBV infected blood or body fluid?

Immediately following an exposure:

  • Wash needlesticks and cuts with soap and water
  • Flush splashes to the nose, mouth, or skin with water
  • Irrigate eyes with clean water, saline, or sterile irrigants

As soon as possible, report the exposure and seek medical care

  • If you are exposed to hepatitis B, it is an OSHA requirement to have blood drawn as soon as possible to determine your baseline serologic status. This test determines if you have protective antibodies.
  • If you do not have protective antibodies, your healthcare provider may decide to give you the vaccine and/or hepatitis B Immune Globulin (HBIG) for immediate protection.

While there is no cure for Hepatitis B, there are a number of medications that may be used to treat symptoms. Persons infected with hepatitis B should protect their liver from further damage, by getting immunized for hepatitis A, avoiding alcohol and having continuing medical care.

HEPATITIS C VIRUS

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What is it?

Hepatitis C is the most common bloodborne virus in the United States. More than 3 million Americans are living with chronic infection. Hepatitis C is responsible for an estimated 8,000 to 10,000 deaths each year in the US due to chronic liver disease (cirrhosis) and liver cancer. Hepatitis C is caused by the Hepatitis C Virus (HCV), one member of a group of viruses that cause this kind of disease. Hepatitis B Virus (HBV) is another important virus in this family. Hepatitis C is a concern for healthcare providers. Blood infected with the HCV is more infectious than HIV infected blood but not as infectious as HBV. Additionally, HCV is more common in the U.S. than HIV.

Hepatitis C is not transmitted efficiently through occupational exposures to blood, with an overall incidence of transmission of about 1.8 percent (range 0 – 7 percent). However, the risk is real. HCV infection is the most common chronic blood-borne infection in the United States (most not through occupational exposures,) and approximately 85 percent of HCV-infected persons develop chronic HCV infection. HCV infection is usually asymptomatic; it is often detected at the time of a routine physical examination (if routine liver-function tests are abnormal) or blood donation (donated blood is screened for HCV).

Post-Exposure Prophylaxis (PEP)

The Advisory Committee on Immunization Practices (ACIP) in 1994 concluded that the use of Immunoglobulins (antibodies) was not indicated after exposure to HCV, because antibodies were not shown to be effective.

The latest data suggest that treatment of acute hepatitis C with interferon (an immune system stimulant) may cure close to 100 percent of cases. Prior to the publication of this paper, it was noted that 15-25 percent of cases of acute hepatitis C resolve spontaneously, and thus no consensus was reached regarding treatment of acute infection.

How can you get it?

Hepatitis C is transmitted via contact with the blood or body fluids of a person infected with HCV.

You can get HCV by:

  • A needle stick from a bloody needle
  • A cut from a bloody sharp object
  • Infectious fluids entering through an open wound, scrape, broken cuticle, or chapped skin
  • Through mucous membranes, such as in the eye, nose, or mouth

Several groups are noted to have a high risk of hepatitis HCV including parenteral (IV) drug abusers, persons who received blood products before 1992, persons with HIV, and hemodialysis patients.

What are the symptoms?

Hepatitis C often shows no symptoms until significant liver damage is done. This is why you must get tested. For people who do show symptoms of acute HCV infection, these include:

  • Mild fever
  • Muscle or joint aches
  • Vague abdominal pain
  • Loss of appetite
  • Jaundice (yellow skin color)
  • Tea-colored urine and light clay-colored bowel movements

Many of these symptoms go undetected because they are so mild and can disappear completely. The majority of people infected with Hepatitis C do not notice symptoms until after the virus causes liver damage, as long as 10 or more years after initial infection.

A small number of people infected with HCV are able to clear the virus from their bodies. Hepatitis C becomes a chronic (life-long) infection in the majority (75-85%) of patients.

Signs and symptoms of liver disease from chronic HCV may include:

  • jaundice, dark urine, light colored bowel movements
  • fatigue
  • abdominal pain, loss of appetite, nausea, vomiting
  • easy bruising or excessive bleeding
  • swollen abdomen and/or ankles
  • joint pain

Persons with the chronic hepatitis C run the risk of developing severe health complications, including cirrhosis, liver cancer, liver failure, and death.

How do you prevent it?

There is currently no vaccine for Hepatitis C. The best ways for fire fighters and other first responders to prevent HCV transmission are to become educated and consistently use safe sharp practices, apply universal precautions and report any possible exposures. This is part of a comprehensive OSHA required program for Bloodborne pathogen exposures.

You can help prevent the spread of HCV through:

  • Sharps Safety
    • Training and consistent use of safer needle techniques and devices
    • Proper sharp disposal
  • Using Universal Precautions
    • Hand hygiene (wash with soap and water or using an alcohol based hand rub)
    • Personal protective equipment (PPE) (gloves, gowns, masks and goggles that offer mouth, nose and eye protection)
    • Proper handling and disposal of instruments/devices and clothing contaminated with blood or body fluids

What should you do if you are exposed to HCV infected blood or body fluid?

Immediately following any sharps injury or body fluid exposure:

  • Wash needlesticks and cuts with soap and water
  • Flush splashes to the nose, mouth, or skin with water
  • Irrigate eyes with clean water, saline, or sterile irrigants
  • Report the incident to your supervisor
  • Immediately seek medical treatment

Medical evaluation for a HCV exposure:

  • You will be evaluated for bloodborne pathogen exposure
  • If you are exposed to Hepatitis C, you should have blood drawn as soon as possible (within 7 days) for baseline testing for antibodies to HCV and liver function
  • The CDC recommends follow-up HCV and liver testing, options include
    • Anti-HCV antibody testing at 4-6 months after exposure, or
    • HCV RNA testing 4-6 weeks post-exposure
  • Since false positive results can occur, all positive anti-HCV antibody results should be confirmed by a second, different test (ex., recombinant immunoblot assay [RIBA™])

The goals of post-exposure medical care are (1) early identification of HCV infection and referral to liver specialists who can offer further management and (2) prevention of future exposures. Other than thoroughly cleaning the wound, there is no specific post-exposure treatment for Hepatitis C. Currently no vaccine for HCV is available. Immune globulin therapy and antiviral medications have not been proven useful and are not recommended.

What kinds of treatment are available for Hepatitis C?

Anyone infected with HCV should discuss all of their medical treatment options with a healthcare provider who specializes in treating hepatitis.

  • Acute HCV: While there is no specific medication to treat acute Hepatitis C infection, it is still very important to see you healthcare provider. Symptoms of acute HCV infection can usually be managed with rest, fluids, and adequate nutrition. Regular medical follow-up is critical to identify signs of liver disease as soon as these develop.
  • Chronic HCV: Treatments for chronic HCV are available. Combination therapy with two medicines, interferon and ribavirin, is most often used. It’s important to know that not every person with chronic Hepatitis C needs or will benefit from treatment. In some cases, these drugs may cause serious side effects.
  • All patients with HCV need to understand how to protect their liver from further damage by getting immunized for hepatitis A/B, avoiding alcohol, discussing all medications with their provider, and having continuing medical care.

HEPATITIS D VIRUS

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What is it?

Hepatitis D (HDV) is a viral infection that only infects individuals who are also infected with Hepatitis B virus. Approximately 5% of those with Hepatitis B also have Hepatitis D.

How can you get it?

Hepatitis D is transmitted just as Hepatitis B, through contact with the blood or body fluids of a person infected with HDV. The risk factors are similar:

  • Exposure to blood through a needle stick or cut from sharp instrument
  • Contact with blood or open sores of an infected patient to mucous membranes or broken skin
  • Sharing personal care items with an infected person (ex. razors, toothbrushes)
  • Injection Drug Use, Sexual Activity, Mother-to-Child

HDV presents in two different forms:

  • Co-infection Infection with HDV and HBV at the same time
  • Superinfection Infection with HBV first, then later infection with HDV

What are the symptoms?

HDV can worsen an acute or chronic Hepatitis B infection. The signs and symptoms of Hepatitis D may include:

  • Fatigue
  • Yellowing of the skin and eyes (called jaundice)
  • Abdominal pain
  • Nausea and/or vomiting

The symptoms typically last 2 to 3 weeks but complications of HDV infection include chronic liver inflammation in 10% of those infected. Complete liver failure may also occur. Those who experience a co-infection with HBV are likely to recover while those with a superinfection are more likely to develop chronic infection and liver failure.

How do you prevent it?

The best way to prevent Hepatitis D is to be vaccinated against Hepatitis B. You can help prevent the spread of HDV by following a comprehensive OSHA required program for Bloodborne pathogen exposures which includes the following:

  • Getting vaccinated against Hepatitis B
  • Prompt treatment of any Hepatitis B infection
  • Sharps Safety
    • Training and consistent use of safer needle techniques and devices
    • Proper sharp disposal
  • Using Universal Precautions
    • Hand hygiene (wash with soap and water or using an alcohol based hand rub)
    • Personal protective equipment (PPE) (gloves, gowns, masks and goggles that offer mouth, nose and eye protection)
    • Proper handling and disposal of instruments/devices and clothing contaminated with blood or body fluids

What should you do if you are exposed to the disease or get the disease?

Immediately following an exposure:

  • Wash needlesticks and cuts with soap and water
  • Flush splashes to the nose, mouth, or skin with water
  • Irrigate eyes with clean water, saline, or sterile solutions

As soon as possible, report the exposure and seek medical care:

  • Determining Hepatitis B status is important since the bloodborne pathogen hepatitis D is an incomplete virus that requires Hepatitis B infection.
    • If you are exposed to Hepatitis B, it is an OSHA requirement that you are offered an evaluation for bloodborne pathogen exposure.
    • This will include having blood drawn as soon as possible to determine your baseline serologic status. This test determines if you have protective antibodies.
    • If you do not have protective antibodies to Hepatitis B, your healthcare provider may decide to give you the vaccine and/or Hepatitis B Immune Globulin (HBIG) for immediate protection.

The medication alpha interferon has been used to manage some of the inflammation but there is no cure for Hepatitis D. Since Hepatitis D can be acquired following infection with Hepatitis B, those infected with Hepatitis B should protect their liver from further damage, by getting immunized for Hepatitis A, avoiding alcohol, avoiding risk factors listed above and having continuing medical care.

HERPES SIMPLEX VIRUS

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What is it?

Herpes simplex virus type 1 (HSV-1) is a common cause of cold sores around the mouth. Herpetic whitlow is an infection on the fingers involving exquisitely painful blisters that are caused by transfer of the virus from other areas of infection, most commonly cold sores or fever blisters, to the hands and fingers. Fire fighters may repeatedly encounter HSV infections as these are among the most common maladies affecting humans.

How can you get it?

The herpes virus is quite contagious and is transmitted in three ways:

  • Direct contact of open skin (a wound) with a herpes lesion
  • Contact with saliva that is contaminated with the herpes virus
  • Self-infection (for instance; nail biting in someone who has oral sores or fever blisters)

What are the symptoms?

Following an incubation period of 2-20 days, the signs and symptoms of herpetic whitlow include:

  • Pain, burning, tingling in infected finger
  • Redness
  • Swelling
  • Blisters or Vesicles filled with clear fluid
    • The vesicles resolve by first crusting and then healing in 7 – 10 days
  • Lymph nodes in the armpit may swell and become painful
The herpes simplex virus infection on the finger is known as herpetic whitlow (see above image). Grouped, fluid-filled or pus-filled, blisters are typical and usually itch and/or are painful.

Oral herpes infections are largely responsible for occupational exposure and appear as:

  • Blisters or ulcers in the mouth, gums, lips, throat and face
    • Blisters are filled with clear fluid
    • Skin around the blister is raised, red and painful
  • However, some individuals do not have symptoms but can still transmit the virus.

Complications that may occur with any herpes virus include:

  • Recurrence of the disease throughout a person’s life.
    • Recurrent episodes are typically triggered by stress, excess sun exposure, surgery, hormonal changes, and other illnesses.
  • Bacteria can infect the skin before the blisters heal if the skin is contaminated.
    • Never try to cut out any of these blisters as this may spread the infection or lead to a bacterial infection in addition to the viral one.
  • The virus can also spread to other areas of the skin and body.
    • A troubling fact is that “Herpes infection of the eye is a leading cause of blindness in the United States, causing scarring of the cornea.”

How do you prevent it?

Prevention:

  • Avoid direct contact with herpes sores
  • Using Universal Precautions
    • Use gloves for patient encounters, especially when managing oral secretions
    • Hand hygiene (wash with soap and water or using an alcohol based hand rub)

No treatment currently exists that will cure herpes infection. Antiviral medications such as acyclovir, famciclovir, and valacyclovir may help the symptoms go away sooner and decrease some of the pain.

What should you do if you are exposed to the disease or get the disease?

Any blisters near the eyes require professional medical attention and evaluation. Herpetic whitlow will resolve without treatment but medications for symptomatic relief are available. Acyclovir may be beneficial.

HUMAN IMMUNODEFICIENCY VIRUS (HIV)/ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS)

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What is it?

Acquired Immunodeficiency Syndrome (AIDS) is caused by the Human Immunodeficiency Virus (HIV). This virus damages the body’s immune system. Patients with AIDS, which is the final stage of HIV infection, have unusual diseases found in people with impaired immune systems such as Kaposi’s sarcoma, a type of cancer, and Pneumocystis carinii pneumonia. The HIV virus infects only selected cells in the body. The most important are infection-fighting white blood cells known as lymphocytes, specifically those lymphocytes known as CD4 T cells. HIV can also infect certain cells in the nervous system.

How can you get it?

HIV is transmitted by contact with blood or bodily fluids (such as semen, vaginal secretions, breast milk, wound exudates or saliva) of a person who is infected with the virus.

Occupational exposure can occur by:

  • Being stuck with a needle or another sharp object that contains the blood of an infected person.
  • Contact between broken skin, wounds or mucous membranes and HIV-infected blood or blood contaminated body fluids.
  • Being bitten by a person who has HIV. These cases occurred when there was severe trauma to the skin and the presence of blood. There is no risk of transmission if the skin remains intact.

Importantly, studies of health care workers have shown that the risk of becoming infected with HIV after a needle stick is very small, less than 1 percent, and the risk of transmission by splashing of mucous membranes is even less.

Non-occupational exposure can occur by:

  • Not using protection when having sex with a person who has HIV
  • Having multiple sexual partners
  • Having another sexually transmitted disease, which can increase the risk of contracting the infection during sex
  • Sharing needles, syringes, rinse water or other equipment that is used to prepare illicit drugs for injection
  • Being born to a mother who has the virus (This transmission can occur during pregnancy, birth or while breast-feeding)
  • Receiving a blood transfusion, blood products or organ transplants from a person who is infected with HIV (This risk is very small because blood products have been tested for HIV since 1985)

Please note that although theoretically transmission of HIV by saliva may occur, it is extremely rare. It is also important to note that HIV is not transmitted via tears, sweat or insects.

What are the symptoms?

The symptoms of HIV may range from an asymptomatic (which means that the person has no symptoms of a disease) carrier state to debilitating and even fatal disorders. Typically, the first symptoms of HIV include “flu-like” symptoms such as fever, fatigue, sore throat and headache. Because the symptoms are not very specific, the only way to know for sure if you are infected or not is to be tested.

How do you prevent it?

There is currently no HIV vaccine for clinical use. The best way for fire fighters and other first responders to prevent exposure to HIV is to become educated about the safety procedures in their workplace and consistently use universal precautions. These are part of a comprehensive OSHA required program for bloodborne pathogen exposure.

You can help prevent the spread of HIV through:

  • Sharps Safety
    • Training and consistent use of safer needle techniques and devices
    • Proper sharp disposal
  • Using Universal Precautions
    • Hand hygiene (wash with soap and water or using an alcohol based hand rub)
    • Personal protective equipment (PPE) (gloves, gowns, masks and goggles that offer mouth, nose and eye protection)
    • Proper handling and disposal of contaminated PPE
  • Know the safety procedures in your department
    • Ask your supervisor to see the written Exposure Control Plan, which should outline all the steps taken in your department to protect workers from blood borne pathogens
    • Attend the bloodborne pathogens training provided by your department

What should you do if you are exposed to HIV-infected blood or bodily fluids?

If you are stuck by a needle or other sharp or get blood or other potentially infectious materials in your eyes, nose, mouth or on broken skin:

  • Immediately flood the exposed area with water
  • If skin contact with blood or bodily fluid occurs, even if skin is not visibly soiled, wash your skin with antibacterial soap and water or use an alcohol-based sanitizer immediately
  • Flush splashes to the nose, mouth or skin with water
  • Irrigate eyes with clean water, saline or sterile irrigants
  • Report the exposure to your supervisor
  • Seek immediate medical attention

Medical Evaluation for HIV:

  • You will be evaluated for bloodborne pathogen exposure.
  • If you are exposed to HIV, you should have blood drawn as soon as possible after the exposure to determine your baseline status and periodically for at least 6 months after the exposure (i.e., at 6 weeks, 12 weeks, and 6 months)
  • Post-exposure prophylaxis (PEP) is currently recommended by the CDC to reduce the risk of HIV infection.
  • PEP should be started immediately after an exposure (within hours)
  • A 4-week course of two antiretroviral medications is recommended for most HIV exposures
    • Three or more antiretroviral medications are recommended for exposures that pose a greater risk of transmitting HIV
  • Differences in the side effects associated with the use of the drug may influence which combinations are given
    • Your health care provider can discuss the side effect profiles with you
  • If you take antiretroviral drugs for PEP, you should have a complete blood count, kidney and liver tests done when starting treatment and 2 weeks after starting treatment.

What kinds of treatment are available for HIV?

Although there is no cure for HIV if a person is confirmed to have the infection, there are treatment options that can help people with HIV live long and productive lives. The CDC publishes new guidelines on the treatment guidelines for people with HIV. With appropriate medications, the HIV infection is not eradicated, it is suppressed. Therefore, the primary goals for initiating antiretroviral therapy are to:

  • Reduce HIV-associated morbidity and prolong the duration and quality of survival
  • Restore and preserve immunologic function
  • Maximally and durably suppress place HIV viral load
  • Prevent HIV transmission to others

How does it progress?

HIV infection progresses through several stages. The most widely used classification includes the following stages: acute HIV infection, asymptomatic HIV infection, symptomatic HIV infection and AIDS. During acute HIV infection, the symptoms may be mild and flu-like, so that they may not detected by the infected patient. HIV antibody tests may not be positive yet. In asymptomatic HIV infection, patients also do not have symptoms, but their HIV antibody test will be positive and they can infect others. Once a person develops symptomatic HIV infection, they will show signs of the disease, which can vary greatly. As the disease progresses further, people are considered to have full-blown AIDS, the most severe form of the infection, when their T-cell count drops below 200 or they develop an AIDS-defining illness.

INFECTIOUS DIARRHEA (CAMPYLOBACTER, SALMONELLA, SHIGELLA, E. COLI)

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What is it?

Infectious diarrhea is caused by ingestion of bacteria such as Campylobacter, Salmonella, Shigella, or E. Coli. Fire fighters may acquire the infection following contact with an infected person.

How can you get it?

Infectious diarrhea is transmitted through contact with infected stool. Bacteria are spread through eating contaminated food or water or direct contact with infected stool. Bacteria can spread from person to person if someone does not wash their hands after a bowel movement and then touches other objects or someone else’s hands.

You can get infectious diarrhea by:

  • Eating meat or poultry contaminated with bacteria during processing of the food or preparation of the food
  • Drinking contaminated water
  • Consuming foods that have been unrefrigerated for too long (dairy products or mayonnaise containing foods such as coleslaw or potato salad)
  • Raw fish or oysters
  • Undercooked meats or eggs
  • Unwashed fruits or vegetables
  • Unpasteurized milk
  • A pet iguana or other lizards, turtles, or snakes (reptiles are carriers of salmonella)
  • Travel to countries without proper water or food sanitation

What are the symptoms?

The signs and symptoms of infectious diarrhea may include:

  • Sudden and severe diarrhea
  • Sometimes bloody diarrhea, especially with E. coli
  • Fever
  • Gas
  • Stomach cramping
  • Nausea and/or Vomiting
  • Muscle pain
  • Severe E. coli may reduce the amount of urine, make bloody urine or easy bruising

The time for symptoms to develop and resolve:

  • E. coli: Symptoms 1 – 3 days after infection; recovery is in 1 – 2 days
  • Campylobacter: Symptoms 2 – 4 days after exposure; lasts about a week
  • Salmonella: Symptoms in 8 – 48 hours and lasts 2 – 5 days
  • Shigella: Symptoms in 1 – 7 days and lasts 2 – 7 days

Depending on the bacteria, complications include dehydration, anemia, kidney failure, and meningitis. Rarely, Campylobacter infection is linked with Guillain-Barre syndrome which is a form of paralysis.

How do you prevent it?

Prevention:

  • Contact precautions
  • Careful hand washing
  • Do not eat or drink contaminated food or water.
  • Cook meats well, especially ground meats which are more likely to be contaminated.
  • If you own a reptile, wear gloves when handling the animal or its feces because animals can easily pass Salmonella to humans.

What should you do if you are exposed to the disease or get the disease?

You should see a health care provider if you have blood in your urine or stool. If you can not stay hydrated or your diarrhea persists you should also seek medical care. Your physician will perform a physical exam and may perform laboratory tests of your food and or stools to isolate the bacteria.

Treatment is directed at making the patient feel better and avoid dehydration. Antibiotics are typically not used as these infections usually resolve without them. Antibiotics may be used for more severe infections such as those that spread outside the gastrointestinal tract and severe Shigella infections. Antidiarrheal medication may prolong the infection by slowing the transit of the bacteria through the intestine.

These things may help you feel better if you have diarrhea:

  • Drink 8 to 10 glasses of clear fluids every day. Water is best along with the drinks noted below.
  • Drink at least 1 cup of liquid every time you have a loose bowel movement.
  • Eat small meals throughout the day, instead of three big meals.
  • Eat some salty foods, such as pretzels, soup, and sports drinks.
  • Eat some high potassium foods, such as bananas, potatoes without the skin, and watered-down fruit juices.

LICE

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What are they?

Lice are small parasites that live entirely on humans. Pediculosis is the term for an infestation of lice. The female lice hold on to skin or hairs and lay their eggs, called nits. Adult lice are the size of a sesame seed, have six legs, and are tan to greyish-white.

Both the adults and the immature larvae feed on human blood. The small bites from the lice are intensely irritating which leads to scratching and potential for secondary skin infections from bacteria on the skin.

There are three types of lice:
  • Body lice
(Pediculus humanus corporis)
  • Larger in size than head or pubic lice
  • Live in seams of clothing
  • Head lice
(Pediculus humanus capitis)
  • Live on scalp, eyebrows, eyelashes
  • Most common in children
  • Pubic lice
(Phthirus pubis; “crabs”)
  • Live in pubic area, occasionally on other coarse hair such as armpits or beard

Scabies is a skin disease caused by mites, a type of parasite, penetrating the skin to dig burrows. The mite lays its eggs underneath the skin in these burrows causing intense itching. The itching can lead to further breaks in the skin which can become infected. One type of scabies, crusted scabies, is a severe form that can occur in persons who are immunocompromised (have a weak immune system), elderly, disabled, or debilitated. It is also called Norwegian scabies. Persons with crusted scabies have thick crusts of skin that contain large numbers of scabies mites and eggs. Persons with crusted scabies are very contagious to other persons and can spread the infestation easily both by direct skin-to-skin contact and by contamination of items such as their clothing, bedding, and furniture.

How can you get infected?

Lice are transmitted by close direct contact with someone who has lice or with infected clothing, towels, or bedding. Lice crawl and cannot fly. You can get lice by:

  • Head-to-head contact with someone who has head lice
  • Re-using bedding and towels infected with lice
  • Sharing personal items such as hats, towels, brushes, or combs of someone who has lice

The mite that causes scabies is usually spread through prolonged, direct skin-to-skin contact. Scabies is common in crowded areas with poor sanitation. Outbreaks have occurred in prisons, nursing homes, and child care facilities. Occupational scabies is primarily a risk with exposure to patients with crusted scabies where transmission can occur even after brief skin-to-skin contact, such as a handshake.

What are the symptoms?

Intense itching is the main symptom. The lice, and symptoms, are typically found: along the scalp, at the waistband, in the armpits, at the bra strap, or anywhere clothing is tighter and closer to the body.

The signs and symptoms of lice may include:

  • Intense itching
  • Red bumps on skin
  • Areas where skin has been excessively scratched
  • Tiny white specks (eggs, or nits) on the bottom of hair shafts that are hard to remove
  • Itching may persist for 2 to 4 weeks after lice have been removed

One complication of pediculosis results from the intense itching that leads to scratching of the skin. Once the skin is scratched, small cuts form and can become infected with bacteria. These parasites are also highly contagious and other family members need to be evaluated and treated as well.

Body lice are known to spread epidemic typhus, trench fever, and louse-borne relapsing fever in conditions of unrest where good hygiene is not possible, such as war. Head and pubic lice do not spread disease.

Itching and skin rash from the immune system response to the mite are the most common symptoms. If a person has never had scabies before, symptoms may take as long as 4-6 weeks to begin. It is important to remember that an infested person can spread scabies during this time, even if he/she does not have symptoms yet. In a person who has had scabies before, symptoms usually appear much sooner (1-4 days) after exposure.

How do you prevent it?

Scabies can be prevented by personal protective equipment to prevent direct skin-to-skin contact. Individuals who have had skin-to-skin contact with an infested individual should notify their infection control officer and seek medical attention. Prophylactic treatment may be indicated, particularly for crusted scabies. Other individuals within the fire station should be evaluated for unrecognized cases. Scabies sometimes also can be spread by contact with items such as clothing, bedding, or towels that have been used by a person with scabies, but such spread is very uncommon, with the exception of crusted scabies. However, as noted below, good hygiene requires that bed linens and clothing be laundered after each use.

Infestation with body lice is unlikely to last on anyone who bathes regularly and who has at least weekly access to freshly laundered clothing and bedding. Head lice are less easily removed and are NOT an indication of poor hygiene, as simple shampoos will not remove the adults or nits.

Prevention:

  • Do not share personal items such as bedding, towels or combs
  • Launder community linens daily with hot water
  • Using Universal Precautions
    • Hand hygiene (wash with soap and water or using an alcohol based hand rub)
    • Proper handling and disposal of instruments/devices and contaminated clothing

What should you do if you are exposed to lice or scabies or get infected with them?

A physician can diagnose the presence of lice through an exam of hair, skin and clothing.

Improved hygiene and access to regular changes of clean clothes is the only treatment needed for body lice infestations.

Head lice can be diagnosed at home by finding the nits or adults along the scalp. Treatment is recommended even if only one egg is found.

For head or lice:

  • Use over-the-counter shampoos containing 1% permethrin; retreatment in 9 days to kill newly hatched eggs may be necessary
  • Prescription shampoos containing malathion 0.5% or benzyl alcohol are recommended if treatment with over-the-counter shampoos is not successful
  • Remove the nits (eggs)
    • Dishwashing detergent can help dissolve the ‘glue’ that helps nits stick
    • Nit combs are specially designed to remove the eggs
    • Repeat combing for nits in 7-10 days
  • Consult a physician if the medications fail or for any signs of skin infection

Pubic lice are also treated with the above shampoos

For all lice infestation:

  • Destroy or carefully wash infected clothing, bedding and towels in hot water (at least 130⁰ F), then machine dry using a hot cycle.
  • Items that cannot be washed in hot water must either be destroyed or sealed (suffocated) in plastic bags and not used for 10 – 14 days.
  • Treat all potentially infected sources to eliminate reinfection.
    • Lice can live for varying periods off the human host:
      • Body lice: 5 – 10 days
      • Head lice: 2 days
      • Pubic lice: 1 day

Scabies mites do not survive more than 2-3 days away from human skin. Spraying or fumigating office or living areas is unnecessary. Transmission can occur even after brief skin-to-skin contact, such as a handshake, with a person who has crusted (Norwegian) scabies. In general, a person who has skin-to-skin contact with a person who has crusted scabies would be considered a good candidate for treatment.

MEASLES

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What is it?

Measles, also called rubeola, is a highly contagious disease caused by a virus.

How can you get it?

Measles is spread by “airborne transmission” of droplets or small particles that remain infective over time and distance. So exposure can occur with close contact to an infected person who coughs or sneezes but also the virus may travel over long distances by air currents and be inhaled by individuals who have not had face-to-face contact with (or even been in the same room with) the infectious individual. Patients with measles are contagious for 4 days before to 4 days after the rash appears. 90% of the people close to a contagious patient will also become infected if not already immune. The virus can live on infected surfaces for up to 2 hours and touching a surface contaminated with viral particles and then touching one’s nose or mouth can also result in infection.

What are the symptoms?

The symptoms of measles begin about 7-14 days after exposure to the virus and include:

  • Fever
  • Cough
  • Runny nose
  • Sore throat
  • Conjunctivitis (red eyes)
  • 3-5 days after these symptoms, a red rash starts on the face and spreads down the back and trunk, as well as to the arms, hands, legs, and feet.

The complications of measles may include: ear infection, diarrhea, pneumonia, and/or inflammation of the brain (encephalitis). One or two of every 1000 children who get measles will die from it.

How do you prevent it?

Measles is now rare in the US; in 2009, only 71 cases of measles were reported. This is due to the success of vaccination programs. The measles vaccine (MMR) also vaccinates against mumps and rubella and is a routine childhood immunization. The MMR vaccine does not cause autism. Currently two doses are recommended in childhood.

According to the Healthcare Personnel Vaccination Recommendations PDF at http://www.cdc.gov/vaccines/vpd-vac/measles/vacc-in-short.htm, healthcare personnel born in 1957 or later who do not have evidence of prior vaccination should be tested for immunity. If not immune, vaccination with 2 doses of MMR, 4 weeks apart, is recommended. This document provides additional information for healthcare personnel born prior to 1957.

In addition to vaccination, you can help prevent the spread of measles by:

  • Ventilation since the measles virus spreads by the airborne route
  • Preventing contamination and performing decontamination surfaces
  • Using Universal Precautions
    • Assume patients with respiratory symptoms are contagious and provide masks for symptomatic patients
    • Limit the number of crew members having direct patient contact
    • Hand hygiene (wash with soap and water or using an alcohol based hand rub)
    • Personal protective equipment (PPE) (gloves, gowns, NIOSH-certified respirators that are N95 or higher, and goggles that offer mouth, nose and eye protection). , IAFF recommends P100 respirators for all patients with respiratory symptoms such as cough

What should you do if you believe you have been exposed to measles?

If you are immune, contact your infection control officer to document a work-related exposure. If you are not immune, contact the infection control officer and healthcare provider to discuss possible testing and treatment. If given within 72 hours of exposure to measles, measles vaccine may provide some protection. In most settings, postexposure vaccination is preferable to use of immune globulin. Immune globulin can be administered within 6 days of exposure and is indicated for susceptible household or other close contacts of patients with measles, particularly contacts younger than 1 year of age, pregnant women and immunocompromised persons, for whom risk of complications is highest.

The CDC has specific guidance for outbreaks in medical settings: all personnel born during or after 1957 should receive two doses of MMR vaccine, unless they have documentation of measles immunity. Personnel born before 1957 without documentation of measles immunity should receive one dose of MMR. Serologic screening of healthcare workers during an outbreak to determine measles immunity is not generally recommended, because stopping measles transmission requires the rapid vaccination of susceptible healthcare workers.

Susceptible personnel who have been exposed to measles should be relieved from patient contact and excluded from the facility from the 5th to the 21st day after exposure, regardless of whether they received vaccine or immune globulin after the exposure. Personnel who become ill should be relieved from all patient contact and excluded from the facility for 4 days after they develop rash.

MENINGITIS

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What is it?

Meningitis is an inflammation of the membranes that cover the brain and spinal cord. It has many causes but the most important infectious ones are caused by bacteria and viruses. The bacteria, Streptococcus pneumoniae and Neisseria meningitidis, are the leading causes of bacterial meningitis. Haemophilus influenzae type b (Hib) was the main cause of bacterial meningitis in the past but children are now vaccinated for it.

How can you get it?

Meningitis spreads from person-to-person through respiratory droplets from coughing and sneezing. Procedures such as suctioning can also cause droplet spread. Droplets can be travel through the air approximately 3 feet. Patients with meningitis are most likely to spread the infection at the time they are diagnosed.

What are the symptoms?

Symptoms usually begin 3-7 days after exposure to bacteria and include:

  • Fever
  • Headache
  • Stiff neck

Other symptoms may include:

  • Nausea
  • Vomiting
  • Photophobia (sensitivity to light)
  • Altered mental status such as decreased awareness and/or confusion

Complications are generally from bacterial meningitis and include sepsis (infection in the blood stream) particularly from Neisseria meningitidis. This is a very serious infection and can cause death. Infants less than one month of age are at highest risk for severe infection.

How do you prevent it?

Meningitis is prevented through vaccination. There are vaccines for three bacteria that can cause meningitis: Neisseria meningitidis, Streptococcus pneumoniae and Haemophilus influenzae type b (Hib). However, pre-placement vaccinations are only recommended for microbiologists working with Neisseria meningitidis and are not routinely recommended for healthcare personnel.
You can help prevent the spread of meningitis by:

  • Preventing contamination and performing decontamination of surfaces
  • Using Universal Precautions
    • Assume patients with respiratory symptoms are contagious and provide masks for symptomatic patients
    • Limit the number of crew members having direct patient contact
    • Hand hygiene (wash with soap and water or using an alcohol based hand rub)
    • Personal protective equipment (PPE) (gloves, gowns, and respiratory protection). IAFF recommends P100 respirators for all patients with respiratory symptoms such as cough

What should you do if you believe you have been exposed?

Antibiotics are given to close contacts of patients with meningitis caused by Neisseria meningitidis. “Close contacts include household members, child care center contacts, and anyone directly exposed to the patient’s oral secretions (e.g., through kissing, mouth-to-mouth resuscitation, endotracheal intubation, or endotracheal tube management).” Antibiotics should start as soon as possible after exposure, within 24 hours if possible.

METHICILLIN RESISTANT STAPHYLOCOCCUS (MRSA)

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What is it?

Staphylococcus Aureus (also known as ”Staph” or S. Aureus) is a common type of bacteria that normally lives on the skin and sometimes in the nasal passages of healthy people. MRSA stands for Methicillin Resistant Staphylococcus Aureus and is a type of S. Aureus that is resistant to a family of antibiotics (penicillin and related agents), normally used to treat this sort of infection. MRSA is an emerging, increasingly important issue for fire fighters and all people.

Under the microscope, S. Aureus looks like clusters of grapes:

Scanning electron micrograph (SEM) depicted numerous clumps of methicillin-resistant Staphylococcus aureus bacteria, commonly referred to by the acronym, MRSA; Magnified 9560x. (Credit: CDC/Janice Haney Carr) via: http://www.sciencedaily.com/releases/2011/02/110210184328.htm

While 25% to 30% of people in the United States carry staph bacteria in the nose, less than 2% carry MRSA.

How can you get it?

There are two types of MRSA infections:

  • Healthcare-associated MRSA (HA-MRSA) infections happen in people:
    • Who are or have recently been in a hospital or other health-care facility (nursing homes, dialysis centers, long term acute care centers)
    • Have recently had surgery or other procedures
  • Community-associated MRSA (CA-MRSA) infections happen in :
    • Otherwise healthy people, who have not recently been in the hospital
    • In athletes who play contact sports and/or share equipment or personal items (such as towels or razors)
    • Children and workers in daycare facilities
    • Military personnel and other people who live in other crowded and/or unsanitary conditions (military barracks, dormitories, correctional facilities)

People with weak immune systems have more serious infections. The number of CA-MRSA cases is increasing.

You can get MRSA:

  • When your skin comes in “contact with someone’s (MRSA) skin infection or personal items they have used, like towels, bandages, or razors that touched their infected skin”
  • Through openings in the skin such as cuts or abrasions (These opening can be visible or so small that they aren’t visible to the naked eye)
  • By coming into contact with items and surfaces contaminated with MRSA
  • By living or working in crowded situations, where there is close contact with others
  • When you or others around you have poor hygiene

Fire Fighters are at risk of being exposed to both types of MRSA.

What are the symptoms?

In the community, most MRSA infections are skin infections. Here is how a skin infection may appear:

Source : http://www.cdc.gov/mrsa/mrsa_initiative/skin_infection/mrsa_photo_010.html

Source : http://www.cdc.gov/mrsa/mrsa_initiative/skin_infection/mrsa_photo_006.html
  • These infections usually start off as small red, white and/or yellow bumps that look like pimples, boils or spider bites. (http://www.mayoclinic.com/health/mrsa/DS00735/DSECTION=symptoms)
  • These bumps can be red, swollen, warm to the touch, painful and can have pus or other body fluids draining from them.
  • These skin infections commonly occur where there as breaks in the skin (cuts and abrasions) and body areas with hair (e.g., back of neck, groin, buttock, armpit, beard area of men).
  • These bumps can quickly turn into deep, painful abscesses that require drainage by a medical professional.

Severe infections can occur if this infection is not treated properly and/or if your immune system isn’t working properly. In these situations, the MRSA skin infection can get worse and can spread to the rest of the body (including the blood, bones, lungs and other organs). The symptoms in severe infections vary by location and extent of infection.

How do you prevent it?

  • Using Universal Precautions
    • Hand hygiene (wash with soap and water or using an alcohol based hand rub)
    • Personal protective equipment (PPE) (gloves, gowns, masks and goggles that offer mouth, nose and eye protection)
    • Proper handling and disposal of instruments/devices and clothing contaminated with blood or body fluids
  • Keep yourself and your environment clean by:
    • Using other barriers, like clothing or towels, between you any surfaces you share with others (like gym equipment)
    • Showering immediately after having direct skin contact with others
    • Decontaminating regularly used clothing and equipment;Check out the “Environmental Cleaning & Disinfecting for MRSA” section of the CDC at this link http://www.cdc.gov/mrsa/environment/index.html for more details.
    • Keeping personal items personal. Avoid sharing personal items such as towels, razors, clothing, bedding
  • Wound Hygiene
    • Avoid contact with other people’s wounds or bandages.
    • Keep cuts and scrapes clean and covered with a bandage until healed.

What should you do if you are exposed or have symptoms of MRSA disease?

You should see a doctor or health care professional if you:

  • Start developing worsening symptoms of skin infections (described above in the What are the symptoms? section)
  • If you develop fever or feel unwell with this skin infection

The doctor may:

  • Get a culture of some of the pus/drainage from your infection
  • Perform nasal swabs
  • Offer abscess drainage and/or specialized antibiotics for MRSA infections

A doctor in a hospital can provide advanced care for severe MRSA infections. Do not try to drain an abscess on your own because this may increase the risk of worsening or spreading the infection.
You should:

  • Keep cuts, scrapes, boils and draining skin areas clean and covered with a bandage until healed, so that you do not infect others or spread the infection to other parts of your own body.
  • Properly dispose of these bandages, as per your fire department’s infection/exposure control plan.

MRSA is not on the current CDC Nationally Notifiable Infectious Disease List. However, it is a reportable disease in many states, so check with your local state health department to see if you should report this in your state.

MIDDLE EAST RESPIRATORY DISEASE SYNDROME (MERS)

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What is it?

A severe viral respiratory illness caused by a coronavirus called MERS-CoV. The first reported case of MERS occurred in Saudi Arabia in 2012. Over 350 people have been infected, and about 30% of those infected have died. Thus far, all cases have been associated with residence or travel to the Middle East.

Have there been any cases reported in the US?

Yes, on May 2, 2014, the Centers for Disease Control and Prevention confirmed the first U.S. case in Indiana. The individual had recently traveled from Saudi Arabia to the United States. This is the only confirmed case of MERS in the United States to date.

How can you get it?

MERS-CoV has been shown to spread between people who are in close contact.[1] Transmission from infected patients to healthcare personnel has also been observed. Clusters of cases in several countries are being investigated.

What are the symptoms?

The majority of people infected with MERS present with severe respiratory illness with symptoms of fever, cough, and shortness of breath. About 30% of infected patients have died. However, some people may develop only a mild respiratory illness.

Am I at risk?

At this time, only people with recent travel to the Middle East or close contact with an infected patient are considered to be at risk for developing MERS. If you are concerned that you have been exposed to MERS, you should contact your healthcare provider and notify your supervisor.

How do you prevent it?

CDC advises that people follow these tips to help prevent respiratory illnesses:

  • Be aware of the symptoms of MERS-CoV. When responding to calls for patients with fever and shortness of breath, ask if the patient has recently traveled to the Middle East or has been in contact with an ill individual who recently traveled to the Middle East.
  • Be aware of any increases in respiratory complaints within your service area and report any suspicions to your supervisor.
  • Protect yourself with standard contact, droplet, and airborne precautions by using personal protective equipment including gloves and, at minimum, an N-95 respirator.
  • Use Universal Precautions
    • Assume patients with respiratory symptoms are contagious and provide masks for symptomatic patients
    • Limit the number of crew members having direct patient contact
    • Personal protective equipment (PPE) (gloves, gowns, and respiratory protection). IAFF recommends P100 respirators for all patients with respiratory symptoms such as cough

Is there a vaccine available?

No, there is no vaccine currently available.

What should you do if you are exposed to the disease or get the disease?

You should contact your infection control officer and seek medical attention if you have been exposed or suspect exposure to MERS or if you develop symptoms of MERS. There are no specific treatments recommended for illnesses caused by MERS-CoV. Medical care is supportive and to help relieve symptoms.

MONONUCLEOSIS

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What is it?

Mononucleosis, also known as mono or the “kissing disease,” is a viral infection. Epstein-Barr virus (EBV) or cytomegalovirus (CMV) are causes.

How can you get it?

Mono is transmitted by saliva and close contact with someone who has the virus or is recovering from the infection. The virus can remain dormant and otherwise healthy people can spread the virus without being sick or knowing they are contagious. Mono is not normally transmitted in the air or through blood.

You can get Mono by:

  • Sharing utensils or cups with someone who has the virus
  • Kissing someone who has the virus

What are the symptoms?

Mono develops slowly with symptoms similar to most viral infections; however, the symptoms persist for several weeks longer than other infections:

  • Fever
  • Sore throat
  • Swollen lymph glands (particularly in the neck)
  • Fatigue
  • Headache
  • Muscle aches
  • Enlarged spleen and/or liver

The time to develop symptoms after contracting Mono is from 4 to 6 weeks. The illness is self-resolving but the duration varies. Typically, the fever will resolve in 10 days. The swollen lymph nodes and spleen will improve in 4 weeks. The fatigue should improve within 1 to 2 months.

Complications of Mono can be serious and include:

  • Inflammation and rupture of the spleen
  • Inflammation of the liver with resulting yellowing of the skin (jaundice)
  • Inflammation of the testicles (orchitis)
  • Anemia
  • Meningitis
  • Death is rare but may occur in patients with weak immune systems

How do you prevent it?

  • No special precautions or isolation procedures are recommended
  • Do not share utensils or cups without proper washing

What should you do if you are exposed to the disease or get the disease?

You should see a healthcare professional if you have a typical viral illness that persists for more than 10 days. If any symptoms progress to include abdominal pain, weakness, yellowing of the skin, difficulty breathing or stiff neck you should seek immediate medical attention.

Your physician will diagnose Mono through a physical exam and may obtain blood work. A rapid diagnostic test called a “mono spot” is available for confirmation and antibody testing distinguishes a new infection from a prior infection.

The treatment for Mono is to make the patient feel better since there is no specific medication to combat the virus.

  • For the sore throat: gargle with warm salt water
  • For the fatigue: get plenty of rest
  • For the fever: use acetaminophen or ibuprofen
  • For the muscle pain: use acetaminophen or ibuprofen

Patients are not to participate in contact sports if the spleen is enlarged as significant bleeding can occur if the spleen is hit and ruptures.

MUMPS

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What is it?

Mumps is a viral disease that affects mainly children. However, it does occur in adolescents and adults.

How can you get it?

Mumps is spread from person-to-person through respiratory droplets from coughs or sneezes. Mumps is most common in the winter and spring months. Patients with mumps are contagious from 1-2 days before the parotid glands (a salivary gland) swell to about 5 days after swelling starts. The virus can survive on surfaces and touching a surface contaminated with viral particles and then touching one’s nose or mouth can also result in infection.

What are the symptoms?

The symptoms of mumps begin about 16-18 days after exposure to the virus and include:

  • Fever
  • Headache
  • Muscle aches
  • Fatigue
  • Followed in a few days by swelling and tenderness of the salivary glands under the ears or jaw on one or both sides of the face (parotitis)

The complications of mumps are rare but may include: temporary or permanent deafness (1 in 20,000 cases), inflammation of various organs such as the brain, or, in those who have reached puberty, of the testicles, ovaries, and/or breasts.

How do you prevent it?

Mumps is now uncommon in the US due to the use of the measles, mumps, and rubella vaccine. However, the 2-dose effectiveness of the vaccine is estimated at 80% to 90% which means that there are enough US residents who remain susceptible to the virus to result in periodic outbreaks, most recently in 2009. Students in close quarters, such as at summer camps and college, are at highest risk. The vaccine (MMR) also vaccinates against measles and rubella and is a routine childhood immunization. The MMR vaccine does not cause autism. Currently two doses are recommended in childhood.

Vaccination of healthcare personnel (2 doses of a live mumps virus vaccine) is recommended unless the worker was born during or after 1957 and has:

  • Documented administration of 2 doses of live mumps virus vaccine OR
  • Laboratory evidence of immunity OR
  • laboratory confirmation of disease.

The CDC also recommends at least 1 dose of a live mumps virus vaccine for unvaccinated workers born before 1957 who do not have physician-diagnosed mumps or laboratory evidence of mumps immunity.

In the event of a mumps outbreak, CDC recommends providing 2 doses of a live mumps virus vaccine to unvaccinated healthcare personnel born before 1957 who do not have evidence of mumps immunity.

Workers who get these vaccinations do not need to be excluded from work in the days immediately following vaccination.

In addition to vaccination, you can help prevent the spread of measles by:

  • Preventing contamination and performing decontamination of surfaces
  • Using Universal Precautions
    • Assume patients with respiratory symptoms are contagious and provide masks for symptomatic patients.
    • Limit the number of crew members having direct patient contact
    • Hand hygiene (wash with soap and water or using an alcohol based hand rub)
    • Personal protective equipment (PPE) (gloves, gowns, and respiratory protection), IAFF recommends P100 respirators for all patients with respiratory symptoms such as cough

What should you do if you believe you have been exposed to mumps?

Exposure = being within 3-6 feet of a patient with a diagnosis of mumps without the use of proper personal protective equipment.

What you do if you were this close depends on whether you are immune to mumps (see prevention criteria above).

  • If you are immune, you may continue working but must report any signs or symptoms of illness during the incubation period, from 12 until 25 days after exposure.
  • If you have had one of the required two vaccinations (partially immune), you should receive a 2nd dose as soon as possible, but no sooner than 28 days after the first. You may continue working but must report any signs or symptoms of illness during the incubation period, from 12 until 25 days after exposure.
  • If you are not immune, you should get vaccinated. You should not work from the 9th-26th days after the exposure. This applies even if you get your first dose of the vaccine as soon as you learn of the exposure.
  • You must be off work if you develop mumps.

NOVEL INFLUENZA

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What is it?

Novel influenza refers to a new strain of influenza that forms through the rearrangement of viral gene segments. Two viruses infect a host and the gene segments “resort” between them. The novel strains of influenza can cause pandemics when the human virus acquires a novel segment from the influenza virus of a nonhuman species. This reassortment leads to forms of the virus that are new to the human immune system and can cause pandemics such as those of 1957, 1968, and 2009.

Subtypes of influenza A:

  • The subtypes of influenza A differ based on surface proteins. These are called hemagglutinin (HA) and neuraminidase (NA). There are 25 different types of HA and NA which may combine into different subtypes.

Avian Influenza (Bird Flu)

  • This type of influenza A naturally occurs among wild birds.
    • The virus is highly contagious among birds but does not usually cause illness in wild birds. Infected birds pass the virus through direct contact, mucus or excretions/waste. When transmitted to chickens and turkeys, these domesticated birds become sick. The illness in poultry can be very mild or may devastate the flock.
  • The risk of avian influenza transferring to people occurs through direct contact with either the infected poultry or contaminated surfaces. This type of avian influenza is rarely contagious among humans. Since Influenza A is known to undergo novel changes, however, concern does exist that bird flu may become contagious between humans.
    • Avian (H5N1) Flu is a subtype of influenza A virus that is highly contagious among birds but rarely infects humans. Scientists follow H5N1 flu closely because it has the potential to cause a deadly pandemic. So far, the majority of human H5N1 cases have occurred outside of the United States.
    • The severity of illness, high mortality, and limited transmissibility may be explained by the higher affinity of the H5N1 viruses to cells of the lower but not upper respiratory tract.

Swine Influenza

  • This type of influenza A naturally occurs among wild birds.
    • Swine Influenza is a common respiratory disease of pigs leading to outbreaks of influenza in these pigs. The virus spreads through close contact and any contaminated objects the pigs contact.
    • Pigs are a source of reassortment as discussed above. Swine, avian and human influenza viruses can infect them. The reassortment (or gene swapping) leads to a mix of swine, human and/or avian influenza viruses. Four main influenza type A virus subtypes in pigs are: H1N1, H1N2, H3N2, and H3N1.
    • Vaccines are available to prevent swine flu in pigs. The human seasonal flu virus now has a component specific to the H1N1 of 2009.
    • Swine flu viruses do not normally infect humans. However, sporadic human infections with swine flu have occurred. Prior to 2009, the CDC received reports of approximately one human infected with swine influenza virus every one to two years in the U.S.. From April 15, 2009 to July 24, 2009, a total of 43,771 confirmed and probable cases of novel influenza A (H1N1) infection” were reported in the US States.

How can you get it?

The major way that influenza viruses are transmitted is though droplet spread. When people infected with flu virus cough, sneeze or talk they produce droplets that can land in the mouth, eyes or noses of people nearby. Less commonly, a person might also get the flu through indirect contact, by touching a contaminated surface or object and then touching their own mucous membranes (mouth, eyes or nose).

Most healthy adults can infect others beginning one day before symptoms develop and up to five to seven days after becoming sick. Several groups are noted to have a high risk of transmitting influenza viruses, particularly school age children (ages 5 to 19) and their parents. Healthcare workers, including first responders, also have significant potential to transmit the virus through multiple patient contacts.

  • Swine influenza cannot be transmitted to humans by eating pork.

What are the symptoms?

Symptoms of novel influenzas are similar to those of the seasonal influenza

  • Fever (not everyone with flu will have a fever)
  • Feeling feverish or having chills
  • Cough, sore throat and runny or stuffy nose
  • Muscle or body aches
  • Headaches
  • Fatigue
  • Vomiting or diarrhea

Although most healthy people recover from the flu within 1 week, certain groups are at high risk for serious complications. Elderly people, young children, pregnant women and people with certain chronic illnesses (asthma, heart disease, diabetes) are more likely to become seriously ill and possibly die from influenza.

How do you prevent it?

CDC recommends a yearly flu vaccine as the first and most important step in protecting against flu viruses. About 2 weeks after vaccination, antibodies that provide protection against influenza virus infection develop in the body. Annual influenza vaccine is recommended for all firefighters in NFPA 1581, Fire Department Infection Control Programs. Emergency responders need to be vaccinated with the seasonal flu vaccine every year. Currently, there are two kinds of flu vaccine available in the US:

  • The “flu shot” — an inactivated vaccine (containing killed virus) is approved for use in people older than 6 months, including healthy people and people with high risk chronic medical conditions
  • The nasal-spray flu vaccine — a live vaccine (containing weakened viruses) that does not cause the flu (sometimes called LAIV for “live attenuated influenza vaccine”; or FluMist®). Nasal vaccines are approved for use in healthy, non-pregnant people 2-49 years of age

In addition to vaccination, you can help prevent the spread of influenza by:

  • Staying home from work and school if you are experiencing flu-like symptoms
  • Creating or promoting good ventilation
  • Decontamination
    • Practicing decontamination procedures will protect you, your crew and your family from indirect contact. Viruses and bacteria can live for up to two hours or longer on surfaces such as radios, doorknobs and equipment.
  • Using Universal Precautions
    • Assume patients with respiratory symptoms have the flu
    • Strictly limit the number of crew members having direct patient contact
    • Hand hygiene (wash with soap and water or using an alcohol based hand rub)
    • Personal protective equipment (PPE) (gloves, gowns, NIOSH-certified respirators N95 or higher, and goggles that offer mouth, nose and eye protection)
    • Provide masks for symptomatic patients

What should you do if you believe you have influenza?

  • Stay home from work or school when you are sick
  • Contact your healthcare provider to discuss possible testing and treatment
    • Because many respiratory illnesses, such as the common cold, have symptoms similar to the flu, it can be difficult to diagnose influenza. If you develop flu-like symptoms and are concerned about your illness, especially if you are at high risk for complications of the flu, it is important to contact your healthcare provider.
    • Tests to diagnose influenza are most effective if performed within the first 2 or 3 days of illness.
    • Antiviral treatments for influenza work best when started within 2 days of symptom onset. While most people do not require medication, antiviral therapy can be very important in certain situations (hospitalized patients, high risk groups, severe complications).

PERTUSSIS

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What is it?

Pertussis, also known as whooping cough, is caused by the bacteria Bordetella pertussis. In 2008, more than 13,000 cases of pertussis were reported and many other cases were never reported.

How can you get it?

Pertussis is highly contagious. It spreads from person-to-person through respiratory droplets from coughing, sneezing, or talking and procedures such as bronchoscopy or suctioning. Droplets can travel through the air approximately 3 feet. Patients with pertussis are most likely to spread the infection during the early symptoms (runny nose, mild fever and cough) and in the first 2 weeks after coughing starts.

What are the symptoms?

Pertussis symptoms usually begin 7-10 days after exposure to the bacteria. Early symptoms can last for 1 to 2 weeks and usually include:

  • Runny nose
  • Low-grade fever
  • Mild, occasional cough
  • Apnea – a pause in breathing (in infants)

During the next stage, severe coughing fits with “whooping” occurs. Coughing can be so severe that vomiting occurs. Coughing episodes can continue for 10 weeks or more.
The whooping sound can be heard at http://www.pkids.org/diseases/pertussis.html

Complications are most severe in infants and include pneumonia, seizures, apnea, encephalopathy (infection around the brain) and death. More than half of infants less than one year old who get pertussis must be hospitalized. In teenagers and adults, complications are much less severe and include pneumonia and rib fractures from severe coughing; hospitalization is uncommon.

How do you prevent it?

Pertussis is prevented through vaccination. The recommended vaccine is DTaP which is a combination vaccine for diphtheria, tetanus and pertussis. Children need five DTaP shots. A sixth dose is now recommended at age 11 or 12 years. Healthcare personnel should receive a single dose of Tdap if they have not previously received Tdap and regardless of the time since last Td (tetanus and diphtheria) dose.

In addition to vaccination, you can help prevent the spread of pertussis by:

  • Preventing contamination and performing decontamination of surfaces
  • Using Universal Precautions
  • Assume patients with respiratory symptoms are contagious and provide masks for symptomatic patients
  • Limit the number of crew members having direct patient contact
  • Hand hygiene (wash with soap and water or using an alcohol based hand rub)
  • Personal protective equipment (PPE) (gloves, gowns, and respiratory protection). IAFF recommends P100 respirators for all patients with respiratory symptoms such as cough

What should you do if you believe you have been exposed?

Pertussis prevention (post exposure prophylaxis) with antibiotics can be provided to close contacts of patients and to exposed persons who are at high risk for having severe pertussis (infants aged <1 year, persons with suppressed immune systems or other diseases such as chronic lung disease or cystic fibrosis).

Exposure includes:

  • Face-to-face exposure within 3 feet of a symptomatic patient
  • Direct contact with respiratory, oral, or nasal secretions from a symptomatic patient (e.g., cough, sneeze, sharing food and eating utensils, mouth-to-mouth resuscitation, or performing a medical examination of the mouth, nose, and throat)
  • Shared the same confined space in close proximity with a symptomatic patient for >1 hour

Some health care workers still get pertussis even though they have been vaccinated. Therefore, in 2011, the CDC’s Advisory Committee for Immunization Practices recommended antibiotic prophylaxis for all health care workers who have unprotected exposure to pertussis and are likely to expose a patient at risk for severe pertussis (e.g., hospitalized neonates and pregnant women). They recommended that all other health care workers either receive postexposure antibiotic prophylaxis or be monitored daily for 21 days after pertussis exposure and treated if they develop signs and symptoms of pertussis.

Antibiotic treatment information can be found at http://www.cdc.gov/pertussis/about/diagnosis-treatment.html which has a link to the Centers for Disease Control and Prevention’s Recommended antimicrobial agents for the treatment and postexposure prophylaxis of pertussis: 2005 CDC guidelines. (MMWR 2005;54[No. RR-14]).

PLAGUE (BUBONIC/PNEUMONIC)

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What is it?

Plague is a bacterial infection caused by Yersinia pestis, a bacteria carried in rodents, such as rats and mice, and their fleas. Plague is rare in the United States but has been found in California, Arizona, Colorado and New Mexico.

There are three manifestations of plague:

  • Bubonic plague — an infection of the lymph nodes
  • Pneumonic plague — an infection of the lungs
  • Septicemic plague — an infection of the blood

How can you get it?

Rodents carry the disease but their fleas spread plague between rodents. People acquire the bacteria when bitten by an infected flea or by handling an animal that has the bacteria. Pneumonic plague can be transmitted from human to human via respiratory droplets.

Risk factors include:

  • Exposure to rodents in areas where plague is present
  • Recent flea bite

What are the symptoms?

The signs and symptoms of plague vary depending on which form of plague occurs:

  • Bubonic plague
    • Fever
    • General ill feeling
    • Muscle pain / aching
    • Lymph node swelling (called a bubo and typical of plague)
      • Typically found near the site of the flea bite
  • Pneumonic plague
    • Fever
    • Difficulty breathing
    • Cough (can be quite severe)
    • Bloody mucus
  • Septicemic plague
    • Fever
    • Abdominal pain
    • Bleeding into organs

Complications: Bubonic plague, if untreated, may spread to the blood causing septicemic plague or the lungs causing pneumonic plague. Both may result in death. Recovery from plague is significantly improved with the initiation of antibiotics in the first 24 hours of infection. Without treatment, 50% of people with bubonic plague die and almost all with pneumonic plague die. Treatment reduces the death rate to 50%.

How do you prevent it?

  • A vaccine for plague is not available in the US
  • Environmental control
    • Eliminating food and shelter for rodents in and around homes and work places
    • Approved and appropriate insecticides to kill fleas during wild animal plague outbreaks
    • Appropriately treat pets (dogs and cats) for fleas
  • Using Droplet and Universal Precautions
    • Assume patients with respiratory symptoms are contagious and provide masks for symptomatic patients
    • Limit the number of crew members having direct patient contact
    • Hand hygiene (wash with soap and water or using an alcohol based hand rub)
    • Personal protective equipment (PPE) (gloves, gowns, goggles, and respiratory protection). IAFF recommends P100 respirators for all patients with respiratory symptoms such as cough
    • Proper handling and disposal of contaminated instruments/devices and clothing
    • Preventing contamination and performing decontamination of surfaces
  • Emergency Responders response to a bio-attack incident
    (http://www.osha.gov/SLTC/plague/index.html#emergency)

    • What personal protective equipment
      • Recommendations for personal protective equipment are based on the anticipated level of exposure risk associated with different response situations
      • Half-mask or full face air-purifying respirators with particulate filter efficiencies ranging from N95 (for tuberculosis) to P100 (for hazards such as hantavirus) as a minimum level of protection
      • Emergency first responders typically use self-contained breathing apparatus (SCBA) respirators…which provides the highest level of protection against airborne hazards when properly fitted and used.
        SCBA respirators are used when hazards and airborne concentrations are either unknown or expected to be high.
    • How should workers decontaminate themselves
      • Decontamination of protective equipment and clothing is essential to remove any particles before taking off the gear. Equipment can be decontaminated using soap and water, and 0.5% hypochlorite solution (one part household bleach to 9 parts water) can be used as appropriate or if gear had any visible contamination.
      • Note that bleach may damage some types of firefighter turnout gear (one reason why it should not be used for biological agent response actions).
      • After taking off gear, response workers should shower using copious quantities of soap and water

What should you do if you believe you have been exposed?

  • Notify your infection control officer
  • See a health care provider
  • Post-exposure prophylaxis with antibiotics for health care workers with close contact to pneumonic plaque patients should be considered. Typical antibiotics include, tetracyclines, chloramphenicol or one of the effective sulfonamides.

POLIOMYELITIS

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What is it?

Poliomyelitis, commonly referred to as polio, is caused by infection with poliovirus. The initial infection occurs in the gastrointestinal tract but then spreads to lymph nodes and the nervous system. The illness can lead to can lead to partial or full paralysis. Due to the polio vaccine, this disease no longer occurs in the US.

How can you get it?

Polio is spread by person-to-person contact and only affects humans. Transmission occurs by contact with infected respiratory mucus or by contact with infected feces. You can get polio by:

  • Eating or drinking contaminated food

What are the symptoms?

The symptoms of polio vary depending on which pattern of the disease a person has. A vast majority of those infected have subclinical infection while few will develop nonparalytic or paralytic polio.

The signs and symptoms of subclinical polio last approximately 72 hours and may include:

  • No symptoms in some
  • Headache
  • General discomfort
  • Sore throat
  • Vomiting

The signs and symptoms of nonparalytic polio last approximately 1-2 weeks and may include:

  • Diarrhea
  • Fatigue
  • Irritability
  • Leg pain (particularly in the calf muscles)
  • Fever
  • Muscle stiffness or spasms
  • Rash

The signs and symptoms of paralytic polio may not resolve and include:

  • Drooling
  • Muscle pain, contractions, spasms
  • Muscle weakness (especially on only one side)
  • Abnormal sensations
  • Breathing difficulty
  • Bloating and/or constipation

The time to develop symptoms once infected with the virus varies from 5-35 days with an average of 7-14 days.

Complications include paralysis, pneumonia, loss of intestinal function, high blood pressure, kidney and bladder infections. Post-polio syndrome can develop decades after the initial infection and present as weakness in various muscles.

How do you prevent it?

Polio is a vaccine preventable disease. Between 1840 and the 1950s, polio was a worldwide epidemic. Since the development of polio vaccines in the 1950s-60s, polio has been eliminated in a number of countries. The disease still exists in some developing countries and can be transmitted to unvaccinated travelers. The oral vaccine is used in various countries throughout the world but the injection is the only form available in the United States. Four doses of polio are given for full vaccination, typically during childhood.

Prevention:

  • Make sure you have completed your full vaccination series
  • Using Universal Precautions
    • Hand hygiene (wash with soap and water or using an alcohol based hand rub)
    • Personal protective equipment (PPE) (gloves, gowns, masks and goggles that offer mouth, nose and eye protection).
    • Proper handling and disposal of instruments/devices and clothing contaminated with blood or body fluids.
  • Make sure all your children are vaccinated for Polio (age 2, 4, 6 months and 4 years)

What should you do if you are exposed to the disease or get the disease?

Contact your health care provider if you have not been vaccinated and you are in contact with someone who has developed poliomyelitis. Brain or spinal cord involvement is a medical emergency that may result in paralysis or death (usually from respiratory difficulties) and needs to be evaluated by medical professionals.

Treatment for polio may be unnecessary for many as the disease can result in no symptoms. Those with nonparalytic or paralytic polio may need medical supportive care in the form of antibiotics, pain control, physical therapy and possibly life-saving respiratory interventions.

RABIES

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What is it?

Rabies is a viral infection from the Rhabdoviridae family that is usually deadly once symptoms progress. Fortunately, rabies is rare in the United States and Canada and can be prevented by post-exposure treatment if started early. It is mainly a disease of animals.

How can you get it?

Rabies is spread through infected saliva. The virus enters the body through a bite or contact with broken skin or mucous membranes, and then travels to the brain. Once in the central nervous system, the virus causes swelling which leads to the symptoms listed below.

Dog bites are a common cause of rabies in developing countries but rarely result in rabies in the United States. Vaccinations of household animals have contributed greatly to this control. However, wild animals may still transmit the disease, including bats, raccoons, foxes and skunks.

You can get rabies by:

  • Bites from infected animals
  • Rare cases of saliva from an infected animal coming in contact with open wounds or mucous membranes, such as the mouth or eyes, have been reported
  • Rare cases of aerosol transmission have been reported

What are the symptoms?

Rabies symptoms do not occur immediately. There is an incubation period of time before onset of symptoms. This period can vary in different people but the average time is 1-3 months.

The signs and symptoms of rabies may include:

  • Fever, headache, general weakness similar to most viral infections

These symptoms progress over time to include:

  • Drooling
  • Convulsions
  • Exaggerated sensation at the bite site
  • Loss of muscle function and spasms
  • Agitation and/or excitation
  • Decreased awareness, hallucinations
  • Swallowing difficulty

Complications: Once the symptoms appear, the person rarely survives the disease, even with treatment. Death from respiratory failure usually occurs within 7 days after symptoms start.

How do you prevent it?

Rabies is a preventable viral infection.

  • Avoid contact with animals you do not know.
  • Pre-exposure vaccinations are for those in a high-risk job (ex. animal control and wildlife officers or those who frequently travel to countries with a high rate of rabies).
  • Make sure all your pets receive the proper immunizations.

What should you do if you are exposed to the disease or get the disease?

If bitten or scratched by an animal, try to gather the following information (enlist the help of others nearby if applicable):

  • Location of the accident
  • Type of animal involved (domestic pet or wild animal)
  • Type of exposure (cut, scratch, licking of open wound)
  • Part of the body involved
  • Number of exposures
  • Whether or not the animal has been immunized against rabies
  • Whether or not the animal is sick or well – if “sick,” what symptoms were present
  • Whether or not the animal is available for testing or quarantine

Do not try to capture the animal yourself. Instead, call your local animal control authorities. The animal can be watched for signs and symptoms of rabies over a ten-day period. Alternately, authorities will euthanize the animal to enable immunofluorescence testing of the brain tissue. Within hours, this test can determine if the animal had the rabies virus.

Immediately following exposure:

  • Clean the wound thoroughly with soap and water. Wound cleansing is especially important in rabies prevention since, in animal studies, thorough wound cleansing alone without other post-exposure prophylaxis has been shown to markedly reduce the likelihood of rabies.
  • If possible, irrigate with a virucidal agent such as povidine-iodine solution.
  • Most bite wounds are not closed with stitches as this may increase the chance for infection. Report the incident to your supervisor and/or infection control officer.
  • Immediately seek medical treatment.

Medical evaluation for an exposure:

In addition to wound cleaning, for non-immunized individuals (which includes most fire fighters and EMS personnel) this includes:

  • A post-exposure vaccination is available as 4 doses over 14 days.
  • Human rabies immunoglobulin (HRIG) is given as a one-time injection around the bite on the day the bite occurred.

There is no known cure once the symptoms of rabies infection have started.

RUBELLA

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What is it?

Rubella, also known as German measles, is caused by a virus. It is now uncommon in the U.S., with fewer than 500 cases per year.

How can you get it?

Rubella spreads from person-to-person through respiratory droplets from coughs or sneezes. Patients with rubella are contagious for 7 days before and 7 days or longer after onset of rash. The incubation period averages 14 days and ranges from 12 to 23 days.

What are the symptoms?

The symptoms of rubella begin about 5-7 days after exposure to the virus. Symptoms are often mild and as many as 50% of infections may not have symptoms. When present, symptoms may include:

  • Fever
  • Rash – starts on the face and progresses down the body to the feet and lasts about 3 days
  • Lymphadenopathy (enlarged lymph nodes) in the head and neck may last several weeks

In older children and adults, symptoms may include a 1-5 day prodrome (days preceding the rash) with low-grade fever, malaise, lymphadenopathy, and upper respiratory symptoms. Muscle and joint pain is common in adults.

Complications: If a pregnant woman is infected with rubella, birth defects, including deafness, cataracts, heart defects, microcephaly, and liver and spleen damage, may occur in the fetus. If the mother is infected in the first 3 months of pregnancy, the chance of a birth defect is at least 20% and the chance of some adverse effect on the offspring is as high as 85%. In contrast, risks are much lower if infection occurs in the last 3 months of the pregnancy. Infection during pregnancy may also result in fetal death or premature delivery. Arthritis, generally lasting less than a month, is common in adult women. Encephalitis occurs in 1 in 6000 cases and bleeding (hemorrhage) into the brain, kidneys or gastrointestinal tract occur in about 1 in 3000 cases.

How do you prevent it?

Rubella is prevented through vaccination. The vaccine (MMR) also prevents measles and mumps and is a routine childhood immunization. The MMR vaccine does not cause autism. Currently two doses are recommended in childhood.

Vaccination of healthcare personnel is recommended for workers born during or after 1957 unless they have:

  • documented administration of 2 doses of MMR or, up to age 13, MMRV (MMR + varicella) vaccine OR
  • laboratory confirmation of rubella disease or immunity

The CDC also recommends at least 1 dose of the MMR vaccine for unvaccinated workers born before 1957 who do not have laboratory evidence of rubella immunity (2 doses are generally given to ensure protection to the other viruses in this vaccine).

In a rubella outbreak, CDC recommends providing one dose of the MMR vaccine to unvaccinated healthcare personnel who do not have evidence of immunity.

Workers who get these vaccinations do not need to be excluded from work in the days immediately following vaccination.
In addition to vaccination, you can help prevent the spread of rubella by:

  • Preventing contamination and performing decontamination of surfaces
  • Using Universal Precautions
    • Assume patients with respiratory symptoms are contagious and provide masks for symptomatic patients
    • Limit the number of crew members having direct patient contact
    • Hand hygiene (wash with soap and water or using an alcohol based hand rub)
    • Personal protective equipment (PPE) (gloves, gowns, and respiratory protection). IAFF recommends P100 respirators for all patients with respiratory symptoms such as cough

What should you do if you believe you have been exposed to rubella?

The MMR vaccine should be given within three days of exposure to non-immune, non-pregnant individuals. Exposed susceptible personnel should be excluded from duty from day 5 after the first exposure to day 21 after last exposure, regardless of post-exposure vaccine.

SEVERE ACUTE RESPIRATORY SYNDROME (SARS)

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What is it?

Severe Acute Respiratory Syndrome (SARS) is a respiratory infection that is caused by a virus, the SARS-associated coronavirus (SARS-CoV). First reported in Asia in 2003, the virus quickly spread globally, infecting 8,098 people and resulting in death in 774 in that outbreak.

How can you get it?

The virus is thought to spread by respiratory droplets (droplet spread) produced when an infected person coughs or sneezes. This requires close person-to-person contact since these droplets are only propelled a short distance (generally up to 3 feet) through the air. Infection occurs when droplets are deposited on the mucous membranes of the mouth, nose, or eyes of persons who are nearby. Patients with SARS are infectious when they have symptoms including fever and cough.

The virus also can spread when a person touches a surface contaminated with infectious droplets and then touches his or her mouth, nose, or eye(s).

Since this is a relatively new virus, it is possible that spread through the air (airborne spread) occurs.

What are the symptoms?

Symptoms begin about 2-7 days after exposure to the virus and may include:

  • Fever
  • Body aches
  • Headache
  • Diarrhea in 10 to 20 % of patients
  • Mild respiratory symptoms at the beginning of the illness that may progress to dry coughing after 2 to 7 days

The severity of illness is highly variable, from mild illness to death.
Complications: pneumonia is common; death occurred in almost 10% of patients in the 2003 epidemic.

How do you prevent it?

Minimizing exposure is essential for SARS since no vaccine is available. According to Supplement I: Infection Control in Healthcare, Home, and Community Settings of the CDC’s Public Health Guidance for Community-Level Preparedness and Response to Severe Acute Respiratory Syndrome (SARS) Version 2 (http://www.cdc.gov/sars/guidance/I-infection/occupational.html)

Employers should have a surveillance system in place to ensure that workers who may have had exposure to SARS-CoV are identified and monitored and that those who develop illness receive appropriate care. This system may include the following activities:

  • Establish a process to identify exposed personnel. Possible mechanisms include self-reports, sign-in sheets, or logs.
  • Instruct personnel who have unprotected contact with patients with SARS-CoV disease or who have early symptoms of SARS-CoV disease to immediately notify occupational health, infection control, or a designee.
  • Develop a system to identify healthcare personnel who provided care to a patient who was later identified as having SARS-CoV disease.

The CDC has written specific guidance for patient transport by EMS personnel in IV. Infection Control for Prehospital Emergency Medical Services (EMS) of the Supplement I: Infection Control in Healthcare, Home, and Community Settings of the CDC’s Public Health Guidance for Community-Level Preparedness and Response to Severe Acute Respiratory Syndrome (SARS) Version 2 (http://www.cdc.gov/sars/guidance/I-infection/prehospital.html). The following are essential for Patient Transport:

  • Transport personnel should be notified in advance when SARS is suspected in a patient needing emergency transport
  • Prehospital care personnel should follow the updated Standard Precautions recommendations to prevent the spread of respiratory infections described in III.B above. These include promoting respiratory hygiene/cough etiquette and using Droplet Precautions, in addition to Standard Precautions, for all patients with symptoms of a respiratory infection.

Key emergency vehicle transport factors:

  • Involve the fewest EMS personnel required
  • Family members and other contacts of SARS patients should not ride in the ambulance if possible.
  • When possible, use vehicles that have separate driver and patient compartments that can provide separate ventilation to each area. Close the door/window between these compartments before bringing the patient on board. Set the vehicle’s ventilation system to the non-recirculating mode to maximize the volume of outside air brought into the vehicle. If the vehicle has a rear exhaust fan, use it to draw air away from the cab, toward the patient-care area, and out the back end of the vehicle. Some vehicles are equipped with a supplemental recirculating ventilation unit that passes air through HEPA filters before returning it to the vehicle.
  • If a vehicle without separate compartments and ventilation must be used, open the outside air vents in the driver area and turn on the rear exhaust ventilation fans to the highest setting. This will create a negative pressure gradient in the patient area.
  • If possible, place a surgical mask on the patient to contain droplets expelled during coughing. If this is not possible (i.e., would further compromise respiratory status, difficult for the patient to wear), have the patient cover the mouth/nose with tissue when coughing.
  • Oxygen delivery with a non-rebreather face mask may be used to provide oxygen support during transport. If needed, positive-pressure ventilation should be performed using a resuscitation bag-valve mask, preferably one equipped to provide HEPA or equivalent filtration of expired air.
  • If a patient has been mechanically ventilated before transport, HEPA or equivalent filtration of airflow exhaust should be available. (EMS organizations should consult their ventilator equipment manufacturer to confirm appropriate filtration capability and the effect of filtration on positive-pressure ventilation.)
  • Cough-generating procedures (e.g., mechanical ventilation, nebulizer treatment) should be avoided during prehospital care.

Personal Protective Equipment:

  • Prehospital care providers who directly handle a patient with SARS-CoV disease or who are in the compartment with the patient should wear PPE as recommended for Standard, Contact, and AII Precautions. These include the following:
    • Disposable isolation gown, pair of disposable patient examination gloves, eye protection (i.e., goggles or face shield).
    • Respiratory protection (i.e., N-95 or higher-level respirator) IAFF recommends P100 respirators for all patients with respiratory symptoms such as cough
  • Personnel in the driver’s compartment who will have no direct patient contact should wear an N-95 or higher-level respirator during transport.
  • Drivers who also provide direct patient care should remove all PPE, with the exception of the respirator, and perform hand hygiene after completing patient care and before entering driver’s compartment to avoid contaminating the compartment.

Safe Work Practices:

  • Avoid touching one’s face with contaminated gloves.
  • Avoid unnecessary touching of surfaces in the ambulance vehicle.
  • Arrange for the receiving facility staff to meet the patient at the ambulance door to limit the need for EMS personnel to enter the emergency department in contaminated PPE.
  • Remove and discard PPE after transferring the patient at the receiving facility and perform hand hygiene. Treat used disposable PPE as medical waste.

Post-Transport Management of the Contaminated Vehicle:

  • Follow standard operating procedures for the containment and disposal of regulated medical waste.
  • Follow standard operating procedures for containing and reprocessing used linen. Wear appropriate PPE when removing soiled linen from the vehicle. Avoid shaking the linen.
  • Clean and disinfect the vehicle in accordance with standard operating procedures. Personnel performing the cleaning should wear a disposable gown and gloves (a respirator should not be needed) during the clean-up process; the PPE should be discarded after use. All surfaces that may have come in contact with the patient or materials contaminated during patient care (e.g., stretcher, rails, control panels, floors, walls, work surfaces) should be thoroughly cleaned and disinfected using an EPA-registered hospital disinfectant in accordance with manufacturer’s recommendations.
  • Clean and disinfect reusable patient-care equipment according to manufacturer’s instructions.

What should you do if you believe you have been exposed?

According to Supplement I: Infection Control in Healthcare, Home, and Community Settings of the CDC’s Public Health Guidance for Community-Level Preparedness and Response to Severe Acute Respiratory Syndrome (SARS) Version2 (at: http://www.cdc.gov/sars/guidance/I-infection/occupational.html)

Management of asymptomatic healthcare workers with unprotected high-risk exposures

An unprotected high-risk exposure occurs when a healthcare worker is in a room with a SARS patient during an aerosol-generating procedure or event and the recommended infection control precautions are either absent or breached. If a healthcare worker has an unprotected high-risk exposure but has no symptoms of SARS-CoV disease, the worker:

  • Should be excluded from duty (e.g., administrative leave) for 10 days after the date of the last high-risk exposure.”
  • Should be actively monitored for the development of fever and/or respiratory symptoms for 10 days after the date of the last high-risk exposure.

Management of asymptomatic healthcare workers with unprotected exposures that are not high risk

Unprotected exposures that are not high risk occur when a healthcare worker is in a room or patient-care area with a SARS patient (not during a high-risk procedure) and the recommended infection control precautions are either absent or breached. If a healthcare worker has an unprotected, non-high-risk exposure and has no symptoms of SARS-CoV disease, the healthcare worker:

  • Need not be excluded from duty.
  • Should be vigilant for the development of fever and/or respiratory symptoms (i.e., measure and record body temperature twice daily for 10 days following the date of last unprotected exposure, and immediately notify the healthcare facility if symptoms develop.)
  • Should be actively monitored for the development of fever and lower respiratory symptoms before reporting to duty.

Surveillance of asymptomatic healthcare workers who have cared for SARS patient(s) but have no known unprotected exposures

  • Instruct workers to be vigilant for the development of fever and/or respiratory symptoms, measure and record body temperature twice daily throughout the 10-day period following the date of last protected contact with a SARS patient, and immediately notify the healthcare facility if symptoms develop.
  • Implement active follow-up surveillance of these workers for 10 days following the last protected exposure

Management of symptomatic healthcare workers

  • Any healthcare worker who has cared for or been exposed to a SARS patient and who develops fever and/or respiratory symptom(s) within 10 days after exposure or patient care should:
    • Immediately contact infection control, occupational health or designee in each facility where s/he works; and
    • Report to the predetermined location for clinical evaluation. (During periods of increased SARS activity in the healthcare facility and/or community, this recommendation extends to all symptomatic personnel working in the facility, regardless of whether they have had contact with a SARS patient.)
  • Any healthcare worker who develops symptoms or fever while at work should immediately put on a surgical mask and notify the appropriate facility contact (e.g., occupational health, infection control, or other designee) and then report to the designated location for clinical evaluation.
  • Symptomatic healthcare personnel should be managed in accordance with the recommendations in Clinical Guidance on the Identification and Evaluation of Possible SARS-CoV Disease among Persons Presenting with Community-Acquired Illness.

Supplement D: Community Containment Measures, Including Non-Hospital Isolation and Quarantine of the Public Health Guidance for Community-Level Preparedness and Response to Severe Acute Respiratory Syndrome (SARS) Version 2 (http://www.cdc.gov/sars/guidance/D-quarantine/index.html) and the local health department should be consulted for decisions regarding activity restrictions outside the workplace for workers in all the above categories.

SMALLPOX

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What is it?

Smallpox is a disfiguring and often-deadly disease caused by the variola virus. The pox part of smallpox is derived from the Latin word for ‘spotted’ and refers to the raised bumps that appear on the face and body of an infected person. There is no specific treatment for smallpox and the only effective way of preventing the disease is vaccination. As a result of vaccination, smallpox as a disease occurring in nature was officially eradicated in 1980. Vaccination against smallpox was then stopped until the threat of biological attack brought vaccination back to certain populations.

How can you get it?

Smallpox is transmitted through droplets in air from face-to-face contact, direct contact with infected bodily fluids or contaminated objects such as bedding. Insects or animals do not carry this virus. The most infectious period is while a person has the rash until the last scab falls off.

What are the symptoms?

The pox part of smallpox is derived from the Latin word for “spotted” and refers to the raised bumps that appear on the face and body of an infected person. The incubation period is 7 to 17 days.

The signs and symptoms of smallpox may include:

  • High fever
  • General ill-feeling (malaise)
  • Backache
  • Rash
    • Initial red spots that become raised bumps, pus-filled blisters and finally scab over in a few weeks
    • Bumps and blisters start in the mouth and spread to cover the entire body from the head moving quickly down to the toes. All lesions are at the same stage of progression. Chickenpox looks roughly similar but the lesions are more superficial, vary with spots, bumps and blisters present at the same time in the same area over the body

Variola Major is the most severe and most common form of smallpox with a fatality rate of 30%. Variola Minor is the less severe and less common form of smallpox with a fatality rate less than 1%.

Complications include disfiguring scars where the blisters healed, skin infections, pneumonia, brain swelling and blindness

Pictures from the CDC are included below to illustrate the differences between smallpox lesions and the lesions of chickenpox:

Smallpox –
Same stage of all the lesions as well as a depression in the middle of each lesion
Chickenpox –
Presence of red spots & blisters together

How do you prevent it?

Smallpox is a vaccine preventable disease. The vaccine does not actually contain the smallpox virus but a similar virus called “vaccinia”. The vaccination cannot give a person smallpox since the viruses are different. However, there are serious complications and contraindications associated with smallpox vaccination. See the Vaccinia pages for more information.

The vaccination process involves the use of a two-pronged needle that holds a droplet of vaccine. The needle pierces the skin several times to produce a sore and a few drops of blood indicate the skin was properly punctured. The vaccination results in a typical progression to a blister and then a scab as seen in this picture. A booster is needed every 10 years.

  • These people should get the vaccine:
    • Laboratory staff working with smallpox viruses
    • Members of the smallpox response teams
    • Military personnel directed to receive the vaccination
Pictures of smallpox vaccination progression and healing over 21 days
  • If there is a known or suspected smallpox bioterrorism event anyone directly exposed to the smallpox virus should be vaccinated
  • Some people are at risk of serious complications if they receive the vaccine. These include anyone with eczema, suppressed immune systems, pregnant, breastfeeding or with specific heart conditions

In addition to vaccination, you can help prevent the spread of smallpox by:

  • Preventing contamination and performing decontamination of surfaces. Use disinfectants such as bleach and ammonia to clean contaminated surfaces.
  • Using Droplet, Contact and Universal Precautions
    • Assume patients with respiratory symptoms are contagious and provide masks for symptomatic patients.
    • Limit the number of crew members having direct patient contact.
    • Cover skin lesions to prevent aerosolization or contact.
    • Hand hygiene (wash with soap and water or using an alcohol based hand rub)
    • Personal protective equipment (PPE) (gloves, gowns, goggles, and respiratory protection).IAFF recommends P100 respirators for all patients with respiratory symptoms, such as cough.
    • Proper handling and disposal of contaminated instruments/devices and clothing.
    • Even those vaccinated against smallpox should use these precautions. The vaccination may offer some but not 100% protection against extremely high viral loads or against bioterrorism and “a genetically engineered virus.”
    • Use respiratory hygiene/Cough etiquette
    • Research has shown that airborne smallpox droplets may travel 6 feet or more from the source.Therefore, the following ambulance features should be used as available:
      • Operate ambulance or vehicle ventilation systems in nonrecirculating mode and bring in as much outdoor air as possible.
      • Operate rear exhaust fan during transport, if available; air should flow from the front of vehicle, over the patient, and out the rear exhaust fan.
      • Use recirculating ventilation units with HEPA filters when available.

What should you do if you are exposed to the disease or get the disease?

  • Notify your infection control officer.
  • See a health care provider who can distinguish the skin lesions from chickenpox

There is no specific treatment for smallpox infection. If an infected person receives the smallpox vaccine within 4 days after exposure this may lessen the severity of the illness.

TETANUS

What is it?

Tetanus is an infection of the nervous system caused by the bacteria Clostridium tetani (C. tetani). Spores of C. tetani live in soil, dust, and manure and can enter the body through breaks in the skin from puncture wounds, lacerations, etc. Once in the body, the spores release bacteria that produce a toxin. The toxin causes painful muscular contractions and rigidity, usually within 7 to 21 days of infection. Tetanus infection is also called lockjaw because the muscle rigidity can be so severe that the jaw becomes tightly closed.

Populations at high risk for tetanus include those with an acute injury who were:

  • Inadequately vaccinated or with unknown vaccination history
  • Adults aged ≥ 60 years
  • Adult diabetics
  • Injection-drug users

How can you get it?

C. tetani in the environment may enter the body through a break in the skin. Contact with soil, dust, and animal or human feces can all result in exposure. Tetanus does not spread by person to person contact.

What are the symptoms?

Symptoms of tetanus may include:

  • Stiffness in the neck and abdomen from muscle spasms
  • Difficulty swallowing
  • Painful contractions of muscle groups (tetany)
  • Lockjaw
  • Drooling
  • Excessive sweating
  • Fever
  • Irritability
  • Uncontrolled urination or defecation

Tetanus can be fatal if left untreated. Hypoxia (lack of oxygen) caused by spasms in the throat or lung muscles may lead to irreversible brain damage.

How do you prevent it?

Immunization is the key to tetanus prevention. A booster shot of Td vaccine should be given every 10 years.

What should you do if you believe you have been exposed to tetanus?

High risk wounds include those that:

  • occurred outdoors
  • had contact with soil
  • occurred in an individual who has not received a tetanus booster (vaccine) within 5 years or is not sure of his/her vaccination status

A fire fighter or other emergency response personnel who has received a wound should:

  • Cleanse the wound immediately
  • Report the exposure it as soon as possible to the infection control officer and/or medical director and see a healthcare provider

An examining health care provider must determine the time since the individual’s last immunization. If the fire fighter sustained a significant or contaminated wound, he or she should receive an additional booster shot, if a tetanus toxiod shot has not been received within 5 years prior to the injury.

TUBERCULOSIS

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What is it?

Tuberculosis (TB) is a serious infectious disease that usually affects the lungs, but can infect any part of the body. TB infection is caused by the bacterium Mycobacterium tuberculosis (MtB). Although TB was once well controlled in the US, since the mid-1980s it has become an increasingly important public health problem. An estimated 10 to 15 million Americans are infected with the TB bacteria and have the potential to develop active disease in the future.

Populations at high risk of contracting new TB infections include:

  • Close contacts of a person with active (infectious) TB
  • Immigrants from areas of the world with high TB rates
  • Babies and children under 5 with a positive TB test
  • Persons who live or work in group facilities (homeless shelters, correctional institutions, nursing homes, hospitals), and injection drug users
  • Persons with medical conditions or receiving treatments that weaken the immune system: HIV/AIDS, substance abuse, silicosis, diabetes, end-stage kidney disease, organ transplants, head and neck cancer and patients receiving cancer chemotherapy or steroids.

Tuberculosis is a serious concern for all healthcare providers, including fire fighters and other first responders who perform emergency medical services. In the IAFF 1998 Death and Injury Survey, tuberculosis exposures accounted for 29.8% of all communicable disease exposures.

How can you get it?

The major way that tuberculosis is transmitted is though airborne spread. When people with active (infectious) TB cough, sneeze or talk they produce droplets that disperse into the air. Other people can breathe contaminated air into their lungs and become infected. TB transmission usually requires prolonged (days or weeks) sharing of airspace with a person with active TB infection. Patients with unrecognized active TB are most likely to transmit it.
You could catch or transmit TB through:

  • Exposure to contaminated air
    • Direct contact with infected person
    • Certain medical procedures that generate aerosols
      • Suctioning, endotracheal intubation
      • Administration of aerosolized medications (nebulizers)

One person with active tuberculosis has the potential to infect many others. TB contaminated droplets can remain airborne for an extended length of time and be carried from one area to another through heating/air conditioning currents. The TB bacteria are also killed by ultraviolet light. Healthcare workers, including first responders, also have significant potential to transmit this bacteria through multiple patient contacts.

What are the symptoms?

TB infection can be active or latent. Patients with active TB have symptoms similar to pneumonia and are contagious. Symptoms may include:

  • Cough that lasts 3 weeks or longer
  • Chest pain
  • Bloody sputum
  • Weakness or fatigue
  • Weight loss or decreased appetite
  • Fever or chills
  • Night sweats

Although most healthy people (90-95%) do not develop active TB disease, two groups are at highest risk of developing symptomatic illness: (1) people with new tuberculosis infections and (2) those with weakened immune systems.

Most people who become infected with tuberculosis develop latent TB infection (LTBI). Persons with latent TB infection do not have any symptoms. They do not cough, have fever or other evidence of active infection and cannot transmit the bacteria to others. Their immune systems are able to contain the infection, but are not eliminate it. Risk of progressing from LTBI to active TB is highest in the years immediately after infection, but some ongoing risk continues unless treatment for LTBI occurs. About 5 to 10% of infected persons who do not receive treatment for latent TB infection will develop active TB disease at some time in their lives. For persons with weakened immune systems the risk is higher. Therefore, it is essential that persons with latent TB infection get treatment to prevent development of active TB.

How do you prevent it?

Early identification and treatment of persons exposed to tuberculosis is critical to preventing transmission of TB. Annual tuberculosis screening is recommended for all firefighters in NFPA 1581, Fire Department Infection Control Programs. First responders can reduce their exposure to TB through consistent use of PPE and respiratory precautions.

In countries like the U.S., where TB is not extremely common, vaccine is rarely recommended. The vaccine used in other countries, BCG (Bacille Calmette-Guérin), is a live bacterial vaccine that works to prevent spread of TB within the body but does not prevent infection from occurring in the first place. Indications for use in health care workers, although rare, can be found at: http://www.cdc.gov/tb/publications/factsheets/prevention/BCG.htm
You can help prevent the spread of tuberculosis by:

  • Getting TB testing every year
  • Using Universal Precautions
    • Assume patients with respiratory symptoms have TB and provide them with surgical masks
    • Strictly limit the number of crew members having direct patient contact
    • Use personal protective equipment (PPE) including NIOSH-certified respirators that are N95 or higher. CDC/NIOSH information on use of respirators by health care workers for protection against TB can be found at: http://www.cdc.gov/tb/publications/factsheets/prevention/rphcs.htm and a video at: http://www.cdc.gov/niosh/docs/video/tb.html
    • Operate ambulance or vehicle ventilation systems in nonrecirculating mode and bring in as much outdoor air as possible
    • Operate rear exhaust fan during transport, if available; air should flow from the front of vehicle, over the patient, and out the rear exhaust fan
    • Use recirculating ventilation units with HEPA filters when available
    • Use respiratory hygiene/Cough etiquette
  • The Ryan White Comprehensive AIDS Resource Emergency Act of 1990 mandates notification of EMS personnel after they have been exposed to a patient with suspected or confirmed infectious TB disease.
  • Maintain a written TB control plan in each workplace

What should you do if you believe you have been exposed to tuberculosis?

If you think you have been exposed to someone with active TB disease, immediately report the exposure to your infection control officer and/or medical director and see a healthcare provider for tuberculosis testing. There are two kinds of TB testing:

  • Tuberculin Skin Test (TST)
  • TB Blood Tests

If your initial test is negative, you should receive a second test 8-10 weeks after the last time you were exposed to the infectious source because your immune system can take several weeks to respond.

A “PPD converter” is someone who has had a negative skin test in the past and now has a positive skin test. On average, people infected with TB have a 10% chance of developing active TB disease at some point in their lives.

For employees who have had negative PPD skin tests in the past and no other sources of exposure, it is likely that a new PPD conversion is due to “on-the-job” exposure. They should be eligible for workers’ compensation for any medical bills or lost work time incurred due to this exposure now or at any time in the future.

Positive TB testing does not tell whether the person has active or latent TB infection. Medical history for symptoms, physical examination, a chest X-ray and sputum sample to test for the TB bacteria are important for follow-up of positive test results.

Treatment for LTBI

If there is no sign of active disease with this follow-up, treatment to prevent future active disease is frequently needed for new “PPD converters”. Usually isoniazid (INH) treatment for 6-12 months is used. INH can be toxic to the liver so people should not drink alcoholic beverages during the months they are taking it. There is a minor risk of developing INH-induced hepatitis (inflammation of the liver), particularly among individuals older than 35, so blood tests are done to check the liver enzymes periodically. While the hepatitis occurs in only a small number of the individuals taking the drug, it must be weighed against the chance of developing TB, which can be a fatal infection. Even older individuals can be safely treated with INH with careful monitoring.

Persons receiving preventive treatment for TB are not infectious and can continue normal work activities.

Treatment for Active (Infectious) TB

Patients who are found to have active TB must take multiple drugs for a prolonged period of time to completely eradicate the active infection. Work accommodations will be needed while they are infectious. Completion of all treatment is important to prevent drug resistant TB.

VACCINIA INFECTION

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What is it?

Vaccinia belongs to a family of viruses that is closely related to the smallpox virus. Because of the similarities between the smallpox and vaccinia viruses, the vaccinia virus is used in the smallpox vaccine. When this virus is used as a vaccine, it allows our immune systems to develop immunity against smallpox. The smallpox vaccine does not actually contain smallpox virus and cannot cause smallpox. Vaccination usually prevents smallpox infection for at least ten years.

The vaccinia vaccine against smallpox was used to successfully eradicate smallpox from the human population. More recently, this virus has also become of interest due to concerns about smallpox being used as an agent of bioterrorism.

How is the virus spread?

Vaccinia can be spread by touching the vaccination site before it has fully healed or by touching clothing or bandages that have been contaminated with the live virus during vaccination. In this manner, vaccinia can spread to other parts of the body and to other individuals. It cannot be spread through the air.

What are the symptoms of vaccinia?

Vaccinia virus symptoms are similar to smallpox, but milder. Vaccinia may cause rash, fever, headache and body aches. In certain individuals, such as those with weak immune systems, the symptoms can be more severe.
What are the potential side effects of the vaccinia vaccine for smallpox?

Normal reactions are mild and go away without any treatment.These include:

  • Soreness and redness in the arm where the vaccine was given
  • Slightly swollen, sore glands in the armpits
  • Low grade fever
  • One in approximately three people will feel badly enough to miss school, work or recreational activities
  • Trouble sleeping

Serious reactions are not very common but can occur in about 1,000 in every 1 million people who are vaccinated for the first time. These reactions are not life threatening, but do require some medical attention. They include:

  • A vaccinia rash or outbreak from accidently touching the vaccination site

    and spreading the vaccinia virus (see Figure 1). Usual areas include the genitals, face and eyes, where the damage can lead to blindness. To help prevent this complication, a person must remember to wash their hands with soap and water after touching the vaccination site.

  • Widespread vaccinia rash- this occurs when the vaccinia virus spreads from the vaccination site into the bloodstream. In this case, the rash will occur in parts of the body away from the vaccination site.
  • Toxic or allergic reaction in response to the vaccine. This can present like any other allergic response and can be mild or severe.

Life-threatening reactions from vaccinia are rare. These occur in between 14 to 52 people in 1 million who are vaccinated for the first time, especially in those with skin disease or weakened immune systems.3 These reactions require immediate medical attention and include:

  • Eczema vaccinatum- this is a serious skin rash that is caused by widespread infection of the skin in people who have prior skin conditions such as eczema or atopic dermatitis.
  • Progressive vaccinia- uncontrolled spread of the vaccinia virus to nearby tissues resulting in tissue death
  • Post- vaccination encephalitis- vaccinia infection that spreads to the brain after vaccination along with an over-response to the vaccine (an inflammatory immune response).
  • Myocarditis or pericarditis- this is inflammation of the heart and is caused by the body’s over responsiveness to the vaccine.

CDC estimates 1 or 2 in 1 million people may die as a result of vaccination.

Who should not get the smallpox vaccine?

Side effects are more likely in a person who:

  • Currently has, or has a history of, skin conditions such as eczema or atopic dermatitis.
  • Has a weakened immune system, such as those who have HIV, have received a transplant, or are receiving treatment for cancer.

Any person who falls in these categories or lives with a person who falls in these categories should NOT get the vaccine unless they are exposed to the disease.

Other categories of people that should NOT get the vaccine are:

  • Pregnant women
  • Women who are breastfeeding
  • anyone who is allergic to the vaccine or any of its components
  • Children younger than 12 months of age
  • Children younger than 18 years of age or adults older than 65 years of age (unless it is in an emergency situation)
  • Anyone using steroid eye drops
  • Anyone who has been diagnosed with heart disease with or without symptoms. This could include individuals with angina (chest pain), previous heart attacks, shortness of breath, congestive heart failure, cardiomyopathy, stroke or a transient ischemic attack (“mini-stroke”)
  • If a person has more than three of the following conditions:
    • High blood pressure
    • A first degree relative (mother, father or sibling) who had a heart condition before the age of 50
    • High cholesterol
    • Diabetes
    • Current smoker

VARICELLA DISEASES/CHICKEN POX

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What is it?

Varicella, also known as chickenpox, is caused by the varicella zoster virus. The same virus, when it recurs, causes Herpes Zoster, also known as shingles. Shingles remains very common, occurring in almost 1 in 3 U.S. residents. Risk increases with age.

How can you get it?

Varicella is highly contagious and spreads from person-to-person through respiratory droplets from coughs or sneezes, by direct contact, and when virus from skin lesions becomes airborne. A person with chickenpox is contagious 1-2 days before the rash appears and until all blisters have formed scabs.

What are the symptoms?

Chickenpox symptoms begin 10-21 days after exposure to the virus and include:

  • Fever
  • Rash consisting of reddish fluid-filled blisters; the rash is usually itchy.

Complications: Bacterial infection of the skin due to open blisters, pneumonia, and, rarely, infection of the brain. Adolescents and adults are more at risk for severe disease.

Herpes zoster presents with blisters in the distribution of a sensory nerve so it is usually on one side only. It can be very painful; pain can persist after the rash is resolved.

How do you prevent it?

Varicella is prevented through vaccination. Currently two doses of the vaccine are recommended. Fire fighters and emergency medical personnel should be vaccinated for varicella unless they have:

  • Blood tests of immunity or laboratory confirmation of prior disease
  • Diagnosis of chickenpox or herpes zoster (shingles) by a healthcare provider
  • Medical contraindication to the vaccine (immunosupression; delay if pregnant or recent blood transfusion)

Workers do not need to be excluded from work in the days immediately following vaccination unless they develop a rash.

A Herpes zoster vaccine is also available for persons age 60 and older. However, this is a different vaccine from the one needed for health care personnel and has no role in the postexpo-sure management of either chickenpox or zoster.

In addition to vaccination, you can help prevent the spread of varicella by:

  • Ventilation since the virus spreads by the airborne route
  • Preventing contamination and performing decontamination of surfaces
  • Using Universal Precautions
    • Assume patients with respiratory symptoms are contagious and provide masks for symptomatic patients
    • Limit the number of crew members having direct patient contact
    • Hand hygiene (wash with soap and water or using an alcohol based hand rub)
    • Personal protective equipment (PPE) (gloves, gowns, and respiratory protection). IAFF recommends P100 respirators for all patients with respiratory symptoms such as cough

What should you do if you believe you have been exposed?

If you are not immune, you should receive the vaccination as soon as possible within 120 hours after exposure and be placed off work beginning 8 days after first exposure until 21 days after last exposure, regardless of post-exposure vaccination

If you are not immune, have a medical contraindication to vaccination and are at high risk for severe disease and complications (immunocompromised patients or pregnant women) you should receive varicella zoster immune globulin as soon as possible within 96 hours. You then need to be placed off work beginning 8 days after the first exposure until 28 days after last exposure.

If you have been previously vaccinated, you should report any fever, headache, skin lesions, and systemic symptoms from day 10 to day 21 after exposure. You should be placed on off duty if symptoms occur.

In a varicella outbreak, CDC recommends providing an additional dose of the vaccine to healthcare personnel who have had only one dose.

VIRAL HEMORRHAGIC FEVERS (LASSA, MARBURG, EBOLA, CRIMEAN-CONGO AND OTHER EMERGING VIRUSES)

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What are they?

Viral hemorrhagic fevers are a group of illnesses causes by several viruses. These viruses affect multiple organs in the body by damaging the vascular (blood vessel) system. The bleeding or hemorrhaging caused by the virus is not usually life threatening but damage to organ systems in the body can range from mild to deadly. The viruses responsible for this type of illness include Lassa, Marburg, Ebola and Crimean-Congo hemorrhagic fever.

How can you get it?

These emerging viral hemorrhagic fevers are presumed to be animal borne (zoonotic) and can be transmitted to humans through contact. Infected humans can spread the virus to each other through contact with contaminated objects or blood. The risk of acquiring these diseases is typically restricted to the geographic regions where the virus is found. Given global travel, rare cases have been reported outside of the host region. These rare cases are probably the greatest form of the occupational threat to fire fighters.

  • Lassa
  • Marburg
  • Ebola
  • Crimean-Congo
  • Associated with specific rodents
  • Transmitted by African fruit bat
  • Transmitted by unknown animal
  • Tick-borne virus
  • Found in West Africa
  • Found in Africa
  • Found in Africa
  • Found in Africa, Asia, Europe

What are the symptoms?

The time to develop symptoms varies by virus but is between 2 to 21 days after exposure to the Ebola virus.
The signs and symptoms of viral hemorrhagic fever vary depending on the virus but include:

  • Flu-like symptoms
    • Fever
    • Fatigue
    • Muscle aches
  • Exhaustion
  • Nausea and/or vomiting
  • Abdminal pain
  • Shock
  • Seizures
  • Delirium
  • Bleeding
  • Organ failure
  • The most common complication of Lassa fever is deafness

How do you prevent it?

No vaccine currently exists to prevent Lassa, Marburg, Ebola or Crimean-Congo hemorrhagic fevers.
Focus prevention on avoiding contact with the host species and stopping further transmission from person to person.

  • Avoid close physical contact with infected individuals and their body fluids.
  • Using Contact and Airborne Precautions until transmission pattern of the particular infection is determined; then Contact and Droplet Precautions
    • Hand hygiene
    • Barrier protection against blood and body fluids (single gloves and fluid-resistant or impermeable gown, face/eye protection with masks, goggles or face shields)
    • Appropriate waste handling.
    • Use N95 or higher respirators. IAFF recommends P100 respirators for all patients with respiratory symptoms such as cough.

What should you do if you are exposed to the disease or get the disease?

You should see a doctor immediately if you have been exposed to the disease. There is no specific treatment for these viral infections but hospitals can provide supportive care. Intravenous fluid and some antiviral medications such as ribavirin may be beneficial.

For more information, contact [email protected]

International Association of Fire Fighters
Attn: Health and Safety Division
1750 New York Avenue, NW
Washington, DC 20006