arrives with a patient at the dedicated entrance of a Regional Ebola and Other Special Pathogen Treatment Center."/>
Figure 23.2 Transport team arrives with a patient at the dedicated entrance of a Regional Ebola and Other Special Pathogen Treatment Center.
Source: Photo courtesy of U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response. public domain photos from the U.S. federal government.
Varicella Zoster Virus
Varicella zoster virus (VZV) causes two distinct diseases: chickenpox and “shingles” (herpes zoster). Acute chickenpox is highly contagious and usually runs its course in about a week or two, producing immunity, but VZV is not eliminated from the body. The virus becomes dormant in the sensory ganglia and may reactivate decades later to produce zoster [58]. To decrease the incidence of chickenpox in adults who were never exposed to VZV as a child, routine childhood vaccination began in 1995. The full vaccine regimen (two doses) is 90‐100% protective against chickenpox, and virtually 100% effective against severe disease [58]. Serologic screening for VZV immunoglobulin G is indicated for adult health care workers who do not have a documented history of chickenpox. VZV is common, so ensuring EMS clinicians are immune prior to patient care is important and cost effective. Only immune health care personnel should care for patients with chickenpox or shingles. If a pregnant EMS clinician has a documented history of chickenpox or has positive titers, she is considered to be immune and can care for patients. Both she and the fetus are protected.
Nonimmune adults exposed to either chickenpox or zoster can develop acute chickenpox, including potential complications of pneumonia, encephalitis, and death. Nonimmune personnel exposed to chicken pox or disseminated zoster must avoid patient contact from 10 days after the exposure (the incubation period) until day 21 [58]. An exposure is defined as a breach of contact precautions (such as localized direct contact with uncovered lesions) and/or breach of airborne precautions (chickenpox or disseminated zoster).
If an unprotected exposure occurs to a nonimmune health care professional, unless that person is pregnant or immunocompromised, the vaccine should be given within 3‐5 days. For people exposed to VZV who are nonimmune or cannot receive the varicella vaccine, varicella zoster immune globulin can prevent varicella from developing or lessen the severity of the disease. It should be given as soon as possible after exposure. Oral acyclovir or valacyclovir treatment should be considered in certain groups at increased risk for moderate to severe illness. These high‐risk groups include healthy people older than 12 years, people with chronic cutaneous or pulmonary disorders, people receiving long‐term salicylate therapy, and people receiving short, intermittent, or aerosolized courses of corticosteroids. Some physicians may elect to use oral acyclovir or valacyclovir for secondary cases within a household. Oral therapy should be given within the first 24 hours after the varicella rash starts, but is not recommended for use in otherwise healthy children experiencing typical varicella without complications.
Meningococcal Meningitis
Neisseria meningitidis, or meningococcus, can be acquired from an infected patient if a mask is not worn [59–61]. All health care workers should understand that preventing transmission of meningococcus requires adherence to droplet precautions and that it is not an airborne‐transmitted disease. The illness has a high case‐fatality rate (10%) [61].
Patients are considered infectious for one week before the onset of symptoms and for 24 hours after effective treatment begins. PEP should be administered when close, unprotected (no mask) contact occurs, such as while performing unprotected mouth‐to‐mouth resuscitation on an infected patient, or if splash/splatter of secretions into mucous membranes occurs, as with suctioning, intubation, vomiting, coughing, or endotracheal tube management. Simple proximity to the patient does not qualify as close contact, unless the EMS clinician was less than 3 feet from the patient for more than 8 hours [61]. Because many patients having symptoms consistent with N. meningitidis infection are actually infected with other viruses or organisms, PEP should be given only after substantial exposure (as defined above) to a patient with culture‐ or Gram stain‐proven meningococcus. There is time to determine if N. meningitidis is present before empirically administering prophylaxis to many EMS personnel unnecessarily. PEP for meningococcus should start within 24 hours but may begin up to 10 days after exposure. PEP options include ceftriaxone, ciprofloxacin, or rifampin. Exposed workers may return to duty 24 hours after PEP begins.
The EMS medical director plays an important role in ensuring that prehospital personnel are treated quickly and appropriately when a true exposure to N. meningitidis has occurred. Often, one of the following situations occurs:
1 A crew transports a patient suspected of having meningitis to an emergency department and calls the infection control officer with concerns about exposure.
2 Hospital infection control personnel attempt to contact exposed prehospital personnel involved with treatment/transport of an inpatient now diagnosed with meningococcus.
Usually, the infection control officer is directly involved, but the medical director can assist hospital infection control, occupational health service, and emergency department personnel by including prehospital clinicians in the pool of exposed workers. The designated infection control officer should gather specific information, confirming which (if any) prehospital personnel were close enough to the patient to warrant having them report for evaluation and possible PEP administration.
Routine vaccination is not recommended for any specific health care worker group, including fire and EMS personnel. However, certain groups of people, who may also be EMS clinicians, are appropriate to consider for vaccination if they have not already received it. They include 19‐ to 55‐year‐olds living in college dormitories or other congregate settings, military recruits, microbiologists routinely exposed to isolates of N. meningitides, travelers to or residents of countries in which N. meningitidis meningitis is hyperendemic or epidemic, individuals with terminal complement‐component deficiencies, and individuals with anatomic or functional asplenia.
Conclusion
EMS clinicians, by the nature of their work on the front lines of the health care system, have unique opportunities to encounter undifferentiated patients with infectious and communicable diseases. Vigilance in recognizing symptoms and signs of these illnesses is an important aspect of their work. First and foremost, EMS clinicians must be aware of the potential risks posed by communicable diseases and ensure they are consistent in using appropriate tools, in the form of PPE, to attenuate those risks.
References
1 1 Jeffress CN. Occupational Exposure to Bloodborne Pathogens: Precautions for Emergency Responders. Washington, DC: Occupational Safety and Health Administration; 1998.
2 2 Verbeek PR, McLelland IW, Silverman AC, Burgess RJ. Loss of paramedic availability in an urban emergency medical services system during a severe acute respiratory syndrome outbreak. Acad Emerg Med. 2004; 11:973–8.
3 3 Centers for Disease Control and Prevention. Influenza antiviral medications: summary for clinicians. Updated January 25, 2021.Available at: https://www.cdc.gov/flu/professionals/antivirals/summary‐clinicians.htm. Accessed February 14, 2021.
4 4 Prevention and Control of Influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2008. MMWR Recomm Rep. 2008; 57(RR‐7):1–60.
5 5 Centers for Disease Control and Prevention. Flu treatment. Last reviewed August 31, 2020. Available at: http://www.cdc.gov/flu/treatment/index.htm. Accessed February 14, 2021.
6 6 Centers for Disease Control and Prevention. Prevention and control of seasonal influenza with