EMS World

SEP 2018

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EMSWORLD.com | SEPTEMBER 2018 29 ties, the homeless present a ripe environ- ment for its transmission. HAV can sur vive for months outside the body. It does not sur vive in freez- ing temperatures but does well when it's warmer. It is also difficult to kill with the usual disinfectant agents. Standard h an d -w a s h p ro d u c t s , eve n alco h o l- based ones, do not kill this virus. There are six genotypes of HAV. Those that cause illness in humans are geno- t ypes I, II, and III. There are al so t wo subt ypes, A and B. In Nor th and South America, genotype 1A is the most com- mon; however, testing has shown that the cases in California are genotype 1B, which is rare in the United States. This strain is more commonly seen in the Middle East and North Africa and is generally associated with persons with liver disease. This suggests this genotype is more virulent and likely to result in a serious case. Two cases of HAV in home- less persons in Colorado have also been of the 1B genotype, linking the cases to California. Each HAV genotype presents with the same signs and symptoms. The type is only identified by serotype testing. The signs and symptoms for all types of hep- atitis (A, B, and C) are the same: They begin like a flulike illness, with fever, mal- aise, headache, nausea /vomiting, and abdominal pain. This progresses to jaundice (yellow- ing of the skin and eyes), dark-colored urine, gray-colored stools, and joint pain. These are impor tant screening factors for patient assessment. Outbreak Response Outbreak response typically follows the familiar hierarchy of controls depicted by the safet y pyramid. This pyramid is not often applied to infection control but fits it well. In this outbreak the Centers for Disease Control and Prevention (CDC) dispatched teams to investigate cases and conduct testing. It sent notice across the state and to local health departments to be on the watch for HAV 1B infections, ensure due attention to identification of HAV infections, and send specimens for test- ing to the CDC Division of Viral Hepatitis laborator y. Health department officials have been advised to provide hepatitis A vaccines to people who are homeless, using drugs, or with other established risk factors for HAV infection. This includes anyone with ongoing contact with the homeless or drug users. This represents the top layer of the hierarchy of control s: elimination, or removal of the risk. This does not rou- tinely apply to EMS providers. The HAV vaccine is not recommended for EMS prov ider s (s ee sidebar), nor even for responders to disa sters in the United States. However, California public health authorities have offered HAV vaccines to EMS personnel who work with the home- less in the San Diego area. Outreach groups are working to get people off the streets. As one example, local organization Father Joe's Villages is refurbishing old hotels that are sitting vacant. A tent was erected to house 700 persons. Some are looking at the use of shipping containers to create housing, as has been done for homeless veterans in San Francisco. Such creative repurposing can be accomplished at low cost. Moving down the hierarchy of controls/ pyramid of safety, engineering controls are implemented to isolate people from the hazard. This is a preferred approach to administrative controls and PPE. In this case it involved the use of portable hand- wash stations, toilets, and showers. We routinely see portable toilets and hand-wash stations at large events such as concerts, and homeless camps show a similar need for such resources. Den- ver authorities recognized the need and made portable facilities available, as did their counterparts in San Francisco, who also provided tents for housing. Engineering control s generally cost more than administrative controls and the use of PPE; however, they have been found to be less costly over the long term. Administrative controls and work prac- tices consist of various policies and pro- cedures such as the use of personal pro- tective equipment. For example, when cleaning feces, using a high-pressure washer may not be the best choice, as it could result in spla shback. Chlorine (s o diu m hy p o chlo r ite) at dilu tio n of 5,000 ppm (1:10) bleach and water trans- lates to high-level disinfection. Keep the solution on the sur face for at least one minute. Mix it fresh daily. Education and training to reduce the duratio n an d f re qu en c y of ex p osure also fall under administrative controls. Here it is impor tant to teach that soap and water is needed for hand-washing because waterless hand sanitizers are not effective against the hepatitis A virus. Here a 1:10 dilution is used instead of the routine 1:100 mixture used for cleaning vehicles and equipment. Standard precautions, in this ca se, would involve the use of gloves and good hand washing for patient assessment. Cover gowns and masks are only need- ed if there is likely contact with patient excretions. ISSUE FOCUS: MANAGEMENT & OPERATIONS The hepatitis A vaccine is not routinely recommended for healthcare person- nel, including fire/EMS, or for persons who work in solid waste management. Twinrix, the combination (hepatitis A and B) vaccine, is also not routinely recommended for healthcare work- ers, sewer workers, or plumbers. This is addressed in the NFPA 1581 infec- tion-control standard. These recom- mendations are evidence-based and reflect science driving practice. —Katherine West Vaccination: Not Recommended for EMS

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