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October 30, 2015

Role of EMS in preventing infectious disease transmission

When it comes to preventing disease transmission, Benjamin Franklin’s famous quote "An ounce of prevention is worth a pound of cure" is lost on far too many EMS providers.

Despite overwhelming evidence, support from professional health care organizations, and increased availability, there remains a significant disparity in the compliance of health care personnel (HCP) with established immunization recommendations [1]. The Advisory Committee on Immunization Practices (ACIP) (2011) reported that preventable disease outbreaks and patient mortality have been scientifically linked to unvaccinated healthcare workers [2]. Preventable diseases such as influenza, measles, mumps, Pertussis and Varicella have been linked to transmission from unvaccinated healthcare workers [3, 4].

Inconsistent and lack of standardized reporting has caused the Centers for Disease Control and Prevention (CDC) to consider unvaccinated healthcare workers to be an "under-recognized problem" [4,5]. In fact, until a particular enactment of the Affordable Care Act in 2013, most health care organizations did not submit the mandated vaccination records of healthcare workers [6]. As if patient mortality from completely preventable diseases was not enough, other types of infectious and communicable diseases have warranted increased attention over the past decade because treatment and containment are a serious growing public health issue.

Not your father's MRSA
In 2006, the CDC altered its assumption that certain antibiotic resistant pathogens such as methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile (C. diff) were solely a nosocomial or "in the hospital" problem [7]. The evidence points toward the alarming trend that these antibiotic-resistant infections were showing up as community-associated infections (in the home) and in patients without traditional risk factors (antibiotic use, advanced age, and prior hospitalization).

What was even more alarming was that these deadly diseases were found with increasing frequency in patients "without any health care setting exposures" [8]. The 2015 report from the CDC identified that over 7.6 percent of new C. diff cases had no contact with people who had the disease [9].

C. diff is now the most common health care associated infection, resulting in over half a million infections annually [9, 10]. Of these new cases, it is estimated that over 150,000 are considered community-acquired and reported exposure to outpatient health care areas such as doctor’s or dentist’s offices, urgent care centers, rehabilitation centers, nursing homes, and dialysis centers to list a few [9, 10]. Although EMS was not specifically not included in the studies, it doesn't take much to imagine what the potential role of EMS is in the transmission of these pathogens from healthcare areas.

The CDC has declared antibiotic resistant superbugs to be the most serious U.S. and global health threat of the modern era of medicine [2, 11, 12, 13]. Some of these dangerous superbugs are not only resistant to multiple antibiotics, but many of them have no effective treatment and have mortality rates as high as 89 percent [2, 11, 12, 13, 14].

Superbugs include organisms such as some resistant strains of C. diff, Vancomycin-resistant Enterococcus (VRE), MRSA, tuberculosis (TB), Campylobacter, carbapenem-resistant Enterobacteriaceae (CRE), and Beta-lactamase producing Enterobacteriaceae (ESBLs) to list a few. Many of these superbugs are so difficult to treat that patients are transported across several states to the renowned National Institutes of Health (NIH) medical facility in Bethesda, Maryland. It is no surprise how these patients are transported—by ambulance [12]!

How are infectious diseases transmitted?
Prehospital strategies for preventing transmission of infectious diseaseare based on the EMS professional’s understanding about how disease is transmitted. The process involves four basic stages:

1. Someone is infected with a pathogen.

2. The infectious pathogen (disease causing bacteria, virus, fungus, parasites, or prions) leaves the infected person’s body. Usually this occurs when an uninfected person is exposed to blood, sputum, or other potentially infectious materials (OPIM) from an infected person.

3. The infectious pathogen reaches another person and enters his or her body. This can occur by bloodborne, airborne, or vector transmission. Direct contact occurs with contact with an infected person or their infected body fluids. Indirect contact occurs with contact with contaminated objects such as food or drink, droplets in the air, or vectors such as insects.

4. The second person develops the infection. Merely having the pathogen enter the body does not automatically mean a person will become ill. Immunizations against the disease will help the immune system destroy the pathogen before it causes the disease [15].

EMS, an unexpected courier?
MRSA and C. diff have been found on the stethoscopes, cardiac monitor wires, uniforms, shoes, medical devices, oxygen tubing, tape, pens, scissors/shears, and even cell phones of healthcare professionals [16, 17, 18, 19, 20]. These pathogens have even been found in the home on bed linens, light switches, sinks, TV remotes, hand towels, counter tops, and even dogs and cats [16, 17].

Although the reality of bloodborne pathogens in EMS has been known for years, only recently have articles identifying MRSA in ambulances and fire stations have appeared in the EMS literature. Studies in the American Journal of Infection Control (2011, 2014) recognized the transmission and harboring of MRSA within fire department and ambulance environments [21, 22]. The University of Washington Department of Environmental and Occupational Health Services (2011) reported that "fire and ambulance personnel have the unique opportunity to acquire and transfer infections from both hospital and community sources" [21].

Rago et al (2012) reported that 70 percent of ambulances in the Chicago metropolitan area contained at least one strain of MRSA [23]. National surveys conducted by the National Institute for Occupational Safety and Health (NIOSH) (2010) revealed a high incidence of exposures to bloodborne pathogens for paramedics [24]. The NIOSH (2010) also identified underreporting of exposures, an absence of safety equipment, lack of PPE, and insufficient training in the use of PPE [24]. 

Although EMS system responders acknowledge the importance of protocols for cleaning and disinfecting equipment, several articles in EMS journals cite contamination of fire stations, ambulances, and equipment, such as with MRSA [18, 25]. 

The role of EMS in preventing infectious disease transmission
EMS professionals render care to diverse populations who are at increased risk of harboring infectious and communicable diseases [26]. EMS disease prevention resources exist, but they are often difficult to find. Resources for EMS professionals, such as the United States Fire Administration Guide to Managing an Emergency Service Infection Control Program (2002) and Infectious Diseases and the Fire and Emergency Services (2001), are out of date and many changes in recommendations have occurred since their publication.

Here are some up-to-date steps for EMS to minimize disease transmission:

  • Consistently use proper personal protective equipment (PPE) to reduce exposure to blood and OPIM. The PPE guidelines have recently been updated to manage extreme infectious and contagious diseases such as Ebola [27].
  • When purchasing new ambulances, choose surfaces that contain polymers that are resistant to microorganism attachment.
  • Stay up to date on the recommended immunizations for health care workers [28].
  • Follow CDC recommendation that all HCP including EMTs and paramedics receive annual vaccination against influenza [28].
  • Verify negative 2-step tuberculosis (TB) skin test (TST) annually [4].
  • Establish isolation protocols with health care organizations so that providers can prepare and safely respond to patients with antibiotic resistant organisms.
  • Use CDC recommended disinfection supplies and processes that kill even the toughest microorganisms (C. diff and TB). These guidelines have recently been updated to manage extreme infectious and contagious diseases such as Ebola [29].
  • Establish a protocol for the routine disinfection of medical devices and the ambulance patient care area and follow it closely.
  • Follow the "Ambulance Cleaning Procedures" on page 78 published in the APIC (2013) Guide to Infection Prevention in EMS [26].
  • Follow the "Exposure Control" plan on page 80 published in the APIC (2013) Guide to Infection Prevention in EMS [26].
  • Maintain hand hygiene standards and remember it is important hand hygiene must occur several times during patient contact [30].
  • Contribute to public health education by promoting and offering information and immunizations to the community [31].
  • Develop and participate in a quality and compliance group within the organization to review and make recommendations after care is rendered to patients with a positive isolation status

Taking an active role in prevention
The role of EMS professionals is to protect others, provide care, and "do no harm". It is clear that immunizations are effective, safe, and often the first step is protecting providers and patients alike [4, 32]. Given that EMS providers care for and transport patients with infectious, contagious, and even deadly antibiotic resistant organisms, it is essential that minimize the potential for harm to themselves, their families and their patients.

References:

1. CDC. (2013, November 3). Influenza vaccination information for healthcare workers. Retrieved from http://www.cdc.gov/flu/healthcareworkers.htm

2. CDC. (2013, January). Antibiotic resistance threats in the United States, 2013. Retrieved from http://www.cdc.gov/drugresistance/threat-report-2013/pdf/ar-threats-2013-508.pdf

3. Baxi, R., Mytton, O. T., Abid, M., Maduma-Butshe, A., Iyer, S., Ephraim, A., . . . O'moore, E. (2013). Outbreak report: Nosocomial transmission of measles through an unvaccinated healthcare worker--implications for public health. Journal of Public Health, 36(3), 375-381. doi:10.1093/pubmed/fdt096

4. CDC. (2011, November 12). Immunization of health-care personnel: Recommendations of the Advisory Committee on Immunization Practices (ACIP). Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6007a1.htm

5. Melville, N. (2015, May 29). Measles outbreaks include unvaccinated healthcare workers. Retrieved from http://www.medscape.com/viewarticle/845568#vp_1

6. Health impact news. (2015, October 12). Are mandatory flu vaccines for healthcare workers part of Obamacare and linked to financial reimbursement to healthcare facilities? Retrieved from http://healthimpactnews.com/2013/are-mandatory-flu-vaccines-for-healthcare-workers-part-of-obamacare-and-linked-to-financial-reimbursement-to-healthcare-facilities/

7. Warny, M., Pepin, J., Fang, A., Killgore, G., Thompson, A., Brazier, J., . . . Mcdonald, L. C. (2005). Toxin production by an emerging strain of Clostridium difficile associated with outbreaks of severe disease in North America and Europe. The Lancet, 366(9491), 1079-1084. doi:10.1016/s0140-6736(05)67420-x

8. Update on Emerging Infections: News From the Centers for Disease Control and Prevention. (2010). Annals of Emergency Medicine, 55(3), 280-282. doi:10.1016/j.annemergmed.2009.12.029

9. CDC. (2015, February 25). Nearly half a million Americans suffered from Clostridium difficile infections in a single year. Retrieved from http://www.cdc.gov/media/releases/2015/p0225-clostridium-difficile.html

10. CDC. (2015, October 8). Healthcare-associated infections (HAI). Retrieved from http://www.cdc.gov/hai/

11. Frontline. (2013, October 22). Ramanan Laxminarayan: The global reach of resistance. Retrieved from http://www.pbs.org/wgbh/pages/frontline/health-science-technology/hunting-the-nightmare-bacteria/ramanan-laxminarayan-the-global-reach-of-resistance/

12. Frontline (Producer). (2013). Hunting the nightmare bacteria [Motion picture on DVD]. USA: WGBH Educational Foundation.

13. CDC. (2014, August 4). Carbapenem-resistant Enterobacteriaceae in healthcare settings. Retrieved from http://www.cdc.gov/HAI/organisms/cre/

14. Riley, T. V. (2010). From obscurity to 'superbug' – The rise of Clostridium difficile. Healthcare Infection, 15(3), 59. doi:10.1071/hi10028

15. American Public Health Association (APHA). (2010, November 9). Annual influenza vaccination requirements for health workers. Retrieved from http://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2014/07/11/14/36/annual-influenza-vaccination-requirements-for-health-workers

16.Fritz, S. A., Hogan, P. G., Singh, L. N., Thompson, R. M., Wallace, M. A., Whitney, K., . . . Fraser, V. J. (2014). Contamination of Environmental Surfaces With Staphylococcus aureus in Households With Children Infected With Methicillin-Resistant S aureus. JAMA Pediatrics JAMA Pediatr, 168(11), 1030-1038. doi:10.1001/jamapediatrics.2014.1218

17. Williams, C., & Davis, D. (2009). Methicillin-resistant Staphylococcus aureus fomit survival. Clinical Laboratory Science, 22(1), 34-38. doi:10.5897/AJMR2013.6512

18. Merlin, M. A., Wong, M. L., Pryor, P. W., Rynn, K., Marques-Baptista, A., Perritt, R., . . . Fallon, T. (2009). Prevalence of Methicillin-Resistant Staphylococcus aureus on the Stethoscopes of Emergency Medical Services Providers. Prehospital Emergency Care Prehosp Emerg Care, 13(1), 71-74. doi:10.1080/10903120802471972

19. DipN, B. (2006). Scissors: An infection risk. Emergency Nurse, 18(8), 8-10. doi:10.1086/588704

20. Shephard, R. (2012). Community-Associated Methicillin-Resistant Staphylococcus aureus Survival on Artificial Turf Substrates. Yearbook of Sports Medicine, 2012, 319-321. doi:10.1016/j.yspm.2011.08.056

21. Roberts, M. C., & No, D. B. (2014). Environment surface sampling in 33 Washington State fire stations for methicillin-resistant and methicillin-susceptible Staphylococcus aureus. American Journal of Infection Control, 42(6), 591-596. doi:10.1016/j.ajic.2014.02.019

22. Roberts, M. C., Soge, O. O., No, D., Beck, N. K., & Meschke, J. S. (2011). Isolation and characterization of methicillin-resistant Staphylococcus aureus from fire stations in two northwest fire districts. American Journal of Infection Control, 39(5), 382-389. doi:10.1016/j.ajic.2010.09.008

23. Rago, J. V., Buhs, L. K., Makarovaite, V., Patel, E., Pomeroy, M., & Yasmine, C. (2012). Detection and analysis of Staphylococcus aureus isolates found in ambulances in the Chicago metropolitan area. American Journal of Infection Control, 40(3), 201-205. doi:10.1016/j.ajic.2011.08.021

24. CDC. (2010, April). Preventing exposures to bloodborne pathogens among paramedics. Retrieved from http://www.cdc. gov/niosh/docs/wp-solutions/2010-139/.

25. Roline, C. E., Crumpecker, C., & Dunn, T. M. (2007). Can Methicillin-Resistant Staphylococcus Aureus Be Found in an Ambulance Fleet? Prehospital Emergency Care Prehosp Emerg Care, 11(2), 241-244. doi:10.1080/10903120701205125

26. APIC. (2013). APIC Implementation guide: Guide to infection prevention in Emergency Medical Services. Retrieved from http://apic.org/Resource_/EliminationGuideForm/e1ac231d-9d35-4c42-9ca0-822c23437e18/File/EMS_Guide_web.pdf

27. CDC. (2015, March). Guidance on Personal Protective Equipment (PPE) To Be Used By Healthcare Workers during Management of Patients with Confirmed Ebola or Persons under Investigation (PUIs) for Ebola who are Clinically Unstable or Have Bleeding, Vomiting, or Diarrhea in U.S. Hospitals, Including Procedures for Donning and Doffing PPE. Retrieved from http://www.cdc.gov/vhf/ebola/healthcare-us/ppe/guidance.html

28. CDC. (2015, May). Recommended vaccines for healthcare workers. Retrieved from http://www.cdc.gov/vaccines/adults/rec-vac/hcw.html

29. CDC. (2013, June). Interim guidance for environmental infection control in hospitals for Ebola Virus. Retrieved from http://www.cdc.gov/vhf/ebola/healthcare-us/cleaning/hospitals.html

30. CDC. (2011, June). Guideline for hand hygiene in health-care settings. Retrieved from http://www.cdc.gov/healthywater/hygiene/hand/handwashing.html

31. World Health Organization (WHO). (2012, November 15). WHO recommendations for routine immunization - summary tables. Retrieved from Available from: http://www. who.int/immunization/policy/immunization_tables/en/

32. Betsch, C. (2014). Overcoming healthcare workers’ vaccine refusal – competition between egoism and altruism. Eurosurveillance, 19(48), 20979. doi:10.2807/1560-7917.es2014.19.48.20979

 

 

About the Author

Dean Meenach, RN, BSN, CEN, CCRN, CPEN, EMT-P has taught and worked in EMS for more than 20 years and currently serves as Director of EMS Education/Paramedic Instructor and co-teacher in the Paramedic to RN Bridge Program at Mineral Area College. He has served as a subject matter expert, author, national speaker, and collaborative author in micro-simulation programs. Dean continues to serve patients part time as a member of a stroke team and in a pediatric and adult trauma center. He can be reached at dmeenach@mineralarea.edu.
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