PANDEMICS

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PANDEMICS
AND
UNIVERSAL PRECAUTIONS
MARILYN EVANS CAPITAL DISTRICT FIREFIGHTERS
IN-HOUSE TRAINING Dec.12, 2005
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OBJECTIVES

• Understand the Virus
• Review the history
• Understanding of the epidemiology
• Our roles
• Exercise

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UNDERSTANDING

• THE VIRUS

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WHAT IS INFLUENZA?

• INFLUENZA Acute onset of respiratory illness
  with fever (gt38 C,100.4 F) and cough with one or
  more of the following sore throat, joint pain,
  muscle aches, headache, malaise.
• Severe illness lasting 7 to 10 days
• In people 65 and older, fever may not be present.
• Other symptoms in the elderly may include change
  in behavior, chest congestion, decrease in
  appetite.

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COMMUNICABLE DISEASES

• DISEASES MAY BE TRANSMITTED FROM PERSON TO PERSON
  BY SEVERAL ROUTES
• DIRECT CONTACT
• INDIRECT CONTACT
• BLOOD AND BLOODY BODY FLUIDS
• VECTORS
• DROPLET INFECTIONS
• AIRBORNE INFECTIONS

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Modes of Disease Transmission

• Airborne
• a more common method of transmission
• bacteria or viruses suspended in air, water
  droplets, or dust particles (coughing, sneezing)
• can be widely scattered via air currents
• examples TB, rubeola (measles), chicken pox
• Direct Contact
• straight from one person to another
• examples kissing, sexual contact, blood dripping
  into a wound, touching feces, eating or smoking
  with contaminated hands

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Modes of Disease Transmission

• Indirect contact
• touching a contaminated surface most likely
  bringing your hands to your face
• examples telephones, door handles, steering
  wheels, faucets, B/P cuffs, EKG cables, swimming
  in contaminated water
• Vector-borne
• infectious agent transferred by common carrier
  (animal insect bites, blood transfusions,
  needle stick injuries, transplants) from 1
  person/source to another
• examples rabies, lyme disease, malaria,
• West Nile disease, HBV, HIV

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About Influenza

• Period of Communicability
• ??24 hours before onset
• ??3-5 days after onset
• ??Hard surfaces 24-48 hours
• ??Porous surfaces 8-12 hours
• ??Hands 5 minutes
• Incubation
• ??1-3 days

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Influenza Virus

• There are three types of influenza viruses
  Types A, B, and C
• The viruses are transmitted among humans by
  respiratory secretions through sneezing, coughing
  and contact with contaminated articles

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Influenza Virus

• Type C influenza Virus
• Restricted to humans
• Relatively Stable
• Causes mild, sporadic illness among humans

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Symptom Influenza Common Cold
Fever Often high sudden onset 38C 40C and lasts 3-4 days Rare
Headache Frequently Rare
Aches and pains Usual often quite severe Slight
Weakness Moderate to extreme may last up to one month Rare/Mild
Bedridden Frequently may last up to 5-10 days Rare
Runny, stuffy nose Sometimes Common
Sneezing Sometimes Usual
Chest discomfort Usual and can be severe Sometimes, but mild to moderate
Complications Respiratory failure complicate a chronic condition Congestion, sinus or ear infection
Prevention Influenza vaccine frequent handwashing cover your cough Frequent handwashing, cover your cough
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Influenza Virus

• Type B influenza Virus
• Restricted to humans
• Can change slowly over time
• More Stable than Influenza A
• Has been associated with widespread illness among
  humans
• Causes milder disease than influenza A

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Influenza virus

• Type A influenza Virus
• Many different sub-types
• Various subtypes infect humans, pigs, horses,
  aquatic animals, birds and most recently dogs.
• Can change frequently and dramatically
• Can sweep across continents and around the world
  in massive epidemics called pandemics
• Causes excess mortality and mordidity

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Epidemic
Pandemic

• Massive global epidemic caused by a antigenic
  shift in the Influenza A virus
• Pandemics are usually worldwide

• Affects a large population in a geographic area
• Abrupt onset
• Rapid spread
• Occurs at unpredictable intervals
• Not seasonal

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Recipe for a Pandemic

• ??Bird flu virus can mix with human flu virus and
  create
• new subtype of virus
• ??The world would have little or no immunity to
  this new
• virus
• ??If this virus replicates in humans and causes
  serious
• disease. AND
• ??If this virus can be spread from person to
  person
• efficiently, then it may cause a.PANDEMIC

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Phases of an Influenza Pandemic
Phase Level Definition
0 0 Inter-Pandemic Period Annual epidemics with 3-4 circulating influenza strains worldwide
0 1 Initial Report of New Strain in Humans Novel virus reported no clear evidence of person-to-person spread or outbreak activity.
0 2 Novel Virus Alert Infection in gt2 humans confirmed ability to spread and cause severe disease questionable.
0 3 Human Transmission Confirmed Person-to-person transmission confirmed or new virus found in several countries at least one outbreak lasting gt 2 weeks
1 Confirmation of Onset of Pandemic Efficient person-to-person spread with outbreaks in gt1 country and evidence of severe morbidity and mortality Confirmation of Onset of Pandemic Efficient person-to-person spread with outbreaks in gt1 country and evidence of severe morbidity and mortality
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Phases of an Influenza Pandemic
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• Review
• Pandemic History

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Past Influenza Pandemics
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Mortality during the pandemic of1918-19A/H1N1
Spanish influenza

• ?? 3 epidemic waves in close succession
• ?? March 1918, Sept 1918, Feb 1919
• ?? Est 40 million deaths world-wide,

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Pandemic Influenza 1918 Influenza Pandemic

• 20-40 million persons died worldwide, possibly
  more
• Death rate 25 times higher than previous
  epidemics
• Ten times as many Canadians died of flu than died
  in WW I
• The epidemic preferentially affected and killed
  younger, healthy persons
• The epidemic was so severe that the average life
  span in Canada was depressed by 10 years

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Understanding of the epidemiology
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Where does it start?

• Evidence suggests most epidemics emerge from
  China
• Close mingling of pigs, chickens, ducks, and
  humans allows reassortment of viruses

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Antigenic Variation

• Influenza viruses change frequently
• Changes or mutations in the virus are referred to
  as antigenic variation
• These variations cause epidemics and pandemics

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Antigenic Variation

• Antigenic variation is referred to as drift or
  shift, depending on whether the variation is
  small or great
• The drift affects both Influenza A and B viruses
  and occurs every 1-3 years within a subtype and
  can result in significant epidemics

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Antigenic Variation

• Antigenic shift affects the Influenza A virus
  only and causes major changes within the virus.
  This can occur every 10-40 years leading to a
  pandemic
• There is no relationship between the surface
  antigens of the old and the new virus, therefore
  a new virus subtype emerges
• The population will have no immunity to the new
  subtype

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The current reality
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Dont worry about it, its probably just a head
cold.
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Pandemic Influenza Outbreak of Avian Influenza A
(H5N1) in Asia

• "We at WHO the World Health Organization
  believe that the world is now in the gravest
  possible danger of a pandemic"
• Dr. Shigeru Omi, the WHO's Western Pacific
  Regional Director, 23 February 2005

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PANDEMIC ?

• The pandemic clock is ticking we just dont
  know what time it is.
• Edgar Marcuse
• University of Washington School of Medicine

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The Pandemic Challenge

• Senior officials are being asked to
• Cope with present realities
• An avian influenza epidemic
• Prepare for an uncertain future
• A human influenza pandemic
• Be ready for major disruption
• Reaction to the pandemic

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Pandemic Influenza Potential Impact of Pandemic
Influenza inCanada.

• Vaccine and antiviral drugs will be in short
  supply
• 6-8 month lag-time needed for vaccine
  availability
• Healthcare workers and other first responders
  will be at higher risk of exposure and illness
  than the general population
• Healthcare system will be overwhelmed
• Risk of sudden shortages of key personnel in
  critical community services police, fire,
  power/utilities, transportation, air traffic
  controllers, etc.

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What do we know.

• Pandemic influenza will happen (at some
• point)
• It is more likely now than three years ago
• It could be mild
• It could be severe
• It could be extremely severe
• It affects younger age groups than "normal"
• influenza

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Are You Prepared?

• What is known..
• An influenza pandemic will happen
• The timing and pattern will be unpredictable
• A short lead time will exist from first
  identification to full scale pandemic
• Outbreaks will occur simultaneously, in multiple
  waves with devastating societal impact

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What do we know - Two

• It could come once or in waves
• It will probably come quickly
• Work forces will be badly affected
• Maybe infectious before symptoms
• appear
• There are infections with no symptoms

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What do we know - Three

• An effective vaccine will take several
• months to develop
• There will probably be few anti-viral
• medicines available and the emergence
• of resistance is possible

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What do we know - Four

• Influenza is infectious but not as highly
• infectious as measles
• Not everyone will be infected
• There are ways of reducing the numbers
• affected
• If an infectious and damaging virus emerges,
• containment of people may be justified
• Need for epidemiological information

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Pandemic Impact

• Health Care System
• Extreme staffing shortages
• Shortage of beds, facility space, supplies
• Hospital morgues, Medical Examiner and mortuary
  services overwhelmed
• Infrastructure
• Significant disruption of transportation, public
  works, commerce, utilities, energy, and
  communications, emergency response

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• Our roles
• Safeguarding front-line personnel
• Educate and Inform
• Continuity of Operations Planning

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• UNIVERSAL PRECAUTIONS

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• The only thing more difficult than planning for
  an emergency is having to explain why you
  didnt.

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Vaccinations

• not all are mandatory, many available to protect
  the individual

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• Infection Control Precautions and PPE for the
  EMS Provider at Suspected Infectious Disease
  Incident
• Standard infection control practices are
  taught to all Emergency Response Providers and
  should be reviewed regularly by agency internal
  training that includes
• Standard Precautions
• Contact Precautions
• Airborne Precautions
• Droplet Precautions

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Standard Precautions

• apply to blood, all body fluids, secretions,
  non-intact skin, mucous membranes and excretions
  for all patients. Gloves and gowns (if soiling of
  clothing is likely) should be used to prevent
  exposure to blood and other potentially
  infectious fluids. Mask and eye protection or
  face shields should be used during procedures or
  activities that may likely generate splashes of
  blood or body fluids. Appropriate hand hygiene is
  always necessary.

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Contact Precautions

• include the use of gloves and a gown if clothing
  is likely to have contact with patient,
  environmental surfaces or patient care equipment.

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Airborne Precautions

• include a properly ventilated
  area/ambulance/room and appropriate respiratory
  protection such as the N95 respirator and placing
  a mask on the patient.

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Droplet Precautions

• include the use of a disposable gown, gloves and
  mask when working on or within 6.5 feet of a
  patient. For patients who are coughing if
  possible and not contraindicated by respiratory
  difficulties, place a surgical mask on the
  patient to prevent droplet spread inside the
  ambulance/room. When transferring or moving a
  patient from room to room inside the hospital or
  any enclosed building, place a mask on the
  patient to prevent contamination of other
  persons.

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• Reminder Even though EMS providers wear gloves
  during a call, vigorous handwashing with soap and
  water or waterless handcleaners must be done
  after each patient contact. This will help reduce
  the potential for contamination.

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Pandemic Preparedness Responsibilities of All
Partners

• Influenza Prevention
• Stay home when sick
• Cover your cough
• Wash hands regularly and use alcohol hand gel
• Avoid touching eyes, nose, mouth

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Check hands and fingernails for cleanliness
The 8 steps of washing your hands
Turn off water using paper towel
Dry hands with paper towel
Rinse under running water
Wash each finger and scrub 15- 20 seconds
Add soap and lather hands including backs and
wrists
EMS personnel should use waterless hand wash as
an adjunct to handwashing to help prevent the
risk of transmission of microorganisms
Wet your hands
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Using Removing Gloves

• Put on eyewear first, then face mask, then gloves
• When finished, remove face mask first, then
  eyewear, lastly gloves
• To remove gloves
• grasp cuff
• remove glove by peeling off of hand fingers
• turn glove inside out as it is being removed
• dispose in proper receptacle

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SAFE REMOVAL / DISPOSAL OF PPE

• SOME HEALTHCARE WORKERS APPEAR TO HAVE ACQUIRED
  SARS INFECTION DUE TO THE IMPROPER REMOVAL
  DISPOSAL OF PPE.
• PROVIDERS MUST USE CARE TO AVOID THE OUTER PART
  OF PPE (MASK, DISPOSABLE GOWNS, BOOTIES, ETC.)
  FROM COMING INTO CONTACT WITH SKIN OR CLOTHING.
• ITEMS SHOULD GO DIRECTLY INTO BIOHAZARD DISPOSAL
  BAGS.
• MASKS SHOULD BE THE SECOND TO LAST ITEM REMOVED,
  FOLLOWED BY GLOVES.
• THOROUGH HANDWASHING WITH EITHER SOAP WATER OR
  WATERLESS DISINFECTANT SHOULD TAKE PLACE
  IMMEDIATELY AFTER ALL PPE IS REMOVED.

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Respiratory Protection

• Goal is to wear a mask that will cover the
• nose mouth not gap at the sides or chin
• Patients are to wear surgical or standard masks
• when being transported
• EMS providers are to wear the
• N95 mask to protect by filtering
• particles out of the air you breathe
• ? risk of exposure
• Additional masks may
• be available for special
• situations or based on
• the stock supplied

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MASKS

• TWO LEVELS OF AIRBORNE PERSONAL PROTECTIVE
  EQUIPMENT (PPE) ARE AVAILABLE PRACTICAL FOR
  EMS
• SURGICAL MASK N-95 MASK

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MASKS

• A SURGICAL MASK IS OFTEN RECOMMENDED FOR AIRBORNE
  PATHOGENS EXCEPT TUBERCULOSIS AND SARS PATHOGENS
• STRONG CONSIDERATION SHOULD BE MADE FOR PLACING A
  SURGICAL MASK ON THE PATIENT AS WELL AS THE EMS
  PROVIDER
• SURGICAL MASK REQUIRES NO FIT TESTING

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MASKS

• AN N-95 MASK IS RECOMMENDED BY CDC FOR CONTACT
  WITH KNOWN OR SUSPECTED SARS PATIENTS
• FOR AN N-95 MASK TO HAVE MAXIMUM EFFECTIVENESS, A
  FIT-TEST PROCEDURE MUST BE DONE BY A QUALIFIED
  INDIVIDUAL
• FIT TESTING DETERMINES
• WHICH SIZE MASK TO WEAR,
• WHETHER A PROPER SEAL IS POSSIBLE
• WHETHER THE EMS PROVIDER HAS ANY MEDICAL
  CONTRAINDICATIONS TO USING AN N-95 MASK

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MASKS

• A PROVIDER MAY BE UNABLE TO ACHIEVE A PROPER FIT
  FOR AN N-95 MASK FOR SEVERAL REASONS (SUCH AS A
  BEARD)
• OTHER OPTIONS, SUCH AS AVOIDING PATIENT CONTACT
  OR USE OF A POWERED BREATHING DEVICE MAY BE
  REQUIRED
• THE CDC SAYS THAT THE USE OF A SURGICAL MASK (IF
  N-95 NOT AVAILABLE) WILL PROVIDE SOME LEVEL OF
  PROTECTION AGAINST SARS

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HOW WILL YOU KNOW WHICH TO USE?

• ITS RECOMMENDED THAT THE USE OF AIRBORNE PPE
  BECOMES A ROUTINE PRACTICE FOR INTERACTIONS WITH
  ALL AT-RISK RESPIRATORY AND FEVER PATIENTS

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HOW WILL YOU KNOW WHICH TO USE?

• THE CDC ADVOCATE THE USE OF N-95 MASKS AS THE
  DEVICE OF CHOICE FOR EMS PROVIDERS TO WEAR FOR
  CONTACT WITH ALL PATIENTS WITH ANY POSSIBLE
  RESPIRATORY COMMUNICABLE DISEASE

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CPR Barriers Masks

• Checking PPE equipment includes readiness of
  emergency CPR devices
• gloves
• CPR masks
• face shields
• ambu bag

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WHEN SHOULD YOU BE THINKING ABOUT APPLYING PPE?

• DISPATCH INFORMATION
• SCENE SAFETY ASSESSMENT
• PATIENT ASSESSMENT

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WHEN SHOULD YOU CONSIDER APPLYING PPE?

• DISPATCH INFORMATION
• RESPIRATORY DISTRESS, SOB, DIFFICULTY BREATHING
• FEVER
• RASH
• SICK PERSON or ILL CALL
• SHOULD GET YOU THINKING AND PREPARED TO DON APPE
  ON SCENE

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WHEN SHOULD YOU CONSIDER APPLYING PPE?

• SCENE SAFETY ASSESSMENT
• AT THE DOORWAY ENTERING THE ROOM - IS THE SCENE
  SAFE?
• IS THE PATIENT COUGHING?
• IF YES, YOU SHOULD APPLY YOUR MASK BEFORE
  PROCEEDING

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WHEN SHOULD YOU CONSIDER APPLYING PPE?

• PATIENT ASSESSMENT
• IN ADDITION TO ROUTINE QUESTIONS BASED ON CHIEF
  COMPLAINT ( AND EARLY IN THE ASSESSMENT ) THE EMS
  PROVIDER SHOULD DETERMINE
• DOES THE PATIENT HAVE A FEVER?
• PT/CAREGIVER HAS TAKEN A TEMP
• PT THINKS HE/SHE HAS A FEVER
• EMS PROVIDERS TAKE A TEMP
• IS THE PATIENT COUGHING?
• DOES THE PATIENT HAVE A RASH?

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IF YES TO ANY OF THE PREVIOUS QUESTIONS.

• AND YOU HAVENT PUT PPE ON YET - YOU SHOULD BE
  DOING IT NOW
• ALSO, ASK IF THE PATIENT HAS BEEN OUTSIDE THE
  CANADA WITHIN THE PAST 10 DAYS. IF SO, DOCUMENT
  WHERE THEY TRAVELED

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PPE ALGORITHM

• CHIEF COMPLAINT

TYPICAL OPQRST QUESTIONS
IS PATIENT COUGHING?

• MAY FEVER
• APPLY
  PRESENT?
• PPE
• 
  YES NO
• APPLY
  PPE MAY NOT

NO
YES
NO
YES
DOES PT APPLY
HAVE RASH? PPE
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YOU MADE THE DECISION TO APPLY PPE NOW EVALUATE
THE EFFECTIVENESS

• IS THE PATIENTS MOUTH NOSE COVERED?
• ARE ALL PROVIDERS IN CONTACT WITH PT WEARING
  MASKS?
• HAVE YOU EVALUATED THE RISK?
• ALERT LEVEL
• CLINICAL CRITERIA
• TRAVEL TO INFECTED AREA
• CONTACT WITH INFECTED PATIENT

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IF HIGH LIKELIHOOD OF INFLUENZA

• ENSURE N-95 MASKS ARE USED
• BY FIT TESTED PERSONNEL
• USING THE RIGHT SIZE MASK
• ALSO USING EYE PROTECTION, GLOVES, GOWN, CAP
  BOOTIES
• AND OTHER PROTECTION

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OTHER PROTECTION

• LIMITATION OF PERSONNEL
• ISOLATE THE PATIENT COMPARTMENT OF THE AMBULANCE
  IF POSSIBLE
• LIMITING SOME PROCEDURES (i.e. Nebulizer )
• HEPA FILTRATION - BVM, SUCTION
• DISINFECTION PRACTICES
• BIOHAZARD WASTE DISPOSAL PRACTICES - MANY
  HEALTHCARE WORKERS HAVE BECOME CONTAMINATED BY
  IMPROPER REMOVAL OF PPE

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OTHER CONSIDERATIONS

• ADVISE THE EMERGENCY DEPT. THAT RESPIRATORY
  PRECAUTIONS ARE IN PLACE, EITHER ROUTINE OR
  REPORT SPECIFIC CLINICAL FINDINGS
• ADVISE THE PATIENT AND FAMILY THAT RESPIRATORY
  PRECAUTIONS ARE A ROUTINE PRACTICE NOW TO PROTECT
  EVERYONE

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SO REMEMBER

• N-95 MASK FOR YOURSELF
• SURGICAL MASK OR O2 MASK FOR YOUR PATIENT

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Infection ControlsGolden Rule
If its wet and its
not yours. DONT TOUCH!!!
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Decontamination Considerations

• Decontamination of victims at a scene is the
  responsibility of responding HazMat and/or fire
  department personnel. This includes
  decontamination procedures for both people and
  equipment.

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People

• In general decontamination of infectious disease
  patients is not necessary. People exposed to a
  biological agent need only to remove their
  clothing, if heavily contaminated, and use
  shampoo, soap and water on themselves (shower).
  Diluted bleach solutions should NEVER be used on
  people.

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Equipment

• Patient care equipment must be appropriately
  cleaned, sterilized or disinfected between
  patients. Environmental surfaces can be
  decontaminated with diluted chlorine beach (110
  dilution of household bleach) or an EPA-approved
  hospital disinfectant.

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EMS Role in Disease Surveillance

• EMS personnel should be alert to illness patterns
  and diagnostic clues that might signal an act of
  bioterrorism (BT). The following clinical and
  epidemiological clues are suggestive of a BT
  event.
• A rapidly increasing incidence of disease in the
  community.
• Unusual increases in the number of people seeking
  medical care, calling for an ambulance,
  especially with fever, respiratory or
  gastrointestinal symptoms.
• An unusual number of people with flu-like
  symptoms, particularly during the non-traditional
  flu season.

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EMS Role in Disease Surveillance

• Any suspected or confirmed communicable disease
  that is NOT COMMON in New Brunswick, (e.g.
  plague, anthrax, smallpox, or viral hemorrhagic
  fever). Note As smallpox has been eradicated in
  its natural state one case of smallpox must be
  viewed as caused intentionally.
• Any unusual age distribution or clusters of
  disease (e.g. chickenpox or measles in adults).
• Simultaneous outbreaks in human and animal
  populations.
• Any unusual clustering of illness (e.g. persons
  who attended the same public event).

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EMS Role in Disease Surveillance

• Careful observations and understanding of
  historic disease patterns in the community can
  help identify a biological incident or epidemic
  early. It is the early detection of any epidemic
  that can prevent or contain the spread of disease
  in a community.
• This rule applies to intentionally spread disease
  or naturally occurring disease. EMS personnel
  should advise hospital triage staff of any
  concerns or patterns in patient presentation as
  hospital staff may have received similar patients
  from other ambulance services.

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• Our best defense against the potentially
  devastating effects of pandemic influenza is to
  take a proactive approach and develop a
  comprehensive, community-specific plan that
  incorporates the unique needs and strengths of
  our communities.

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• Exercise

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Pandemic Influenza Contingency PlanningScenario

• You return to your community from this workshop
  and lead a process to develop a respiratory
  illness emergency plan. You want to integrate
  this with the plans for fire and flood
  evacuations since many of the same people and
  processes are involved. You discover that your
  communitys fire and flood plan is an empty
  folder. Describe what you will do and who should
  be involved in what you propose

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