X-Message-Number: 2661
Date: 22 Mar 94 16:25:57 EST
From: Mike Darwin <>
Subject: SCI.CRYONICS BPI TECH BRIEF #7
BPI TECH BRIEF #7
22 March, 1994
Copyright 1994 by Biopreservation, all rights reserved.
As with Tech Brief #6 on assessment and identification
of human cryopreservation patients this Tech Brief is a
reprint of a chapter from our Level I Transport Manual. It
is presented here both for criticism and comment and to
serve as a starting point for the generation of community-
wide standards for infection control during transport
operations.
Infection Control In the Standby and Transport Setting
By Michael Darwin and Steven B. Harris, M.D.
Introduction
Infectious disease is any illness which can be
transmitted from organism to organism. All infectious
diseases fall into the class known as parasites: they live
at the expense of the host organism by extracting energy and
materials from the host's body. Disease organisms which are
poorly adapted to their hosts rapidly kill or quickly
provoke immunity (neutralization) in the host, and thus
require a large population of susceptible individuals to
infect in order to propagate and survive. Such diseases
usually must spread rapidly and are known as epidemic
diseases. Examples of epidemic diseases are polio,
smallpox, Plague (Black Death), and the childhood diseases
such as chicken pox and measles. The causes or "etiologic
agents" of an infectious illness may be broadly divided into
four classes:
1) Viruses and associated sub-viral particles (virion) of
DNA and RNA; instructional material inside the cell's
nucleus which in effect "tells the cells what to do.".
Examples of viral etiologic agents (to name a very few) are
influenza, polio, hepatitis A, B, and C, and the human
immunodeficiency virus (HIV) the cause of Acquired
Immunodeficiency Syndrome (AIDS). An example of a "sub-
viral" etiologic agent is the Delta Particle which is a
small piece of nucleic acid which is harmless alone, but
when present in an individual suffering from Hepatitis B
virus infection, greatly exacerbates the morbidity and
mortality associated with the illness.
Viruses and virions, unlike the other etiologic agents
discussed below, are not capable of reproduction without a
living host cell, in other words, they rely upon a host to
provide most or all of the machinery for their reproduction.
In fact, a virus is often nothing more than a carefully
packaged set of instructions for making more virus (there
are many exceptions to this generalization: the smallpox
virus is large enough to see by "eye" with a high powered
light microscope and contains many enzymes and complex
structures which it uses to take over the host cell). The
"package," consisting of an outer coat of specialized lipids
or proteins, is designed to allow the virus to attach itself
to, enter, and take control of the cell's metabolic
machinery subverting it to the purposes of producing
thousands of additional copies of the virus (usually
resulting in the death of the infected cell).
2) Bacteria, protozoa, and fungi are capable of
reproduction outside of living cells of other organisms .
These organisms use the host's structure and nutrients as a
food source to further their multiplication. Illnesses
caused by these microorganisms are responsible for an
enormous range of human disease and suffering. Leprosy,
tuberculosis, the Plague , bacterial pneumonia, malaria,
syphilis, and gonorrhea are but a few.
3) Multicellular parasites are more complex organisms such
as mites (arthropods) and worms (helminths such as the
Cestodes, Trematodes and Nematodes) which can also infect
human beings and cause illness. Examples of such organisms
encountered in the Developed Western World are scabies, and
head, body, and public lice among the arthropods, and
pinworm (enterobiasis), trichinosis and filariasis among
the helminths. While illness caused by such muliticellular
parasites is less common in developed countries than it was
even a few decades ago, it is still common enough to be of
some concern to the Transport Technician and to merit
discussion of symptoms, and prophylaxis and treatment.
Transmission of Infection
Infectious agents may be found in many places in both
the animate and inanimate environment which surrounds us.
Transmission of infectious disease requires three factors: a
source of infecting organisms (or reservoir), a means of
transmission of the organism, and a susceptible host. These
three factors may be imagined as three overlapping circles:
*Illustration not included.
Figure 15-1: Elements of infection.
Source (Reservoir)
Infectious agents may survive in a reservoir but may or
may not multiply. Three common sources or reservoirs of
infection are: people, fomites, and animals:
People: The source of etiologic agents may be patients and
may include persons with acute disease, persons in the
incubation period of the disease, or persons who are
colonized by infectious agents but who have no apparent
disease. Patients may also become infected with their own
microbial flora (such as bacteria normally present in the
gut, on skin, and on mucous membranes). This is called
endogenous infection.
Fomites: The inanimate environment can also serve as a
source of etiologic agents. Bedding, work surfaces,
contaminated medical devices, door handles, and so on, can
all carry infectious agents from viruses to insects.
Animals and Insects: Fleas may transmit the Plague, ticks
may transmit Rocky Mountain Spotted Fever, and skunks and
bats serve as reservoir animals for rabies. Generally,
animals and insects are not considered of any significance
as a mode of disease transmission to the Transport
Technician at this time, although acquisition of infestation
with several species of insects from patients (scabies and
the body louse) are of slight concern.
Transmission:
Transmission is the mechanism for transfer of an
infectious agent from the source (reservoir) to a
susceptible host. There are four main routes of
transmission:
Contact Routes:
1) Direct Contact: This involves direct physical transfer
between an infected or colonized individual and a
susceptible host. Examples of this are when a transport
technician touches, intubates, suctions, surgerizes, or
performs other procedures which put him/her in direct
contact with the patient.
Indirect Contact: This occurs when there is contact between
the susceptible host with a contaminated object (usually
inanimate) such as instruments, clothing, linens, dressings
and so on.
Droplet Contact: The occurrence of droplet contact is as a
result of the production of aerosols of body fluids which
are expelled or propelled from the source (usually the
infected person) and which come into contact with the ,
skin, , conjunctivae, or other mucous membranes of a
susceptible host. This mode is considered direct
transmission since the droplets are usually large particles
which settle out of the air on environmental surfaces within
no more than three feet of the source. Examples of sources
of aerosols are coughing, suctioning, operation of
respiratory equipment, and aerosolization of body fluids
mixed with air (such as bloody foam being withdrawn from an
extracorporeal circuit) being discharged from a syringe into
an open waste container.
*Illustration not included.
Figure 15-2: Transmission Via Droplet Contact:
Aerosolization of infectious material during a sneeze. Note
the mucous strings and relatively coarse particle size.
Vehicle Route
The vehicle route transmits infectious agents or their
toxins through the following media:
Food - as in salmonella and staph infections
Water - as in giardia and legionellosis or Hepatitis A
Drugs and IV Fluids - as in septicemia secondary
to administration of a contaminated parenteral product.
Blood: as in HIV, or Hepatitis B or C.
Airborne Transmission
Transmission of etiologic agents by the airborne route
involves the creation of droplets or dust particles which
are less than 5 microns in diameter. These particles are
small enough to remain in the air currents in the ambient
environment and get onto or into the susceptible host
(conjunctiva, skin, or contact by inhalation).
Volume of Innoculum
The quantity of etiologic agent which is transferred
usually affects the liklihood of subsequent infection. This
will vary greatly from etiologic agent to etiologic agent.
For instance, it is estimated that a single smallpox virus
is capable of routinely causing infection. By contrast,
many, many HIV particles are typically required to cause
infection.
Vector-borne Transmission
This route of transmission involves an infectious agent
which is transmitted to the susceptible host by an arthropod
(insect). This is not a serious or common mode of disease
transmission in the developed world.
Host
The so far unmentioned but by no means unimportant
final element in the process of infection is the susceptible
host. Susceptibility to a given infectious disease can and
does vary greatly between hosts. Some hosts will easily
become infected. Others will be resistant to infection.
Still others will become infected and will experience mild
or not clinically obvious illness. Others may become
infected and serve as asymptomatic carriers of the disease.
Age, general health, the presence of stress, trauma, wounds,
nutritional status, and many other factors alone or in
combination all may act to impact the host's susceptibility
to a given etiologic agent. Finally, the genetic make-up of
the host and past history of exposure to the etiologic agent
or its antigens (such as vaccination) can have a profound
effect on the likelihood of infection as well as on the
course of the illness if infection occurs.
Prevention of Infection
Transmission of etiologic agents can only be inhibited
by "breaking the chain" of events which lead to infection.
Logically, the best place to do this is at the weakest link
in this chain.
1) Patients with known infections should be identified
promptly and their diseases assessed for the need for
special precautionary measures. Inanimate sources of
pathogens associated with caring for the patient can be
addressed through disinfection or sterilization. In all but
rare instances (which will be discussed briefly below)
standard "Universal Precautions" which isolate the Transport
Technician from contact with the patient's blood,
secretions, and other body fluids will be sufficient to
"break" the link at its weakest point, the point of
transmission.
With the emergence of HIV with its long, asymptomatic period
and its unusual feature of infectivity throughout all 5
phases of the illness, it has become imperative to presume
that all patients are HIV infected or carry other diseases,
both blood borne and respiratory, which may not be
clinically apparent at the time of standby or transport
(such as Hepatitis B, C, or tuberculosis (TB)).
2) Interrupting the mode of transmission is the most
frequently employed method of preventing the spread of
infectious disease. Hand washing, wearing of masks, gloves
and gowns, and disinfection of surfaces, linens and
instruments are all examples of interrupting transmission.
3) Hand washing has consistently been shown to be the most
effective single means of preventing transmission of
etiologic agents. All personnel should wash their hands
both before and after patient contact regardless of whether
or not gloves have been worn.
4) Manipulation of the host's susceptibility is one of the
more difficult factors to control. Vaccination and
administration of products conferring passive immunity (such
Hepatitis B immune globulin), and the use of
chemotherapeutic prophylaxis (such as the administration of
Ribavirin to personnel Transporting and perfusing HIV cases)
may help boost host defenses. Proper nutrition and stress
reduction are also important considerations and will be
discussed in greater detail later.. However, these are
downstream interventions and the best place to prevent
infection is to prevent contact of the infectious agent with
the host.
5) Isolation in the form of Universal Body Substance
Precautions (UBSI) is to be practiced at all times during
patient contact since they are the best way to break the
chain of infection. The isolation precautions mandated in
this manual are predicated on this concept.
Diseases of Concern in the Standby/Transport Setting
From the moment the Transport Technician first has
contact with the patient it is important to be aware of the
patient's medical history and to pay particular attention to
the following diseases which are of special concern:
(AIDS) Human Immunodeficiency Virus Infection. HIV is a
lipid coated retrovirus (an RNA virus) which is transmitted
through intimate contact with body fluid containing the
virus. Examples of such contact which are of special
concern to the Transport Technician are contact of mucosa or
open wounds with blood or body secretions, needle sticks or
cuts with instruments contaminated with infected blood or
body fluid, conjunctival contact with blood or body fluid
during suctioning, catastrophic rupture of the
extracorporeal circuit, or aerosolization of
blood/secretions during Thumper support in the presence of
fulminating pulmonary edema, or contact with circulating
water in the Portable Ice Bath (PIB) which is contaminated
with body fluids.
HIV is a disease with 6 stages beginning with infection
and ending with complete compromise of the host's immune
system and death. This first stage of the disease
(infection) is sometimes (though not always) accompanied by
flu-like symptoms; fever, malaise, sore throat... The
disease infects T-lymphocytes, in particular "helper" T-
lymphocytes either killing them or rendering them
ineffective. When the population of helper T-cells drops
below 400 per cubic mm of blood or about 1/2 of normal the
infected individual becomes increasingly susceptible to
attack by bacteria, viruses and malignancies which are
normally kept in check by this arm of the immune system.
Infection with single or multiple etiologic agents ensues
eventually resulting in death from failure of one or more
organ systems. HIV may also infect other body cells such
as those in the central nervous system and gut, causing
dementia and
*Illustration not included.
Figure 15-3: The Walter Reed Classification System chart
show the progression of patients from exposure to HIV (WR-0)
through stages of progressive immunocompromise ending with
complete collapse of T4 cell function and death. The
criteria by which patients are staged are shown in the 4th
and 5th columns from the left and consist of T4 cell count
and decay of the delayed hypersensitivity response (skin
anergy: in other words failure of the patient to develop a
local inflammatory response on the skin after cutaneous
administration of common disease antigens such as measeles,
mupms and so on). The chart below shows WR staging versus
both T4 cell count and associated clinical changes (i.e.,
lymphadenopathy, opportunistic infections, etc.).
intestinal failure. The mean incubation period for AIDS
(the final stage of HIV disease) is believed to be 10.25
years. However, individuals have been to known to die of
AIDS as early as 12 months after infection and to have
remained healthy for as long as 17 years.
Because HIV compromises the arm of the immune system
most responsible for protecting the individual against
tuberculosis (TB), this disease is epidemic amongst HIV
infected individuals in the 3rd through 5th stages of the
disease. Unlike HIV, TB is a highly communicable disease.
TB will be discussed in great detail below, however it is
worth mentioning here that all AIDS patients must be
presumed to have concurrent TB infection since AIDS destroys
the immune response used to detect the presence of TB
infection. It is estimated that between 1/4th to 1/3rd of
all AIDS patients are infected with TB; an increasing number
with a strain of TB which is resistant to most antibiotics
known to be effective at treating TB (so-called multi-drug
resistant TB (MDR-TB)).
HIV has been found in virtually all body fluids but is
present in the highest concentration in semen, blood and
cervical secretions. Although not common, it is a
theoretical possibility that HIV may be transmitted through
contact with any body fluid such as urine, saliva, tears,
cerebrospinal fluid, peritoneal fluid, pericardial fluid,
pleural fluid, synovial fluid, amniotic fluid and breast
milk. While HIV has been found in saliva there are no
documented cases of transmission by this route. Extensive
studies involving the use of shared eating utensils, tooth
brushes, and intimate oral contact between infected and
uninfected persons have failed to demonstrate theses routes
as a means of transmission. Because HIV is a lipid coated
virus it is very fragile and does not survive long on
environmental surfaces. Furthermore, its lipid coating
makes it very susceptible to destruction by soaps and
detergents. Thus, cleansing of environmental surfaces with
detergents and disinfectants and hand washing are very
effective at destroying the virus.
*Illustration not included.
Figure 15-5: Typical patient clinical course and T4 cell
count as staged using the Walter Reed staging classification
for HIV infection. Approximately 3 months after exposure
the patient shows significant levels of virus in the blood.
The T4 cell count drops and then rebounds in response to
initial antibody production by the host. By about 9 months
lymphadenopathy develops. At approximately 36 months after
infection the T4 cell count has declined to below 400. At
68 months the patient became symptomatic with oral thrush.
Twevele months later the patient experiences multiple
opportunistic infections and at 83 months death occurs with
a T4 cell count of essentially zero. (From Scientific
American 259:4, 1988.)
Risks Of Transmission
Of special concern to the Transport Technician is the
risk of acquiring HIV infection as a result of incidents of
exposure or "breaks" in technique which may occur during the
course of transport operations. The "good" news is that HIV
is not very infectious compared to most other epidemic viral
illnesses and in particular in comparison to Hepatitis A, B,
and C. The Hepatitis viruses are by comparison thousands of
times more infectious than HIV.
The bad news is that HIV infection is generally
presumed to carry a mortality rate of 100%. Thus, it is of
paramount importance that the Transport Technician not
become infected with HIV during the course of delivering
cryopreservation care. The unbreached application of UBSI
Precautions to be described below will virtually guarantee
protection from transmission of HIV to transport staff.
*Illustration not included.
Figure 15- 4: The graphic above shows the wide variety of
tissues which are currently known to be infected with the
Human Immunodeficiency Virus (HIV). All cells which can be
infected with HIV carry the CD4 molecule on the surface of
their cells.
However, accidents can and do happen and it is
important that staff be aware of the risks they face in the
event of an incident of exposure. While there is no way to
know what the response of a given individual will be to
exposure, the risks for statistical populations are known
and they are as follows:
1) Needle Sticks/cuts with HIV contaminated sharp objects:
This is by far the most serious and common source of
exposure. It is estimated by the CDC that the risk of
infection from this route is roughly 1 in 250. In other
words, for every 250 people who experience this kind of
contamination 1 will become infected with HIV.
*Illustration not included.
Figure 15-6: Recapping needles is strictly forbidden
because of the obvious risk of needle-stick.
2) Conjunctival/Respiratory Contact With Aerosols or Blood:
Good numbers for this route of transmission are not known.
Personal communication with infectious disease physicians
experienced in this area place the risk for conjunctival
contact at between 1 in 500 and 1 in 1,000. The risk for
respiratory contact is not known.
3) Blood Contact With Open Wounds (cuts, abrasions, etc.):
Risks are not well established here although there have been
several documented cases of transmission by this route
amongst health care workers.
It should be noted that the CDC has stated that the
risk of infection from needle sticks is low. The author
believes this statement to be hypocritical since the risk of
acquiring HIV from needle sticks, puncture, or incision by
other contaminated sharps, is the same as quoted for
unprotected anal intercourse with an infected partner: a
practice which the CDC defines as very high risk.
Universal Body Substance Isolation
Universal body substance isolation precautions (UBSI)
are called "universal" for the simple reason that you must
assume that all patients you care for are infected with HIV
or one or more other blood or airborne pathogens.
Since medical history, testing , and examination cannot
reliably identify all patients infected with HIV and TB the
following blood/body fluid and airborne disease precautions
must be consistently used for all patients:
From the time Standby begins all Transport Technicians who
will have contact with the patient including being present
in the room where the patient is being cared for must wear a
mask at all times. Gloves must be worn for touching blood
and body fluids, mucous membranes, tissues or non-intact
skin of all patients. Gloves must be latex, not vinyl.
Vinyl gloves are easily torn and rapidly develop microscopic
holes which allow more than two times the penetration of
bacteria and viruses than do latex gloves.
*Illustration not included.
Figure 15- 7: The Human Immunodeficiency Virus.
Once transport operations begin all transport personnel
must wear the following protective items at all times during
transport operations:
o Hand/skin protection consisting of nitrile glove liners
with latex exam or surgical over-gloves. Personnel who will
not be doing surgery must wear heavy-duty minimum 12 mil
nitrile gloves with latex over-gloves. Surgical or other
personnel requiring good "feel" or touch sensitivity may
wear sheer 5 mil nitrile liners with surgical or latex exam
over-gloves.
o Respiratory protection consisting of either tie-on or cup-
type surgical masks.
o Eye protection consisting of goggles or full face shields.
Personnel involved in perfusion operations or surgery must
wear full face shields.
o Body skin protection consisting of Tyvek suits which cover
arms, trunk and legs.
o Shoe covers must be worn to prevent contamination with
ice water contaminated with body fluid which may accumulate
on the floor during PIB leaks or movement of the patient out
of the PIB. If the Tyvek clothing has integral shoe covers
these are acceptable.
Hands and other skin surfaces should be washed thoroughly
with soap and water if contaminated with body fluids or
blood. Hands should also be washed immediately after
removal of gloves. Nitrile liner gloves should also be
washed while on the hands (and left in place) if there is a
need to discard the latex over-glove (such as when exiting
the transport or operating area to a "clean" area or working
on clean equipment). If possible all hand washing and skin
cleansing should be carried out with an antimicrobial soap.
Extreme care should be taken to avoid sticks or cuts
from scalpels, needles or other sharp objects both during
and after procedures and when cleaning instruments. To
prevent needle-stick injuries needles should never be re-
capped, purposely bent, or broken by hand, removed from
syringes, or otherwise manipulated by hand. Immediately
after use needles, scalpel blades, syringes and other
disposable sharp objects must be placed in rigid walled,
puncture resistant "sharps containers" for disposal.
Locate the sharps container as close to the point of use as
possible. Never lay a used needle or sharp down on any
surface for any reason. Sharps must disposed of promptly.
Transport Technicians who have lesions or weeping
dermatitis should refrain from all direct patient contact
and from handling contaminated patient care equipment until
the condition is gone.
Where possible Transport Technicians who are pregnant
should refrain from involvement with invasive aspects of the
procedure and should exercise special care to protect
themselves during discharge of their duties. While pregnant
women are not known to be at increased risk of contracting
HIV in a healthcare or transport setting, the fact remains
that if infection does occur their is significant risk of
its prenatal or natal transmission to the fetus/infant.
Although saliva has not been known to be responsible for
HIV transmission it is capable of transmitting Hepatitis
and other infectious agents. For this reason bag-valve
resuscitators or other ventilation equipment providing
isolation for the Transport Technician should always be
available for use during transport operations.
HIV Chemoprophylaxis and Surveillance
Transport personnel involved directly in invasive
surgical operations employing sharps under field conditions
should be prophylactically treated with Ribavirin (Vilona)
obtained from Mexico. While this drug is not an effective
treatment for HIV infection because of its failure to cross
the blood-brain barrier, it is the prophylactic agent of
choice at this point. Zidovudine (AZT) should probably not
be used for prophylaxis since most AIDS patients have
received this drug during their illness and thus harbor
Zidovudine resistant virus. The HIV chemotherapeutic
agents ddI and ddC are unacceptable for prophylaxis due the
high incidence of both mild (GI disturbances) and serious
(pancreatitis) side effects. By contrast, Ribavirin, used
for the short period of transport operations, and a brief
window beyond, is very unlikely to produce serious side-
effects. The following protocol of Ribavirin prophylaxis
is indicated for surgical personnel involved in transport:
When the patient becomes frankly agonal, at-risk team
members should take a dose of 400 mg of Ribavirin (Vilona).
Thereafter doses of 400 mg should be administered at 8
hour intervals for 48 hours after transport operations or
other risk of exposure ceases.
In the event of needle stick or other contamination or
break in technique Ribavirin therapy should be continued for
14 days. Follow up serologic examination should then be
conducted at 90 days, 6 months, and 12 months to rule out
the possibility of infection.
All Transport Team Members must have routine
surveillance for the presence of HIV infection at 90 days
and 6 months following transport operations when it is
documented that HIV infection was present in the patient.
(NOTE: all patients are serologically evaluated for the
presence of HIV antibodies following cryopreservation..)
*Illustration not included.
Figure 15-8: Ribavirin for use in prophylaxis against HIV
infection.
Transport personnel with known exposure to HIV should
continue Ribavirin prophylaxis for at least 2-weeks. The
Technician should then be tested for HIV antibody at 6
weeks, three months, six months and one year. Until HIV
seronegativity is firmly established (antibody
seronegativity by ELISA at 1-year and/or antigen negativity
by PCR at 6 months) the exposed individual should be
counseled to avoid unprotected sexual contact and operate
under the assumption that they are HIV infected and act to
protect their sexual partners accordingly. Similarly,
exposed individuals should refrain from blood, blood
component, or semen donation, and females should defer
pregnancy until absence of infection can be determined.
Hepatitis A, B, and C
Hepatitis A is a highly infectious form of hepatitis
(liver inflammation/injury) which is transmitted primarily
through oral-fecal contact (as in lack of or improper hand
washing during food preparation) or by blood or salivary
contact. It is most often a childhood disease with a peak
incidence between the ages of 5-14 years. It has a short
incubation period (15 to 50 days) usually causes little
morbidity (though this is variable) and is only rarely
associated with mortality (<0.5%). However, several caveats
apply in this regard: pregnant and post menopausal women
appear to have a more severe course of the illness and the
morbidity rises for both males and females the later in life
that infection occurs.
The incidence of Hepatitis A is somewhat seasonal
occurring mostly in Autumn or Winter. The clinical course
is one of abrupt onset with anorexia, fever, nausea,
vomiting, lassitude and sometimes right upper quadrant
abdominal pain. Symptoms persist for several days to a week
after which time jaundice (yellowing of skin and the whites
of the eyes) appears if it is going to occur. Once jaundice
occurs fever and associated symptoms usually decrease in
severity. Jaundice is frequently accompanied by dark urine,
and light or white colored stools. The onset of jaundice
usually signals the beginning of recovery. The patient is
infectious throughout the illness and often into
convalescence which may be prolonged (lasting several weeks
to months). The usual course of the disease is benign and
recovery is almost always complete. Comparatively rarely
the disease may become fulminant and the patient experience
significant morbidity or even mortality.
Patients recovered from Hepatitis A are believed to
have lifetime immunity and do not develop carrier state.
Hepatitis B and C
Hepatitis B and C will be discussed together since the
clinical course of both illnesses is roughly the same and it
is believed that the incubation period, mortality and
morbidity are also comparable.
There are several important differences between
Hepatitis B and C and Hepatitis A. The onset of B and C is
slower, indeed often insidious, and the incubation time is
far longer: 45 to 160 days. Not infrequently the first
appearance of the disease is jaundice. However, fatigue,
malaise, changes in urine color, and occasional febrile
illness accompany initial manifestation of the illness.
While the onset of Hepatitis B and C is slower with
patients often being afebrile, the clinical course is much
more serious than with Hepatitis A. Hospitalization is
frequently necessary and the mortality may approach 10 % to
20% in some outbreaks. The symptoms of the illness:
jaundice, malaise, anorexia, fever, white or cream-colored
stools, and dark urine are much the same as with Hepatitis A.
It should be noted that many individuals in the
population have had Hepatitis A, B and/or C and have never
manifested clinical symptoms. In the case of Hepatitis A it
is believed that the ratio of asymptomatic (undiagnosed)
cases to symptomatic cases is 10 to 1. For Hepatitis B and
C the ratio is lower, possibly as low as 2 to 1 or 3 to 1.
While the clinical course of Hepatitis B and C may run
the gamut from virtually no symptoms to death, it is an
unfortunate reality that the less severe the course of the
illness, the more likely the illness is to become chronic
and/or to result in carrier status for the infected
individual. The chronic active form or Hepatitis B and C
has a high mortality both from liver failure as a result of
the direct action of the virus and from liver cancer
associated with the chronic presence of the virus.
Similarly, carriers of the B and C viruses have an
approximately 100-fold greater risk of developing primarily
carcinoma of the liver and of course they are a life-long
source of infection to those with whom they come into
intimate contact, or with whom they share needles or blood
products.
The primary routes of transmission of Hepatitis B and C
are sexual contact, intimate personal contact (shared tooth
brushes, or other hygienic utensils), contaminated needles
or sharps (such as those used in IV drug abuse, ear
piercing, and tattooing) and blood products.
Hepatitis Precautions
The UBSI techniques discussed above for use with HIV
are also effective at protecting against all three varieties
of Hepatitis. It is important to point out that unlike
HIV, Hepatitis B is easily transmitted through routine
contact such as bed bathing, kissing, and so on. Thus,
Transport Technicians present in standby operations
(particularly long standbys) who become involved in routine
patient care should be especially vigilant when dealing with
individuals infected with Hepatitis. The use of gloves,
masks and cover gowns is required during all patient handing
operations including turning, bathing, suctioning, and
handling of linens soiled with body secretions.
Hepatitis Prophylaxis
A very safe and highly effective vaccine is available
against Hepatitis B (HB vaccine). It is required that all
transport personnel be immunized against hepatitis B using
either of the commercially available vaccines (Recombivax or
Engerix-B). Following vaccination the Transport Technician
should be evaluated for anti-hepatitis B antibodies (anti-
HBs) to ensure the presence of a sufficient titer of
antibody to confer protection.
In the event of documented exposure to Hepatitis A, a
single dose of pooled gamma globulin (0.02 to 0.04 ml of 16%
solution per kilo of body weight) should be administered
intramuscularly as soon as possible after exposure. Exposed
personnel must then be followed by the Suspension Team
Medical Director or their own physician and development of
any disease documented and reported as required by law.
*Illustration not included.
Figure 15-9: Hepatitis B vaccine is a safe, highly
effective and nearly side-effect free product for protection
against Hepatitis B.
Personnel with documented exposure to Hepatitis B
should be treated with Hepatitis B Immune Globulin (Hyper-
Hep). The usual dose for adults is 1 ml administered
intramuscularly. Simultaneously, the Team Member should be
evaluated for anti-HB titer and if the titer is inadequate a
booster dose of HB vaccine given.
Personnel exposed to Hepatitis A or C should refrain
from intimate contact with others (including sexual contact
with or without use of a condom) until seronegativity for
the antigen can be established or the maximum common
incubation period has passed without evidence of
seroconversion or illness.
Mucocutaneous Herpes
Herpes infections of the skin and/or mucous membranes
are common in patients suffering immunocompromise from HIV,
cancer, chemotherapy or advanced age. UBSI precautions
should used to protect against transmission of these agents.
The Herpes viruses cause a wide range of human illness but
have a predilection for tissues derived from the embryonic
ectoderm, usually infecting the skin and/or the nervous
system. Herpes viruses are lipid coated but can persist for
clinically relevant times on environmental surfaces. A
rather unpleasant, albeit fascinating aspect of Herpes
viruses, is their ability to establish latent infection
after the initial invasion of the host. This characteristic
can result in repeated symptomatic outbreaks of the illness
even decades after initial infection. A brief summary of
the most common Herpes viruses responsible for human
diseases of concern to the Transport Technician is discussed
below:
Herpes Simplex viruses are the class of etiologic agents
responsible for cold sores, and genital herpes. H. Simplex
may infect the eyes, lips, mouth, anus, vagina, and
occasionally the central nervous system. Infection with one
or more varieties of H. Simplex is almost universal. UBSI
precautions should be used when caring for patients with H.
Simplex. The illness does not usually cause significant
mortality except in immunocompromised hosts.
Cytomegaloviruses (CMV) are among the most ubiquitous
viruses infecting man. It is estimated that in the United
States 60 % to 80% of the population is infected with one or
more strains of CMV. The CMVs can cause a wide array of
illness most of which are not serious. CMV mononucleosis is
common. More serious forms of CMV such as CMV disease of
the liver (CMV hepatitis), central nervous system, liver,
kidneys, and lungs most often occur in immunocompromised
hosts. CMV is not highly infectious and requires contact
with body fluids. UBSI should be effective in preventing
transmission of CMV in most cases.
Epstein-Barr Virus (EBV) is the primary causative agent of
infectious mononucleosis. The exact mode of transmission of
EBV is unknown however, like CMV and the other herpes
viruses, infection with EBV is ubiquitous. Certain strains
of EBV in certain susceptible individuals seem to be
responsible for, or at least closely associated with,
several malignancies: including Burkitt's lymphoma, and
carcinoma of the post-nasal space. While the route of
transmission of EBV is as yet not well established (although
it is often referred to as the "kissing disease"; an
unproved theory!) it is clear that EBV is not very
infectious, rarely results in serious illness, and with the
use of UBSI precautions presents little risk to the
Transport Technician.
Varicella-Herpes Zoster is more commonly known as
chickenpox, a benign disease of the skin usually seen in
childhood. It commonly causes pustular eruptions on the
skin and runs its course in 7-10 days. The incubation time
is quite consistently between 15 and 18 days.
In many individuals infected with H. Zoster the
infection re-emergence late in life as shingles: an acutely
painful lesion of the skin confined to the path of the
infected underlying nerve and characterized by the same kind
of papule with the same crusting progression observed in
chickenpox. The exudate from these lesions is highly
infectious.
UBSI should be used in handing individuals exhibiting
active H. Zoster disease. Typically H. Zoster is not a
major concern for the Transport Technician since most have
been previously infected and are thus immune to acute re-
infection. The exception to this rule is adults who have
not had previous H. Zoster infection (i.e., chickenpox). In
the case of such immunologically naive individuals transport
of patients with active H. Zoster infection should be
avoided since infection with H. Zoster in the adult is more
serious and can occasionally result in significant morbidity
and even (rarely) death. While UBSI precautions should be
used in H. Zoster infections it should be noted that in
patients with extensive lesions these precautions may well
fail to protect the immunologically naive Transport
Technician; H. Zoster, much like smallpox, is highly
infectious and even the slightest exposure to the etiologic
agent is likely to produce disease (witness the near
universality of infection in the global human population).
Alternatively, the immunologically naive Transport
Technician may choose to transport such a patient accepting
the likelihood of subsequent infection and choosing to
undergo therapy with Acyclovir (an oral antiviral of low
toxcicity which is effective against Herpes viruses) to
moderate the course of the illness. Prophylaxis with
Acyclovir is also a possible option and may be decided upon
by the Transport Technician and the Medical Director.
Influenza
Influenza is an acute, highly contagious disease that
is almost always associated with fever and profound fatigue.
Severe headache, myalgia and malaise accompanied by
(usually) relatively mild respiratory symptoms is typical.
The outcome is usually benign with the notable exceptions
being the very young, the very old, and the
immunocompromised. The usual cause of morbidity and
mortality in these groups is viral and/or bacterial
pneumonia with a few individuals succumbing to acute
cardiomyopathy with resultant congestive heart failure.
There are three types of influenza: A, B and C each of
which is antigenically distinct and unrelated to the other.
All three are lipid coated viruses all three are susceptible
to chemotherapy with the antiviral Ribavirin.
Additionally, early influenza A infection can be treated
with two other antivirals, amantadine and rimantadine. A
bivalent vaccine for influenzas A and B exists and it is
recommended that transport personnel be immunized against
influenza annually.
Influenza is of particular concern to the
Transport Technician for the following reasons:
1) It is highly infectious and UBSI precautions may fail to
check its spread to staff caring for the patient. It is not
inconceivable that most or all of the staff may contract the
illness at once making patient care delivery problematic to
say the least!
2) It has a very short incubation time (24-48 hours) so that
staff may become ill with it before the end of standby,
during transport, or during subsequent cryoprotective
perfusion and cool down.
3) It is a prostrating and incapacitating illness which
demands inactivity and bed rest. It cannot be "worked
through". Failure to get adequate rest can result in
exacerbation of the illness and serious complications.
4) It is a common cause of death in the elderly and
immunocompromised patient; the prime patient population
for cryopreservation.
5) Infection of Transport and Perfusion staff with influenza
from a cryopreservation patient has already occurred and has
resulted in serious compromise of key personnel to perform
effectively in a patient safety threatening emergency
which immediately followed the patient's cryopreservation.
For these reasons Ribavirin and amantadine
hydrochloride (another prophylactic chemotheraputic agent
effective against influenza A) are maintained in the
Transport Team Leader's ONK and may dispensed at the
discretion of the Medical Director in the event that
vaccination and UBSI fail to prevent staff infection.
Meningitis/Encephalitis
Meningitis with or without accompanying encephalitis
may be caused by a wide range of viral and bacterial
infections. Of most concern here are those caused by
communicable viruses and the meningicocci. The virulence of
these etiologic agents varies considerably. UBSI
precautions as described above should be used.
Chemoprophylaxis or Bioprophylaxis should be determined by
the etiologic agent and the judgment of the Cryopreservation
Team Medical Director as to their appropriateness.
While the occurrence of an outbreak of meningicoccal
meningitis in an institutional setting (camp, prison,
military barracks) is often the cause of near hysteria, the
fact is that the overall risk of transmission is very low
and lower still in a medical setting where respiratory
protection is in place. Most patients who have had 24 to 48
hours of antibiotic therapy for the disease will present no
risk of transmission. Prophylaxis in the form of
minocycline and rifampin (or other suitable agents) may be
initiated by the Medical Director at his/her discretion
based upon the virulence of the organism and the degree of
exposure of the staff.
Vaccination against several strains of meningicoccal
meningitis is also an option and may be administered at the
discretion off the Medical Director and Transport Team
Member.
Pneumococcal Pneumonia and Meningitis were until recently
of little concern to the Transport Technician in the
Transport setting. However this has begun to change with
recent emergence of several strains of pneumococcus which
are resistant to almost all antibiotics including the third
generation cephalasporins, pennicillin and streptomycin.
The only antibiotic effective in some cases against these
organisms has been vancomycin administered in high doses.
At such doses vancomycin is both nephro- and oto- toxic.
There have been several deaths from these strains of
pneumococcus and almost uniform severe morbidity (due
largely to delays in diagnosis as a result of the failure of
the illness to respond to conventional antibiotic therapy).
Transport Technicians are at special risk of acquiring
antibiotic resistant pathogenic pneumococcal organisms as a
result of their contact with the elderly nursing home
patients who have often had repeated courses of antibiotics
for pneumococcal pneumonia. There is thus the risk that the
Transport Technician may become carrier for such organisms
and later succum to infection with antibiotic resistant
pneumonia or meningitis. It is for this reason that all
Transport Technicians are required to be vaccinated for
pneumonia.
Tuberculosis (TB) was once the leading cause of death in the
United States and was known as the White Plague. It
devastated generations of Americans. It is still the
leading cause of death worldwide. The causative organism is
Mycobacterium Tuberculosis a non-motile bacillus which is
transmitted primarily by the airborne route. Humans are
very susceptible to TB. In epidemics of TB resulting from
contact with an open case of pulmonary tuberculosis (such
as in a classroom or homeless shelter setting) 50 % to 70%
of the exposed individuals will become infected although
only a few will develop clinical disease during the first
few years after infection. The age at which infection
occurs has a significant relationship to the time at which
subsequent active disease is likely to develop.
While most associated with its pulmonary manifestations
the disease may affect many organ systems. Tubercular
disease located elsewhere than in the lung is referred to as
miliary TB. Organs or tissues affected by miliary TB may
include (but are not limited to): bones, joints, skin,
bladder, kidneys, liver/gallbladder, lymphatic system,
cervix, and most devastating, the brain and meninges.
TB was once thought a thing of the past in U.S. and was
of little concern to either the general population or to
health care workers. Changes in the handling of the
mentally ill (with the resultant creation of "street
people") and the emergence of large numbers of
immunocompromised individuals as a result of HIV infection
have changed all that. The incidence of TB is climbing
rapidly in the United States and, what is more troubling,
there has emerged several strains of the organism which are
resistant to virtually all currently available (and so far
to all experimental) chemotheraputic agents. It is now
estimated that as many as 10% of all TB infections in AIDS
patients are of the multi-drug resistant variety. This is
a very serious public health issue which, in this author's
opinion, is not being addressed well in the United States.
The U.S. strategy to controlling TB has long relied on
surveillance with a skin test of tuberculin antigen (PPD or
tine)(originally developed by the Bacilli's discoverer
Robert Koch) to identify infected individuals and then treat
them with a combination of drugs (usually Isoniazid and
Rifampin) most commonly administered over a 12-month period.
Unfortunately, due to poor or nonexistent follow-up on the
part of U.S. public health authorities, particularly among
the lower socioeconomic classes and "street people" has lead
to the emergence of strains of the organism which are
completely resistant to all currently available
chemotheraputic protocols.
Another distressing development is the growing
population of immunocompromised individuals in whom active
tubercular disease cannot be easily detected with the skin
test. Unfortunately, tubercule bacilli are notoriously
difficult to culture and this procedure is not only costly
but not very effective in identifying active cases. These
three developments: the resurgence of TB, the emergence of
multi-drug resistant TB, and the presence of a growing
reservoir of undetectable hosts for TB make it imperative
that the Transport Technician protect his/herself against
tuberculosis by every means available.
*Illustration not included.
Figure 15-10: A 12-year follow-up on children infected by a
single school teacher (From: Hyge. Danish Med. Bull., 4:13,
1957).
This is especially true since a significant percentage
of patients presenting for cryopreservation have done so
because of HIV infection. In fact, using the Alcor
Foundation (the largest cryopreservation organization)
experience as representative, 18% of all patients who have
presented for cryopreservation after the beginning of the
AIDS epidemic did so because of HIV disease. As has been
previously noted, AIDS patients constitute a significant
reservoir of TB.
TB Precautions
TB is spread by airborne particles (droplets or dust)
and thus respiratory protection is of paramount importance.
Masks should be worn by transport personnel at all times
when caring for or standing by in the home of any patients
with known tubercular disease or HIV. UBSI precautions
should be used during transport.
TB Prophylaxis
It is urged that all Transport Technicians be
vaccinated against TB with Bacillus Calmette Guerin (BCG).
This vaccine is a live bacillus which is inoculated into
excoriated or punctured skin. It confers immunity to
subsequent TB infection in approximately 80% of those
vaccinated with no prior history of TB.
*Illustration not included.
Figure 15-11: The effectiveness of BCG in preventing TB
infection. An 80% rate of protection can be expected.
In cases where prolonged contact with the patient is to
occur (as during a lengthy standby in the patient's home)
with a TB infected or likely TB infected individual
Isoniazid in doses of 100 mg three times a day may be given
during the period of standby, transport and for a minimum of
two weeks following the conclusion of transport as
prophylaxis against infection.
Measles, Mumps, and Rubella are not normally serious
concerns during transport of cryopreservation patients.
Most Transport staff will have either had these childhood
illnesses or been vaccinated against them. If the Transport
technician believes s/he might not have had these illnesses
NOW is the time to get vaccinated.
Scabies, head and body lice are normally of little concern
in the transport setting. Most patients presenting for
cryopreservation will have been under medical care and will
come from a socioeconomic background where such arthropod
infestation is uncommon.
The use of UBSI precautions is very effective in
inhibiting transmission of these arthropods. If
transmission does occur pediculosis (lice) may be treated by
the application of any of a variety of inexpensive, highly
effective over-the-counter preparations such as A-200.
Scabies may be easily and effectively treated by any of
several prescription insecticides such as Kwell.
The Pregnant Transport Technician
Because of the risk to both the mother and fetus
posed by both the infectious agents, and chemotherapy to
treat infection, pregnant women should be excluded from
transports where there exists reasonable possibility of
exposure to infectious disease.
Disinfection and Cleaning of Equipment and Environmental Surfaces
The first and most important rule in disinfection and
cleaning of equipment and instruments is: avoid having to do
it in the first place. Wherever possible use disposable
equipment; particularly where such equipment will contact
blood or be used in invasive procedures.
Disconnect any disposable equipment from non-disposable
equipment (suction lines, extracorporeal tubing, etc.) while
wearing gloves, a mask, gown and shoe covers; sanitize or
sterilize the non disposable equipment according to the
guidelines following this Chapter, and properly dispose of
the rest.
Non critical items that do not ordinarily touch the
patient or that touch only intact skin (such as blood
pressure cuffs) rarely, if ever, transmit disease. Simple
sponging, wiping, or washing with regular detergent is
usually all that is required. Rinse with clear water and
allow to air dry thoroughly. Wash the PIB, Thumper, and
similar equipment with hot soapy water.
All pieces of equipment that are first to be disinfected
or sterilized should first be thoroughly cleansed to remove
all organic matter (blood, tissue, saliva) and other residue.
Patient care equipment that enters normally sterile
tissue or that touches mucous membranes must be sterilized
before each use and subjected to high level disinfection.
Chemical sterilants that are registered with the U.S.
Environmental Protection Agency (EPA) as "sterilants" may be
used either for sterilization or for high-level
disinfection. Also acceptable is a solution of household
bleach diluted in water (concentrations ranging in 1:10 to
1:100) to disinfect equipment and surfaces. Clean all
organic matter and other debris off of the equipment before
disinfecting, and follow the manufacturer's instructions for
disinfecting any equipment. Be sure to clean any visible
blood and secretions out of all cracks and crevices.
Disinfection and Cleaning of the Ambulance
Extraordinary attempts to disinfect and/or "sterilize"
the interior surfaces of the ambulance are unnecessary and
liable to result in damage to upholstery and equipment. The
environmental surfaces of the vehicle are rarely associated
with transmission of disease. The most important aspect to
minimizing the risk of disease transmission in the ambulance
is general cleanliness, good housekeeping and organization.
Do not allow trash in the form of medical disposables
wrappers to accumulate. Keep working surfaces uncluttered
and promptly clean up spills of any kind. Where body fluids
have spilled use a Body Fluid Spill Clean Up Kit and wipe
the surface down with a commercial disinfectant or bleach
solution.
Following completion of a transport the ambulance
interior should be cleaned with soap and water and
environmental surfaces wiped down with 1:100 solution of
household bleach. Keep the vehicle well ventilated during
cleaning. The following guidelines are recommended for
cleaning the vehicle interior following completion of a
case:
Wear disposable gloves and eye protection during all
cleaning and decontamination procedures.
Remove any blood, body fluids, or other matter with paper
towels or disposable linens; dispose of these properly and
immediately. Whenever blood is found clean with a
disinfectant or bleach solution.
Transport Technician Prophylactic Health Recommendations
Before the Transport Technician begins active duty
s/he should:
Receive a PPD skin test for tuberculosis, unless the
individual has documentation of a previous significant
reaction or vaccination with BCG. Persons with significant
reactions on initial PPD screening should be followed in
accordance with American Thoracic Society Guidelines.
Contact the local Department of Health Services for further
information and notify the staff physician.
Show evidence of immunity to the following diseases:
a) Measles by proof of appropriate immunization or history
of disease or infection, or serologic evidence.
b) Hepatitis B by proof of appropriate immunization or
history of disease or infection, or serologic evidence.
c) TB (if PPD negative) by immediate vaccination with BCG
or proof of prior vaccination with BCG.
d) Rubella by proof of appropriate immunization or serologic
evidence of past disease. (History of disease is not
sufficient).
e) Tetanus, diphtheria and polio by proof of prior
immunization. (Prior disease does not impart immunity).
f) Influenza by vaccination.
Be counseled on the importance of good nutrition and
judicious micronutrient supplementation in improving
resistance to infectious disease. It is especially
important for any health requirements such as ongoing
vitamin/mineral supplementation, prescription medications,
and so on to be available and continued throughout
transport operations.
Transport of cryopreservation patients almost
invariably results in marked stress both psychological and
physiological to the Transport Technician. Interruptions in
normal sleep-wake cycles and sleep deprivation are common.
Dietary alterations (reliance on fast food or foodstuffs not
commonly eaten at home), confinement for extended periods
with colleagues and strangers, often in an alien home
setting, the psychological demands of the terminally ill
patient and family, plus the not infrequently present added
stress of familial hostility and medical/legal complications
all contribute to both physiological and psychological
stress. It is now well understood that both these kinds of
stress result in secretion of adrenalcorticoids and related
steroid hormones which are markedly immunosuppressive even
in the healthy individual, and further that such stress
results in depletion of micronutrients due to both their
increased metabolism and excretion (for instance serum
levels of both vitamin C and the B vitamins decline markedly
in humans and animals under stress. It is thus of added
importance that the Transport Technician continue
uninterrupted any nutritional or medical regime s/he is
normally on during the period of Transport operations.
Nutritional Supplementation Recommendations
It is the recommendation of the Cryopreservation Team
Medical Director that all transport personnel follow the
supplementation regime recommended below during the course
of standby and transport operations, or an equivalent regimen:
o 1 capsule of Daily One multivitamin/multimineral
supplement manufactured by Twinlabs, Inc. Females of
reproductive age should use the iron containing version of
this product.
o 1,000 mg of vitamin C (time release is not necessary).
It is recommended that this be acquired in single dose,
film-tab or coated tablets, to ease consumption under field
conditions.
o 400 I.U. vitamin E.
o 500 elemental magnesium in the form of magnesium oxide.
The above supplements are available without a
prescription from most health food stores and pharmacies.
The Transport Team Leader will maintain a modest supply of
these nutrients for distribution to team members, however it
is urged that each team member maintain their own supply.
Further, it is strongly urged that as a minimum Transport
Team members carry on a program of nutritional
supplementation such as the one outlined above on an ongoing
basis since when an emergency is going to occur (inside or
out of human cryopreservation activities) can never be
predicted.
Recommended Immunizations For Transport Technicians
Before you participate in Transport Operations you must
be immunized against the following infectious diseases.
Immunization against TB is optional, however if immunization
is declined a TB skin test (tine test) is required annually.
o Hepatitis B vaccination (3 doses over 6 months).
o Influenza vaccination (annually).
o DPT (diphtheria/pertussis/tetanus) with a DT booster
every 10 years.
o Polio immunization.
o Rubella (German Measles) vaccination.
o Measles vaccination.
o Mumps vaccination.
o Pneumococcal pneumonia vaccination
o Meningicoccal Meningitis vaccination.
General Guidelines For Preventing the Transmission of
Infectious Disease
In addition to the specific precautions outlined
above, the following general guidelines should be observed
when transporting patients for human cryopreservation:
Wash your hands thoroughly after the completion of your
patient handling duties. If running water is not available,
use a commercial germicidal hand rinse to clean your hands.
If you need to clean or disinfect any equipment in the
vehicle, thoroughly wash your hands again afterwards.
Whenever possible, use disposable equipment and supplies,
particularly on patients with known infectious disease.
When you have finished, double-bag all used equipment in a
red Biohazardous Waste Bag (red bag), seal it to prevent
leakage, and transport it to the Biopreservation facility,
hospital, mortuary or other facility which is authorized to
dispose of biohazardous wastes.
Maintain at hand a supply of disposable gloves, masks,
hats, gowns and shoe covers at all times. Follow the
procedures outlined above to dispose of any soiled gloves,
masks, gowns or shoe coverings.
Always wear disposable gloves when working with or
cleaning up blood.
Never retain disposables for clean-up and use in
teaching, training or for any other purpose. Disposables
are to be thrown away at the end of the transport with the
only exception being in the case of equipment (disposable)
malfunction where the device may need to be retained for
subsequent medicolegal investigation.
In the case of a device being retained for investigation
of malfunction it should be double red bagged and returned
to the facility for disinfection. If there is to be a delay
in return the device should be refrigerated on ice taking
care not to allow water to enter the red bags. The cooler
the device is in should be clearly labeled with a
Biohazardous Materials Trefoil. If refrigeration is not
practical or possible, call the facility for an appropriate
protocol of on-site disinfection (such as treating the
device with Cidex or Sporocidin).
Disassemble and disinfect all non disposable equipment
after every use. Thoroughly clean equipment first to remove
blood, vomitus, or other organic soil; then wash in a strong
disinfectant and let the disinfected equipment soak (i.e.,
Cidex or Sporocidin).
Bag all tissues, dressings, and other disposable paper
items in double red bags and seal to prevent leakage (tie
the bag or use a cable tie).
If your clothing becomes soiled with body fluids remove
it as soon as possible, bag it and label it, take a hot
shower and wash with germicidal soap. Rinse thoroughly.
Your clothing should be washed for at least 25 minutes in
hot water containing a germicide which will not damage the
fabric (Sanisol or other benzyl ammonium chloride
containing detergent is acceptable).
Dump any secretions, blood, or vomitus from suction
devices down the drain, hopper or toilet at the hospital
mortuary or Biopreservation facility (as appropriate) and
wash thoroughly into the sewer system. If disposing of such
wastes at Biopreservation they must first be admixed with
bleach in an approximately 1:10 concentration (i.e., 1
volume bleach to 10 volumes liquid waste).
Remove all equipment and linens from the ambulance and
wash all ambulance surfaces contacted by the patient with
Sanisol or similar product. Wipe down the vehicle walls
with 1:100 bleach solution. Let the ambulance air-dry and
restock it with clean supplies.
After you have finished all cleaning of equipment and the
ambulance, wash your hands again thoroughly.
Document in the ambulance log-book that cleaning was
done.
Promptly report any suspected exposure, including the
date and time of exposure, the type of fluid involved, the
amount of fluid, and details of the exposure using the
Exposure Incident Investigation Form.
Disposal of Biohazardous (Infectious) Waste
Federal and State law mandate stringent guidelines for
the disposal of Biohazardous waste. It is very important to
understand that the liability for such waste is perpetual ,
that it originates with the generator of the waste, and that
the liability cannot ever be transferred. Thus, if an
individual is injured by a sharp generated by
Biopreservation 100 years after the sharp was generated,
Biopreservation (if it is still in existence) is fully
liable for any damages. Furthermore, this liability cannot
be given away or bought by others. Thus, if you hand over a
bag of Biohazardous waste to a hospital or mortuary and they
improperly dispose of it (even after agreeing to dispose of
it properly) Biopreservation and/or the Transport Technician
are fully liable.
*Illustration not included.
Figure 15-12: Universal biohazard symbol: the Biological
Hazard Trefoil. The biohazard trefoil must be present on
all biohazardous/infectious waste containers.
For this reason Biopreservation deals with a licensed
and heavily insured Biohazardous waste hauler (TCI of
Colton, Ca) to dispose of Biohazardous wastes. In the event
the Transport Technician relies on a hospital or mortuary to
dispose of such waste it is critical that it be determined
that the waste will be handled appropriately. Sharps
(except in out-of-state cases) must never be disposed of by
handing off to a mortuary or hospital. All sharps must be
transported back to Biopreservation for incineration with
TCI. Transport is to be carried out in the ambulance in
sealed sharps containers (use duct tape to close double
close the lid, then place the sharps container inside two
red Biohazardous waste bags and label appropriately).
Bulk blood, suctioned fluids, excretions, and secretions
can be carefully poured down a drain connected to a sanitary
sewer. If it is possible and safe to do so, such wastes
should first be mixed with bleach in a 1:10 ratio per the
instructions above. Always wear a face-sheild whendisposing
of such waste, in addition to gloves, gowns shoe covers and
so on.
*Illustration not included.
Table 15-1: Comparison Of The Relative Effectiveness of
Various Chemical Sterilants and Disinfectants
Selected Bibliography
1) Comstock WG, et al: A controlled trial of community-wide
isoniazid prophylaxis in Alaska. Amer Rev Resp Dis.
1976;95:935-42.
2) Occupational Health and Safety Administration:
Occupational exposure to blood-borne pathogens final rule:
29 CFR Part 1910.1030. Washington D.C. Federal Register
1991;56.
3) Gerty RJ, ed: Hepatitis B. New York: Academic Press.
1985.
4) Green WC: AIDS and the immune system. Scientific
American 1993;269:99-105.
5) Haffen BQ, Karren KJ, eds: Pre-Hospital Emergency Care
and Crisis Intervention. Englewood Cliffs, New Jersey:
Prentice Hall. 1992.
6) Joklik WK, Smith DT, eds: Zinsser Microbiology: 15th
Edition. New York: Appleton-Century-Crofts. 1972: 454-469.
7) Pantaleo G, et al: HIV infection is active and
progressive in lymphoid tissue during the clinically latent
stage of the disease. Nature 1193;362:355-358.
8) Price RW, et al: The brain in AIDS: Central nervous
system HIV-I infection and AIDS dementia complex. Science
1988;239:586-592.
9) Putnam RD, Langerman N: OSHA Bloodborne Pathogens
Exposure Control Plan. Boca Raton: Lewis Publishers. 1992.
10) Redfield RR, Burke DS: HIV infection: The clinical
picture. Scientific American 1988;259:90-298.
11) Redfield RR, et al: The Walter Reed staging
classification for HLTV III-LAV infection. New Eng J Med
1986;314:131-32.
12) Riley RL, et al: Infectiousness of air from a
tuberculuous ward. Amer Rev Resp Dis 1962;85:511.+
13) Rose SL: Clinical Laboratory Safety. New York: Van
Nostrand Rheinhold. 1984.
14) Tiollais P, Buendia MA: Hepatitis B virus. Scientific
American 1991;264:116-123.
15) Weiss RA: How does HIV cause AIDS? Science
1993;260:1273-1279.
16) Zuckerman AJ, ed: Viral Hepatitis and Liver Disease.
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