varicella (chicken pox), and tuberculosis.
Vector‐borne transmission refers to the spread of infectious agents by means of an insect or animal (the “vector”). Examples of vector‐borne illnesses include rabies, where the infected animal is the vector, and West Nile virus or malaria, where infected mosquitos are the vectors. Transmission of vector‐borne illness does not occur between patients and EMS personnel.
Common vehicle transmission refers to the spread of infectious agents by a single contaminated source to multiple hosts. This can result in large outbreaks of disease. Examples of this type of transmission include contaminated water sources (Escherichia coli); contaminated food (Salmonella); or contaminated medication, medical equipment, or intravenous solutions.
General Approach and Patient Assessment
The risk of communicable disease is not as apparent as other physical risks, such as road traffic, power lines, firearms, or chemical agents. EMS personnel must use the same heightened level of suspicion and precaution whenever approaching a patient. All personnel must take appropriate precautions when a patient presents with any signs or symptoms potentially due to an infectious or communicable disease. All EMS and first responder agencies must provide appropriate training that prepares personnel to identify at‐risk patients and to use personal protective equipment (PPE). Table 23.1 outlines suggested PPE based on procedure or intervention. Table 23.2 provides suggested precautions based on the suspected infection.
Appropriate use of PPE is tantamount to implementation of isolation as it might be described in a hospital setting. One important principal difference is that the patient’s location is far less static. Thus, it is important that personnel, EMS and hospital alike, soon to come in proximity to the patient, have enough forewarning to enable them similarly to prepare with appropriate PPE. Further, in the case of a receiving hospital, advance notice may facilitate preparation of an optimal isolated receiving area for an infectious patient.
The risk assessment begins with information from the public safety answering point, prior to making patient contact. Call‐taking procedures should include basic screening to identify potential communicable disease threats. The screening can identify patients with symptoms of fever, chills, cough, shortness of breath, or diarrhea. The call‐taker can also determine if the patient location, such as nursing home, group home, or other institutional setting, poses a potential risk to the responding personnel. This information appropriately conveyed to EMS clinicians helps them prepare and determine what precautions are necessary before they make patient contact.
When patient contact is made, personnel should continue to determine if the patient has a potential risk for a communicable disease. A brief history and physical examination can help raise suspicion. The following screening questions may help identify a patient with a communicable disease:
Do you have a new or worsening cough or shortness of breath?
Do you have a fever, shakes, or chills?
Do you have a sore throat, runny nose, or nasal congestion?
Do you have nausea, vomiting, or diarrhea?
Do you have a headache or muscle pains?
Have you had an abnormal temperature (above 38 degrees C)?
Have you been in close contact with anyone who is ill or known to have a communicable disease?
Have you been in contact with anyone who has traveled to an area affected by a communicable disease outbreak?
A screening physical examination will also identify obvious signs of a communicable disease. This may include a rash, skin lesions, or draining wounds.
Specific Illnesses
Influenza
Influenza classically presents with the abrupt onset of fever, usually 38‐40 degrees C, sore throat, nonproductive cough, myalgias, headache, and chills. Influenza is caused by a virus with three subtypes in humans: A, B, and C. Influenza A causes more severe disease and is mainly responsible for pandemics. It has different subtypes determined by surface antigens H (hemagglutinin) and N (neuraminidase). Influenza B causes more mild disease and mainly affects children. Influenza C rarely causes human illness and is not associated with epidemics [3].
Influenza transmission occurs primarily through droplets when a person coughs or sneezes but may also occur indirectly by contact with surfaces contaminated by respiratory secretions. Handwashing and shielding coughs and sneezes help to prevent spread. Influenza is transmissible from 1 day before symptom onset to approximately 5 days after symptoms begin and may last up to 10 days in children. Time from infection to development of symptoms is 1‐4 days [4].
Influenza has been responsible for at least 31 pandemics in history. The most lethal “Spanish flu” pandemic of 1918‐1919 is estimated to have caused 50 million deaths globally with 700,000 of those deaths occurring in the United States in a single year. In this pandemic, deaths occurred mainly in healthy 20‐ 40‐year‐olds, which differs from the usual pattern of mortality and morbidity in young children and the elderly during seasonal outbreaks of influenza.
Table 23.1 Suggested Personal Protective Equipment Based on Procedure or Intervention
| Intervention | Gloves | Facial and Eye Protectiona | Gowns |
|---|---|---|---|
| Drawing blood or starting an IV/IO line | Yes | No | No |
| Controlling minor bleeding with pressure or dressing minor skin wound | Yes | No | No |
| Contact with patient with cough or vomiting | Yes | Yes | Yes (if febrile respiratory illness or vomiting) |
| Needle thoracostomy | Yes | Yes | Yes (if febrile respiratory illness present) |
| Tracheal intubation | Yes | Yes | Yes (if febrile respiratory illness present) |
| Oral or nasal suctioning | Yes | Yes | Yes (if febrile respiratory illness or vomiting present) |
| Controlling arterial or heavy venous hemorrhage | Yes | Yes | Yes |
| Emergency childbirth | Yes | Yes | Yes |
| Known infection or colonization with antibiotic‐resistant organism (VRE, MRSA, etc.) | Yes |
