Captain Randy Gwyn R.N., I.C.P.Captain Randy Gwyn R.N., I.C.P.Program DeveloperProgram Developer

Captain Bill Sault BA, ACP Captain Bill Sault BA, ACP Program ManagerProgram Manager

Firefighter Pre-hospital Care Disease Transmission /

Designated Officer Program

Routes of TransmissionRoutes of Transmission

There are 4 general routes of transmission

• Contact (Direct)

• Airborne (Indirect)

• Vehicle (Indirect)

• Vector (Indirect)

There are 4 general routes of transmission

• Contact (Direct)

• Airborne (Indirect)

• Vehicle (Indirect)

• Vector (Indirect)

Contact TransmissionContact Transmission

• most common mode for infectiousdisease transmission

• infection may occur by Directcontact or Droplet contact

• most common mode for infectiousdisease transmission

• infection may occur by Directcontact or Droplet contact

Direct TransmissionDirect Transmission• contact / person to person spread

• there must be actual physical contact between sourceand firefighter

• Droplet Spread (3 feet or less) by means of talking, sneezing or coughing

i.e. Cold & flu viruses

• some sources of infection include:soil, eating utensils, door handles

• contact / person to person spread

• there must be actual physical contact between sourceand firefighter

• Droplet Spread (3 feet or less) by means of talking, sneezing or coughing

i.e. Cold & flu viruses

• some sources of infection include:soil, eating utensils, door handles

Indirect ContactIndirect Contact

• Airborne Transmission• Similar to droplet spread• lighter particles from a sneeze or coughare carried on air currents

• Infections such as legionnaire’s diseasespread through the air systems ofbuildings, airplanes, etc.

• Airborne Transmission• Similar to droplet spread• lighter particles from a sneeze or coughare carried on air currents

• Infections such as legionnaire’s diseasespread through the air systems ofbuildings, airplanes, etc.

Vehicle TransmissionVehicle Transmission

Infected person Inanimate object

Non-infected personSources:• Needle stick injury - HIV, Hepatitis B / C• Contaminated water - Typhoid, Hep. A• Contaminated food - Botulism / Salmonella

Infected person Inanimate object

Non-infected personSources:• Needle stick injury - HIV, Hepatitis B / C• Contaminated water - Typhoid, Hep. A• Contaminated food - Botulism / Salmonella

Indirect ContactIndirect Contact

Indirect TransmissionIndirect Transmission

Vector Transmission• Transmission by an intermediate carrier

Sources include:• Mosquito – West Nile• Raccoon - Rabies• Tick – Lyme’s Disease

Vector Transmission• Transmission by an intermediate carrier

Sources include:• Mosquito – West Nile• Raccoon - Rabies• Tick – Lyme’s Disease

Chain of Disease Transmission

Chain of Disease Transmission

• Infectious Agent

• Reservoirs

• Portal of Exit

• Mode of Transmission

• Portal of Entry

• Susceptible Host

• Infectious Agent

• Reservoirs

• Portal of Exit

• Mode of Transmission

• Portal of Entry

• Susceptible Host

Chain of Disease Transmission

Chain of Disease Transmission

• Break the Chain

•Transmission can not occur

• Break the Chain

•Transmission can not occur

Communicable Diseases of ConcernCommunicable Diseases of Concern

Human Immunodeficiency Virus (HIV)

• A severe disorder of the immune system

• Not highly infectious to general population

• Transmitted by:Direct blood / body fluid contact

• PEP (post exposure prophylaxis) is available for asignificant exposure

Human Immunodeficiency Virus (HIV)

• A severe disorder of the immune system

• Not highly infectious to general population

• Transmitted by:Direct blood / body fluid contact

• PEP (post exposure prophylaxis) is available for asignificant exposure

Communicable Diseases of ConcernCommunicable Diseases of ConcernHepatitis A, B, C

• Worldwide problem- All affect the liver but aredifferent infections/agents

• Hepatitis A - fecal, oral route

• Hepatitis B & C - blood, saliva, semen and otherbodily fluids

• Hepatitis B vaccine and PEP (post exposureprophylaxis) are available

Hepatitis A, B, C

• Worldwide problem- All affect the liver but aredifferent infections/agents

• Hepatitis A - fecal, oral route

• Hepatitis B & C - blood, saliva, semen and otherbodily fluids

• Hepatitis B vaccine and PEP (post exposureprophylaxis) are available

Communicable Diseases of ConcernCommunicable Diseases of Concern

Meningitis

• Inflammation of the meninges - what are they?

• May be viral or bacterial

• Primarily a disease of small children

• Exposure - shared saliva ( kissing contact )• Vaccine is available but is not currently

recommended for healthcare workers (CanadianImmunization Guide Edition 6, 2002)

Meningitis

• Inflammation of the meninges - what are they?

• May be viral or bacterial

• Primarily a disease of small children

• Exposure - shared saliva ( kissing contact )• Vaccine is available but is not currently

recommended for healthcare workers (CanadianImmunization Guide Edition 6, 2002)

Exposure Determination

Meningitis Meningococcal Disease

hViral or Bacterial ?

hNeisseria Meningitidis ( the bacteria's real name )

hShared saliva ( a.k.a. kissing contact )i.e. shared utensils, cigarettes, airway management

hExposures of exposures / Are they legitimate? e.g. family of exposed firefighter

Communicable Diseases of ConcernCommunicable Diseases of Concern

Tuberculosis

• exposure to airborne droplet when the pt. coughs or sneezes ( prevention ? )

• transmission requires frequent and prolongedexposure

• growing problem in large urban areas

Tuberculosis

• exposure to airborne droplet when the pt. coughs or sneezes ( prevention ? )

• transmission requires frequent and prolongedexposure

• growing problem in large urban areas

Caring for Patients who May Have TBCaring for Patients who May Have TB• Use a fit tested N-95

on yourself.

• Use a surgical maskon patient (iftolerated)

• Use a fit tested N-95 on yourself.

• Use a surgical maskon patient (iftolerated)

Tuberculosis

hAirborne / Droplet contact

hDid the patient have an active and productive cough ? Fever ?

hIs patient currently under treatment?

hWas patient masked? Was the firefighter?

hWorking environment? Small, enclosed, poor ventilation and over an extended timeperiod?

Exposure Determination

Other Exposures

Antibiotic Resistant Organisms (ARO’s):

hMRSA, VRSA, VRE, ESBLs, C-difficile

hWest Nile Virus

hG.A.S.

All firefighters should have physicals each year.

Current immunization status or results of screening testsshould be determined for the following diseases:

All firefighters should have physicals each year.

Current immunization status or results of screening testsshould be determined for the following diseases:

MMONITORING PERSONAL HEALTHONITORING PERSONAL HEALTH

• Hepatitis• Tetanus/diphtheria• Measles• Mumps• Rubella

• Hepatitis• Tetanus/diphtheria• Measles• Mumps• Rubella

• Chicken pox• Polio• Tuberculosis (TB)• Influenza immunization• Flu shots offered yearly

• Chicken pox• Polio• Tuberculosis (TB)• Influenza immunization• Flu shots offered yearly

Designated Officer Program

hIdentifies police, fire and paramedics as high risk exposure group

hDeveloped to educated emergency service workers

hEstablish exposure protocols

hProgram setup by MOH in 1994

Designated Officer Program1994 Ministry of Health Guideline

• Establishes a means of notification of exposures.

• Toronto Fire Services Designated Officer (DO) is on call 24/7/365 days a year. TFS program incorporates a Occupational Health and Safety component so is identified as the SDO (Safety/Designated Officer).

• Should be contacted IMMEDIATELY following a suspected exposure via communications.

• Contact TFS communications and ask that the on-call SDO be paged. You will then be contacted by the SDO directly.

Patient Confidentiality

hThe Designated Officer will be working within a mutually shared environment with other health professionals.

h It is imperative that the D.O. maintains the appropriate level of patient confidentiality (both firefighter’s and source patient’s)

Bill 105• Legislation enacted on Sept.1, 2003.

• Under specific circumstances, can legally mandate a source patient to provide a blood sample.

• A legal application must be made and specific process followed.

• Application can be denied.

• Process is lengthy and complicated.

Bill 105• The DO should be contacted IMMEDIATELY!• The DO will assist with application process.• TFS staff are encouraged to utilize the TFS

Chief Medical Officer (Dr. Forman).• All discussions with DO and/or Chief Medical

Officer are CONFIDENTIAL.

DO advises firefighter to be evaluated and followed up by a doctor or other appropriate health care professional.

Public Health notifies DO of possible exposure (contact tracing).

Airborne Exposure Procedure

The medical facility must notify public health within 48 hours.

The medical facility diagnoses the disease in the client you treated.

You treat a client who is infected with a life-threatening airborne disease, such as TB, but you are not aware that the client is infected.

Bloodborne Exposure Procedure

All results of blood work will be received by ordering physician and reported to Public Health Unit.

If patient refuses to give sample, get your baselines and initiate a bill 105 application with Public health Unit (where patient resides).

If possible, attend same facility as source patient, the SDO will attempt voluntary consent for source patient bloodwork via attending physician.

Seek immediate medical attention, contact the SDO via communications and document the incident for worker’s compensation.

You come into contact with blood or body fluids of a patient, and you wonder if that patient is infected with life-threatening bloodborne disease such as HIV and/or HBV and/or HCV.

Self Study Suggestions

hUnderstand difference between bloodborne (HIV, Hep B, Hep C etc.) vs droplet (SARS, Meningitis, influenza etc.) exposures vs airborne transmission types

hReview Antibiotic Resistant Organisms (ARO’s) MRSA, VRE, ESBL’s, C-Difficile etc.

hReview known treatments of all aforementioned diseases

Self Study Suggestions cont...

hUnderstand difference between Meningococcal Disease and other Meningitis causing organisms

hUnderstand difference between Active Pulmonary T.B. versus Inactive or other site T.B.

hReview known treatments of all aforementioned diseases

Self Study Suggestions cont...

hReview applicable legislation

hBill 105, Bill 31, DO program

hReview patient confidentiality laws

hBill 105 application process

Exposure Risk Review

• Needle stick ? Needle type / function?• Uncooperative pt spits in face?• Blood splash in eyes?• Febrile, coughing pt in close quarters?• What about the driver? Families ?• Normal pt care duties?• To determine exposure, does pt’s disease

status matter?• How do you contact the DO??????

SOBERING REALITY

hPhiladelphia FD (2/3 size of TFS) have 200+ Hep.C positive firefighters

hMedical PPE use vs. SCBA use? Think 30 years ago (SCBA use) vs. 30 years from now (medical PPE use)?

Captain Randy Gwyn R.N., I.C.P.Captain Randy Gwyn R.N., I.C.P.Program DeveloperProgram Developer

Captain Bill Sault BA, ACPCaptain Bill Sault BA, ACPProgram ManagerProgram Manager

Questions ?