Small pox; Tuberculosis; Polio – All were once classified as “emerging infections” and under that name ravaged populations in the United States and many other countries. The development of vaccines and treatment modalities worked to erase them from Western health concerns – but lack of health care in Third World countries, lax security at bio-stock facilities in the former Soviet Union, and the appearance of new drug-resistant strains of infections are breathing new life into these and other “old” threats.
Monkeypox; Ebola Virus; SARS – As global travel and the expansion of commerce continue to make the world an ever closer community, these previously isolated illnesses find themselves carried across oceans and continents, often without warning, within days of their initial outbreak. Which brings up an immensely important question: What are the responsibilities of emergency medical services (EMS) organizations and agencies in the field of emerging infections?
To answer that question one might start with the generic definition of Emerging Infection offered by the National Association of Emergency Medical Technicians in a 2005 position paper that described it as “a new, reemerging, or drug-resistant infection whose incidence in humans has increased within the past two decades or threatens to increase in the near future.” That definition not only encompasses the diseases mentioned above but also brings to mind certain other well-known infections such as Multi-Drug-Resistant Tuberculosis (MDR-TB) and HIV/AIDS.
Another recent definition/classification, this one from Columbia University, refers to three circumstances that indicate the presence of an emerging infection – namely, that it is either: (1) a new previously unknown infectious agent or disease; or (2) a previously described infectious agent in a new geographic location, as a new syndrome, in a new type of host, or with an increased drug-resistant pattern or other new genetic characteristic; or (3) a new or previously described infectious agent used as a bioweapon.
Their Own Worst Enemy
According to statistics compiled and maintained by the federal Centers for Disease Control and Prevention (CDC), Western healthcare is not only an essential part of the solution in the battle against emerging diseases but also, unfortunately, often a key part of the problem as well. The failure to follow well established personal and patient protective protocols as simple as the washing of one’s hands and the wearing of respiratory personal protective equipment (PPE) has led to a significant increase in healthcare-associated infections in the United States itself, where approximately 1.8 million hospitalized patients are infected annually, and 88,000 die as a result.
Five principal pathogens are associated with about half of all of the reported infections. The 2003 Sudden Acute Respiratory Syndrome (SARS) epidemic, which caused numerous deaths in Taiwan and Canada, demonstrated how just one emerging pathogen could have a profound impact by serving as a healthcare-associated infection. The healthcare-associated transmission of SARS was considered to be the primary accelerator of the disease in both of the countries named.
The SARS experience represents the confluence of emerging-infections issues and patient-safety issues. The continued awareness of and search for healthcare-associated infections is therefore a key factor both in preventing the emergence of infectious diseases and in improving patient safety.
A Focus on Syndromic Surveillance
As has been suggested by the World Health Organization, an emerging infection will probably not be immediately recognized as such. This is one of the principal reasons why EMS systems must endeavor to participate in public-health and emergency-management monitoring activities. “Syndromic surveillance” – a recent and rapidly developing procedure defined by the CDC as “using health-related data that precede diagnosis and signal a sufficient probability of a case or an outbreak to warrant further public health response” – is proving to be a key tool in this effort. As used in the EMS field, syndromic surveillance involves the live analysis of data – e.g., 911 calls and dispatch data – to identify patterns and trends as they emerge, rather than waiting days or even weeks for conventional detection methods, such as the one-by-one review of patient charts, to provide actionable evidence. The variables or triggers for a natural epidemic and/or an artificially induced disease threat would include any cluster of pre-determined key symptoms such as breathing difficulties, abdominal pain, or fever accompanied by a rash.
Early detection allows appropriate action to be taken more quickly, not only saving lives but also protecting the healthcare infrastructure. Unlike the conventional syndromic surveillance data sources used in public health monitoring – or similar reports developed from private physician visits and/or the “patterning” of pharmaceutical purchases – EMS dispatch data is not only exceptionally time-sensitive but also systematically links gathered information with medical symptoms and provides an accurate geographic “distribution map” of disease incidents.
A growing number of cities across the United States have already started to use syndromic-surveillance technology and/or procedures to develop early-warning notifications on various clusters of patients suffering from specific illnesses or injuries, and this practice has thus far performed above expectations. The possibility of developing a nationwide syndromic-surveillance network within the foreseeable future is therefore no longer a concept but an achievable goal.
Protection for EMS Providers a High Priority
Individual EMS providers can actually do something personally about emerging infections. Following the suspicion of the SARS outbreak, governmental authorities overseas immediately instituted certain policies, including the use of full PPE gear for each EMS provider, as well as specific training – in infection-control techniques, for example – and frequent updates on the general situation to protect EMS personnel. The importance of developing and emphasizing personal awareness and preparedness cannot be overstated, and encompasses everything from paying attention to the public-health updates provided around EMS stations and/or medical-control facilities to knowing where PPE masks and other gear are stored in an EMS unit to considering the principal complaints and symptoms of patients not only individually but also collectively.
Here it should be noted that an important but frequently overlooked aspect of an EMS provider’s assessment is the reconciling of pertinent signs and symptoms with the individual patient’s recent travel history (which countries, and when, has the patient visited?) as well as other anecdotal evidence – contact with certain animals, for example – that might indicate the presence of an infectious disease.
Another common-sense test would be to ascertain if there is an unusual increase in the number of patients with common complaints, especially when those patients represent different groups (male vs. female, for example, or old vs. young). The EMS provider should make it a habit to speak to the nurses and doctors at local emergency departments and ask them if they have been seeing the same clustering of symptoms.
The list of protection requirements for EMS must also, of course, include paying strict attention to the basic rules of medical hygiene, including but not limited to the following:
- The use of appropriate PPE – this means gloves, gowns, and a mask with eye protection (and preferably a face shield); after use these items must be treated as medical waste and disposed of properly;
- A requirement that EMS providers ensure that appropriate PPE is provided for patients; if there are concerns about a possible airborne contagion, the patients must wear either non-rebreather masks or surgical masks; contact with skin lesions can be minimized by wrapping the body part with loose gauze, or the entire patient with a clean sheet;
- An insistence that EMS providers thoroughly clean all of the vehicles used after every call – “thoroughly” includes the use of suitable disinfectants, and “vehicles” refers to all non-disposable equipment that was used as well as the surfaces of the vehicle itself;
- Finally, a similar insistence that EMS providers wash their hands after every patient contact. (The use of alcohol-based disinfectants is acceptable for the short term, but as soon as possible the EMS provider must wash his or her hands thoroughly with soap and tepid water, remembering to clean under the nails.)
To briefly summarize: Previously unseen and/or metamorphosized infections are making themselves known all of the time. Just over four years ago – on 18 February 2005, specifically – two separate and apparently unrelated disease outbreaks were reported in the New York Times. One involved more than 400 people near Amsterdam who had tested positive for TB following contact with an infected supermarket cashier. More frightening was the fact that an additional 21,000 people were reported to have possibly come in contact with the 400 already identified. The other case focused on an outbreak of rare pneumonic plague in the Congo that killed over 60 people and had possibly infected hundreds more. Several thousand workers self-evacuated the area without follow-up with medical authorities, fleeing “into the forests,” the Times reported, “to escape the highly contagious disease.”
EMS systems, and the providers who operate in them, cannot afford to live in the proverbial vacuum. What the new emergence of so many infectious diseases means for EMS agencies, their staffs, administrators, and medical directors is that there is a much increased need for real-time information about emerging infections; that need translates into: (a) consistent communications with relevant health-care authorities; (b) the constant updating of policies and procedures to reflect realities such as those described above; and (c) a requirement that EMS providers themselves stay constantly vigilant in developing and following up on their own assessments and not be lulled into thinking that “it’s only the flu.”
Raphael M. Barishansky, DrPH(c), is a consultant providing his unique perspective and multi-faceted public health and emergency medical services (EMS) expertise to various organizations. His most recent position was as the Deputy Secretary for Health Preparedness and Community Protection at the Pennsylvania Department of Health, a role he recently left after several years. He is also currently a doctoral candidate at the Fairbanks School of Public Health at Indiana University.