Role of EMS in Preventing Infectious Disease Transmission
Dean Meenach // October 30, 2015
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.
This digitally-colorized scanning electron micrograph (SEM) depicts a number of mustard-colored, spheroid-shaped Staphylococcus aureus bacteria that were in the process of escaping their destruction by blue-colored human white blood cells. (Image courtesy of the National Institute of Allergy and Infectious Diseases)
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 recommendations1. The Advisory Committee on Immunization Practices (ACIP) (2011) reported that preventable disease outbreaks and patient mortality have been scientifically linked to unvaccinated healthcare workers2. Preventable diseases such as influenza, measles, mumps, Pertussis and Varicella have been linked to transmission from unvaccinated healthcare workers3,4.
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 healthcare organizations did not submit the mandated vaccination records of healthcare workers6. 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.
Antiobiotic-resistant pathogens: 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" problem7. 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 disease9.
C. diff is now the most common health care associated infection, resulting in over half a million infections annually9,10. 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 few9,10. 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 medicine2,11,12,13. 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 percent2,11,12,13,14.
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 ambulance12!
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 infectious diease transmission 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 disease15.
EMS, an unexpected courier of infectious diseases?
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 smartphones of healthcare professionals16,17,18,19,20. These pathogens have even been found in fire stations, in the home on bed linens, light switches, sinks, TV remotes, hand towels, counter tops, and even dogs and cats16,17.
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 environments21,22. 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 MRSA23. National surveys conducted by the National Institute for Occupational Safety and Health (NIOSH) (2010) revealed a high incidence of exposures to bloodborne pathogens for paramedics24. The NIOSH (2010) also identified underreporting of exposures, an absence of safety equipment, lack of PPE, and insufficient training in the use of PPE24.
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 MRSA18,25.
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 diseases26. 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:
- Use PPE: 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 Ebola27.
- Microrganism-resistant surfaces: When purchasing new ambulances, choose surfaces that contain polymers that are resistant to microorganism attachment.
- Get vaccinated: Stay up to date on the recommended immunizations for health care workers28.
- Follow CDC recommendations: All healthcare providers including EMTs and paramedics receive annual vaccination against influenza28.
- Annual TB test: Verify negative 2-step tuberculosis (TB) skin test (TST) annually4.
- Isolation protocols: Establish isolation protocols with healthcare organizations so that providers can prepare and safely respond to patients with antibiotic resistant organisms.
- Disinfection supplies: 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 Ebola29.
- Clean medical devices: Establish a protocol for the routine disinfection of medical devices and the ambulance patient care area and follow it closely.
- Clean the ambulance: Follow the "Ambulance Cleaning Procedures" on page 78 published in the APIC (2013) Guide to Infection Prevention in EMS26.
- Prevent infections: Follow the "Exposure Control" plan on page 80 published in the APIC (2013) Guide to Infection Prevention in EMS26.
- Wash your hands: Maintain hand hygiene standards and remember it is important hand hygiene must occur several times during patient contact30.
- Spread prevention education: Contribute to public health education by promoting and offering information and immunizations to the community31.
- Follow-up on patients: 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 alike4,32. 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.
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