Treating Patients with Diseases of High Risk

Subject: Treating Patients with Diseases of High Risk
Effective Date: February 5, 2009
Revision Date: December 2014, September 2016

Purpose

To provide a clear clinical protocol for treating patients with known diseases that are highly infectious and/or have elevated rates of mortality. These include (but are not limited to) Ebola Virus Disease (EVD), Middle East Respiratory Syndrome (MERS), highly drug resistant Methicillin-resistant Staphylococcus aureus (MRSA), active tuberculosis (TB), Severe Acute Respiratory Syndrome (SARS), and influenza (flu).

General Policy

UW SOD recommends that clinicians evaluating patients suspected of possible high-risk diseases should apply standard precautions (e.g., hand hygiene), airborne precautions (e.g., masks), and contact precautions (e.g., standard personal protective equipment). Until the disease has been positively identified and precisely defined, full PPE also should be worn for all contact with such patients.  As a general rule, patients who are positively identified as having EVD, MERS, MRSA, SARS, flu, or active TB with positive sputum, or any other high-risk disease, should not be treated in the UW SOD dental clinics.  Such patients shall be referred to a facility that is equipped to manage highly infectious patients.

Although the Zika virus infection is considered a serious condition, there is no known risk of transmission in the dental environment at this time. Clinicians and patients appear to be adequately protected by the use of established infection prevention protocols. The Centers for Disease Control (CDC) provides up to date information on Zika for healthcare providers at: http://www.cdc.gov/zika/hc-providers/index.html. In addition, the CDC’s “Key Zika Considerations for Healthcare Settings” can be found at:  https://www.cdc.gov/pregnancy/zika/materials/documents/Key-Zika-Considerations.pdf

In cases where a patient with a suspected high-risk disease requires emergent dental care, treatment along with disinfection protocols, should be provided only by fully trained faculty and clinical staff, not students.

The following policy aims at divisions and departments that routinely encounter patients with potential serious infectious illness that has either not been identified, or there has been a delay in recognizing patients with serious infectious illnesses at the start of an epidemic.

Implementation

I. EVD, MERS, MRSA, active TB, SARS, flu and other high-risk diseases

A. Administrative Measures

  1. Educate dental personnel about the risk, management and protective strategies for each disease, including specific infection control, case identification, and patient screening questions.
  2. Periodically check the websites for the Centers for Disease Control and Prevention and the World Health Organization to keep abreast of new developments and recommendations.
  3. Periodically check the websites of our local and state health departments for the latest information on any outbreak/prevalence of high-risk diseases in our community. Public Health Seattle and King County: http://www.kingcounty.gov/healthservices/health.aspx. Washington State Department of Health: http://www.doh.wa.gov/.
  4. Periodically check UW Medical Center materials for the latest information on high-risk diseases.
  5. Continue to implement and reinforce strict infection control measures and be aware of protocol for managing patients deemed to be high-risk.
  6. Place signs in reception areas and operatories advising patients to notify the dentist or other dental personnel if they have infection, fever or respiratory symptoms.
  7. Establish a written protocol for referring patients with suspected highly infectious diseases disease to facilities that can evaluate and treat them properly.
  8. Modify health history practices to include screening questions that address any high-risk diseases based on information available from resources mentioned above. Make sure these questions are asked at every patient visit and do not limit screening questions to specific patient populations.
  9. If “yes” responses place patients in a high-risk category, have the patient don a surgical mask. Raise your concerns with the patient, and then refer the patient to the appropriate UW medical facility (UW Hospital Emergency Department (206) 598-4000, or, if a high risk situation, telephone the UW Hospital Emergency Department triage nurse (206) 598-8366 for immediate evaluation and diagnosis. If indicated, notify the medical center that you are sending a patient to be evaluated for the specific high-risk disease identified.

B. Engineering Measures

  1. Using appropriate PPE, escort the patient to the “holding area” for evaluation by medical personnel.
  2. If an area has been contaminated, it should be closed until appropriate decontamination has been completed.

C. Dental Personnel Protection

  1. Disposable gloves must be changed after every patient. Non-sterile nitrile disposable gloves should be provided for hand barrier protection. During potential high infectious risk exposures, emergency department staff should double-glove to protect against inadvertent glove perforations.
  2. Chin-length plastic face shields or surgical masks and protective eyewear are a must. Make sure the mask covers the mouth and the nose.
  3. Reusable gowns should not be reused until washed. Disposable gowns should be properly placed in a biohazardous waste container.

D. Cleaning & Disinfection

  1. Use a hospital-grade disinfectant or 1:100 dilution of household bleach. Make sure the disinfectant is compatible with our dental equipment.
  2. Disinfect any equipment and surfaces with which the patient has come into contact before the next patient is seen.

E. Hand Hygiene

  1. Wash hands often with soap and water for at least 20 seconds between patients. If soap and water are not available, an alcohol-based waterless hand rub may be used when hands are not visibly soiled.

F. Additional Precautions

If exposure to a patient’s body fluids has occurred and it is not possible to obtain a history, the patient should be regarded as infectious and all appropriate measures should be taken.

  1. Any blood or saliva-contaminated instruments are potentially infectious and should first be disinfected, then sterilized using moist heat (steam) sterilization or chemical sterilization, then cleaned and heat-sterilized once again.  Gloves and protective clothing should be worn while collecting and cleaning contaminated materials and instruments.
  2. Spills of blood and other infected materials should he covered with a disinfectant solution before washing thoroughly. Protective clothing and gloves should be worn while cleaning accidental spillages of this nature. Used cloths and mops must be sterilized before being disposed of or reused.
  3. Clothing worn during treatment and cleanup should be removed only when all cleaning and sterilizing is complete. Such clothing should be regarded as infectious and collected and disinfected prior to normal laundering to clinical standards. Clothing should be removed in the clinical area.
  4. Wash and disinfect hands, forearms and areas of exposed skin thoroughly following removal of gloves and protective clothing after completion of treatment. 

Appendices:    

Appendix A:        Tables on EBV, MERS, SARS. TB & Influenza

Appendix B:         CDC Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis

Appendix C:        ADA Statement on the Treatment of Patients with Infectious Diseases of Uncertain Transmission

Appendix D:        HIPAA Privacy in Emergency Situations

References: CDC Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5417a1.htm

ADA News & Guidance: http://www.ada.org/en/publications/ada-news/2014-archive/september/cdc-offers-ebola-virus-guidance

 Dean of UW SOD:

October 24, 2016

Joel Berg, Dean of the UW School of Dentistry

APPENDIX A: Tables on EBV, MERS, SARS, TB & Influenza

Ebola (Ebola viral disease)

a severe hemorrhagic viral disease (like Marburg)

Last updated: 12/09/2014

For updated information please visit the Center for Disease Control Ebola site
http://www.cdc.gov/vhf/ebola/about.html

Cause a rare and deadly viral respiratory illness caused by a filovirus of the genus Ebolavirus, first discovered in 1976.

There are five identified Ebola virus species, four of which are known to cause disease in humans. Filoviruses can cause severe hemorrhagic fever in humans and nonhuman primates.

Only two members of this virus family have been identified: Marburgvirus and Ebolavirus
Ebola viruses are found in several African countries. Ebola was first discovered in 1976 near the Ebola River in what is now the Democratic Republic of the Congo.

Since then, outbreaks have appeared sporadically in Africa. Past outbreaks have occurred in the Democratic Republic of the Congo (DRC), Gabon, South Sudan, Ivory Coast, Uganda, republic of the Congo (ROC), and imported cases to South Africa).

There is a current outbreak of Ebola virus disease in the West Africa countries of Guinea, Liberia, and Sierra Leone (as of December 2014).

Symptoms

  • fever
  • severe headache
  • muscle pain
  • weakness, fatigue
  • muscle or body aches
  • abdominal (stomach) pain
  • diarrhea
  • vomiting
  • unexplained hemorrhage (bleeding or bruising)

Transmission

Direct contact is required – transfer of body fluids

  • Relatively few viral particles are necessary to cause infection
  • Direct contact means that body fluids from an infected person have touched someone’s eyes, nose, or mouth or an open cut, wound, or abrasion.
  • Ebola has been detected in blood and many body fluids. Body fluids include saliva, mucus, vomit, feces, sweat, tears, breast milk, urine, and semen.
  • Ebola virus is transmitted through direct contact with the blood or body fluids of a person who is sick with Ebola;
  • The virus is not transmitted through the air (like measles virus). There is no evidence indicating that Ebola virus is spread by coughing or sneezing.
  • However, droplets (e.g., splashes or sprays) of respiratory or other secretions from a person who is sick with Ebola could be infectious, and therefore certain precautions (called standard, contact, and droplet precautions) are recommended for use in healthcare settings to prevent the transmission of Ebola virus from patients sick with Ebola to healthcare personnel and other patients or family members.
  • Risk of transmission of Ebola virus from a patient to a healthcare worker depends upon the likelihood the patient will have confirmed EVD combined with the likelihood and degree of exposure to infectious blood or body fluids.
  •  That risk depends on the severity of disease.
  • Severe illness is strongly associated with high levels of virus production. In addition, close contact with the patient and invasive medical care can increase opportunities for transmission.

In general, the majority of febrile patients presenting to the ED do not have EVD, and the risk posed by patients with early, limited symptoms is lower than that from a patient hospitalized with severe EVD. Nevertheless, because early symptoms of EVD are similar to other febrile illnesses, triage and evaluation processes in the ED should consider and systematically assess patients for the possibility of EVD.

NEED TO KNOW

Elective dental care on patients suspected of infection with a highly infectious disease (such as Ebola virus) should not be performed until the person’s symptoms have fully resolved and a physician has cleared the patient for treatment.

Patients suspected of infection with a highly infectious disease should be further evaluated by faculty. A medical evaluation may be sought.

With patients suspected of infection with Ebola virus, healthcare providers will use the algorithm “Identify, Isolate, and Inform: Emergency Department Evaluation and Management of Patients with Possible Ebola Virus Disease”  http://www.cdc.gov/vhf/ebola/pdf/ed-algorithm-management-patients-possible-ebola.pdf

Note there are alternative causes of febrile illness (e.g. malaria in travelers, etc.)

EVALUATION PROTOCOL

  • A thorough health history
  • Targeted patient interview regarding fever, travel, and signs and symptoms of infectious disease.
  • Vital signs including temperature. Note that recent use of aspirin or an NSAID can lower a fever and cause a false negative response to fever.

Clinics are encouraged to use the screening form “Health Screening questions for UW Dental patients” currently in use by the UW Dental Urgent Care Clinic.

  1. This screening form is used in reception areas,
  2. Patients self-report symptoms and travel risks,
  3. “Yes” responses reviewed by faculty,
  4. On patients deemed at risk of infectious disease, determination made to delay elective care, proceed with treatment, or refer for medical assessment.

Assessment of risk –

  1. travel to countries where Ebola is found
  2. contact with Ebola patients such as family and friends in close contact with Ebola patients, healthcare providers who have come in contact with an Ebola patient
  3. AND signs and symptoms of Ebola

As of March 31, 2016:

Countries with widespread transmission (the entire country):
• None

Countries with former widespread transmission and current, established control measures1 (the entire country):

  • Liberia2
  • Sierra Leone3
  • Guinea4

Cases in urban settings with uncertain control measures:5
None

Cases in urban settings with effective control measures:
None

Previously affected countries6 (these countries currently Ebola free):

  • Nigeria (Lagos, Port Harcourt)
  • Senegal (Dakar)
  • Spain (Madrid)
  • United States (Dallas, TX; New York City, NY)
  • Mali (Bamako)
  • United Kingdom (Scotland, England)
  • Italy (Sardinia)

1This category also includes countries that have experienced widespread transmission but are transitioning to being declared free of Ebola. The World Health Organization (WHO) is responsible for determining when a country will be declared free of Ebola virus transmission. Public health authorities in these countries should maintain active surveillance for new cases of Ebola and identify, locate, and monitor any potential contacts.

2On May 13, 2015, CDC changed the country classification for Liberia to a country with former widespread transmission and current, established control measures.

3On November 10, 2015, CDC changed the country classification for Sierra Leone to a country with former widespread transmission and current, established control measures.

4On December 29, 2015, CDC changed the country classification for Guinea to a country with former widespread transmission and current, established control measures.

5Transmission in urban areas indicates the potential for spread through international air travel. Control measures in these countries are considered to be uncertain because of the inability of public health authorities to identify, locate, or monitor a large proportion of potential contacts. People arriving from these countries should be screened upon entry.

6In these countries, which previously had locally acquired or imported Ebola cases, at least 42 days (two incubation periods) have elapsed since the last day that any person in the country had contact with a person with confirmed Ebola.

IDENTIFY, ISOLATE, INFORM

  1. Healthcare facilities and providers should be able to:
  2. Rapidly identify patients with relevant exposure history AND signs or symptoms compatible with Ebola virus disease (EVD).
  3. Isolate any patient with relevant exposure history AND signs or symptoms compatible with EBV.
  4. Immediately notify the hospital/facility infection control program that a patient has been identified who has relevant exposure AND signs or symptoms compatible with Ebola virus disease.
  5. Discuss with the hospital/facility infection control program to transfer the patient to a medical assessment area for further evaluation and testing. Local and state public health agencies should be notified (usually by the hospital/assessment facility).
  6. Confirmed EVD patients should be transferred by the hospital to an Ebola treatment center (currently University of Washington Hospital and Harborview Hospital (as of December 2014)).
    To evaluate patients suspected of infection with Ebola virus, use the CDC algorithm located on the CDC website.  “Identify, Isolate, Inform: Emergency Department Evaluation and management of Patients with Possible Ebola Virus Disease”  http://www.cdc.gov/vhf/ebola/pdf/ed-algorithm-management-patients-possible-ebola.pdf

Severity

Ebola virus disease is a rare and deadly disease. Though not highly contagious (not spread airborne, requires direct contact), Ebola is highly infectious (causes disease once exposed).

Person-to-person transmission follows and can lead to large numbers of affected people.

No FDA-approved vaccine or medicine (e.g., antiviral drug) is available for Ebola.

Symptoms of Ebola and complications are treated as they appear.

Experimental vaccines and treatments for Ebola are under development, but they have not yet been fully tested for safety or effectiveness.

Recovery from Ebola depends on good supportive care and the patient’s immune response. People who recover from Ebola infection develop antibodies that last for at least 10 years, possibly longer. It is not known if people who recover are immune for life or if they can become infected with a different species of Ebola. Some people who have recovered from Ebola have developed long-term complications, such as joint and vision problems.

Prevalence

Since March 2014, West Africa has experienced the largest outbreak of Ebola in history, with multiple countries affected. (see “Evaluation protocol” section above)

In response to the outbreak, CDC activated its Emergency Operations Center to coordinate technical assistance and control activities with other U.S. government agencies, the World Health Organization, and other domestic and international partners. CDC also deployed teams of public health experts to West Africa. Widespread transmission of Ebola in West Africa has been controlled, although additional cases may continue to occur sporadically. However, because of ongoing surveillance and strengthened response capacities, the affected countries now have the experience and tools to rapidly identify any additional cases and to limit transmission.

Incubation time

Symptoms may appear anywhere from 2 to 21 days after exposure to Ebola, but the average is 8 to 10 days.

High risk factors

Healthcare providers caring for Ebola patients and family and friends in close contact with Ebola patients are at the highest risk of getting sick because they may come in contact with the blood or body fluids of sick patients.

Prevention

General precautions:

  • Respiratory hygiene/cough etiquette
    • Practice hand hygiene. Wash your hands often with soap and water, especially after you cough or sneeze. Alcohol-based hand cleaners are also effective.
    • Cover your nose and mouth with a tissue when you cough or sneeze. Throw the tissue in the trash after you use it.
    • Avoid touching your eyes, nose or mouth. Germs spread this way.
    • Try to avoid close contact with sick people.
    • If you get sick with influenza, the U.S. Centers for Disease Control and Prevention recommends that you stay home from work or school and limit contact with others to keep from infecting them.
  • Masking and separation of symptomatic persons.
  • Wear appropriate personal protective equipment (PPE).
  • Practice proper infection control and sterilization measures. For more information, see Information for Healthcare Workers and Settings.

Precautions with patients at risk of Ebola Virus Disease:

  • Predoctoral students are not to treat patients suspected of highly infectious diseases such as Ebola virus disease. Faculty should evaluate and further medical evaluation accessed.
  • Isolate patients with suspected Ebola Virus Disease from other patients. A private room for patient interview and assessment is available next to the UW Dental Urgent Care Clinic in B229.
    • If interviewing (and only interviewing) patients with suspected Ebola virus infection, use standard personal protective equipment (PPE) – (provider will have no contact with body fluids including saliva, and there is no risk of patient vomiting or creating droplets)
  • If contact with body fluids is likely, healthcare providers will use appropriate personal protective equipment (PPE) for management of patients with Ebola Virus Disease – this is a higher level of personal protective equipment than normally used in regular dental clinics (see CDC information on “Guidance on Personal Protective Equipment To Be Used by Healthcare Workers During Management of Patients with Ebola Virus Disease in U.S. Hospitals, Including Procedures for Putting On (Donning) and Removing (Doffing)”).
  • Before any dental treatment, patients with suspected Ebola virus infection will require medical evaluation. The UW Medical Center is to be notified and appropriate transport arranged.
  • Any treatment of patients with suspected Ebola virus will occur in secure areas designed and dedicated for highly infectious diseases. UW Medical Centers and Harborview Medical Center both have areas prepared for patients with suspected Ebola virus infection.
  • Any treatment of patients with suspected Ebola virus infection will be done by experienced clinicians with special training in management of patients with Ebola virus infection.

Notify health officials if you have had direct contact with the blood or body fluids, such as but not limited to, feces, saliva, urine, vomit, and semen of a person who is sick with Ebola. The virus can enter the body through broken skin or unprotected mucous membranes in, for example, the eyes, nose, or mouth.

Additional information available:

CDC Hand Hygiene in Healthcare Settings:  http://www.cdc.gov/handhygiene/

Hand Hygiene Basics:
http://www.cdc.gov/handhygiene/Basics.html
http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/distribution-map.html#areas
http://www.cdc.gov/vhf/ebola/symptoms/index.html
http://www.cdc.gov/vhf/ebola/transmission/qas.html
http://www.cdc.gov/vhf/ebola/hcp/ed-management-patients-possible-ebola.html
http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/index.html
http://www.cdc.gov/vhf/ebola/hcp/ed-management-patients-possible-ebola.html
http://www.cdc.gov/vhf/ebola/treatment/index.html
http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/index.html
http://www.cdc.gov/vhf/ebola/symptoms/index.html
http://www.cdc.gov/vhf/ebola/hcp/procedures-for-ppe.html
http://www.cdc.gov/vhf/ebola/prevention/index.html
http://www.cdc.gov/coronavirus/mers/risk.html
http://www.who.int/csr/disease/coronavirus_infections/faq/en/
http://www.cdc.gov/coronavirus/mers/
http://www.cdc.gov/coronavirus/MERS/about/symptoms.html
http://www.cdc.gov/coronavirus/mers/about/transmission.html
http://www.cdc.gov/coronavirus/MERS/risk.html#peninsula

 

Middle East Respiratory Syndrome

Last updated: 12/09/2014

For updated information please visit the Center for Disease Control MERS information
http://www.cdc.gov/coronavirus/mers/

Cause a viral respiratory illness caused by a coronavirus called MERS-CoV – first reported in Saudi Arabia in 2012

NEED TO KNOW

  • Patients should be referred for medical evaluation if
    • Have symptoms of upper respiratory infection (see symptoms below),
    • AND have traveled to the Arabian Peninsula within the last 14 days (Saudi Arabia, United Arab Emirates (UAE), Qatar, Oman, Jordan, Kuwait, Yemen, Lebanon, Iran, etc.),
    • OR had contact with symptomatic travelers from the Arabian Peninsula within the last 14 days.
  •  Cases currently limited geographically to Arabian Peninsula countries (Saudi Arabia, United Arab Emirates (UAE), Qatar, Oman, Jordan, Kuwait, Yemen, Lebanon, Iran, etc.) and countries with travel-associated cases of MERS.
  • Additional information available on CDC website: http://www.cdc.gov/coronavirus/mers/faq.html

Symptoms

  • Fever (take your temperature twice a day)
  • Coughing
  • Shortness of breath
  • Other early symptoms to watch for are chills, body aches, sore throat, headache, diarrhea, nausea/vomiting, and runny nose.

If you develop symptoms, call ahead to your healthcare provider as soon as possible and tell him or her about your possible exposure to MERS-CoV so the office can take steps to keep other people from getting infected. Ask your healthcare provider to call the local or state health department.

Transmission factors

MERS is contagious only to a limited extent. The virus does not seem to pass easily from person to person unless there is close contact, such as occurs when providing unprotected care to a patient.

Severity

About 30% of people confirmed to have MERS-CoV infection have died.

Prevalence

Cases limited to Arabian Peninsula countries (Saudi Arabia, United Arab Emirates (UAE), Qatar, Oman, Jordan, Kuwait, Yemen, Lebanon, Iran, etc.) and countries with travel-associated cases of MERS.

So far, all the cases have been linked to countries in and near the Arabian Peninsula. This virus has spread from ill people to others through close contact, such as caring for or living with an infected person. However, there is no evidence of sustained spreading in community settings.

CDC continues to closely monitor the MERS situation globally and work with partners to better understand the risks of this virus, including the source, how it spreads, and how infections might be prevented. CDC recognizes the potential for MERS-CoV to spread further and cause more cases globally and in the U.S. We have provided information for travelers and are working with health departments, hospitals, and other partners to prepare for this.

MERS in the U.S. On May 2, 2014, the first U.S. imported case of MERS was confirmed in a traveler from Saudi Arabia to the U.S. On May 11, 2014, a second U.S. imported case of MERS was confirmed in a traveler also from Saudi Arabia. The two U.S. cases are not linked.
More information about MERS in the US and Arabian Peninsula can be found at http://www.cdc.gov/features/novelcoronavirus/index.html

Incubation time

2 to 14 days

High risk factors

People with diabetes, kidney failure, chronic lung disease, and people who have weakened immune systems.

Transmission

MERS-CoV has spread from ill people to others through close contact, such as caring for or living with an infected person. Infected people have spread MERS-CoV to others in healthcare settings, such as hospitals. Researchers studying MERS have not seen any ongoing spreading of MERS-CoV in the community.

All reported cases have been linked to countries in and near the Arabian Peninsula. Most infected people either lived in the Arabian Peninsula or recently traveled from the Arabian Peninsula before they became ill. A few people became infected with MERS-CoV after having close contact with an infected person who had recently traveled from the Arabian Peninsula.

Public health agencies continue to investigate clusters of cases in several countries to better understand how MERS-CoV spreads from person to person.

Prevention

  • Respiratory hygiene/cough etiquette
  • Masking and separation of persons with respiratory symptoms
  • Use standard personal protective equipment (PPE) for droplet precautions

Healthcare personnel should adhere to recommended infection control measures, including standard, contact, and airborne precautions, while managing symptomatic close contacts, patients under investigation, and patients who have probable or confirmed MERS-CoV infections.

http://www.cdc.gov/coronavirus/mers/risk.html
http://www.who.int/csr/disease/coronavirus_infections/faq/en/
http://www.cdc.gov/coronavirus/mers/
http://www.cdc.gov/coronavirus/MERS/about/symptoms.html
http://www.cdc.gov/coronavirus/mers/about/transmission.html
http://www.cdc.gov/coronavirus/MERS/risk.html#peninsula

 

Severe Acute Upper Respiratory Syndrome (SARS)

(no cases since 2004)
Last updated: 12/09/2014

For updated information please visit the Center for Disease Control SARS information http://www.cdc.gov/sars/

Cause a viral respiratory illness caused by a coronavirus, called SARS-associated coronavirus (SARS-CoV). SARS was first reported in Asia in February 2003. The illness spread to more than two dozen countries in North America, South America, Europe, and Asia before the SARS global outbreak of 2003 was contained.

Since 2004, there have not been any known cases of SARS reported anywhere in the world.

Frequently asked questions about SARS http://www.cdc.gov/sars/about/faq.html

Prevention

 

Tuberculosis (TB)

Last updated: 12/08/2014
For updated information please visit the Center for Disease Control TB information
http://www.cdc.gov/tb/

Cause a contagious and an often severe airborne disease caused by a bacterial infection of mycobacterium tuberculosis

Tuberculosis (TB) is a disease caused by germs that are spread from person to person through the air. TB usually affects the lungs, but it can also affect other parts of the body, such as the brain, the kidneys, or the spine.

NEED TO KNOW

Two TB-related conditions exist

  1. Latent TB infection
  2. TB disease Elective dental care on patients suspected of active TB disease should not be performed until the person is declared non-infectious by a physician.

Latent TB: Persons with latent TB are not infectious and can be treated in the dental office under standard infection control precautions.

Active TB: Persons with symptoms suggestive of active TB should be separated from other patients, instructed to wear a mask, assessed for the urgency of their dental care, and referred for medical evaluation and care

Urgent dental care for a person with TB disease should be provided in a facility with the capacity for airborne infection isolation that has a respiratory protection program in place. Standard surgical face masks are not designed to protect against TB transmission. Dental personnel should use respiratory protection in accordance with CDC and OSHA requirements.

Dental students should not be providing treatment to patients with active TB disease.

Symptoms

  • a bad cough that lasts 3 weeks or longer
  • pain in the chest
  • coughing up blood or sputum
  • weakness or fatigue
  • weight loss
  • no appetite
  • chills
  • fever
  • sweating at night

Transmission factors

Active Tuberculosis is contagious. TB is spread through the air from one person to another.
Not everyone infected with tuberculosis becomes sick. As a result, two TB-related conditions exist: latent TB infection and TB disease.

Latent TB infection: Persons with latent TB infection do not feel sick and do not have any symptoms. They are infected with M. tuberculosis, but do not have TB disease. The only sign of TB infection is a positive reaction to the tuberculin skin test or TB blood test. Persons with latent TB infection are not infectious and cannot spread TB infection to others.

Many people who have latent TB infection never develop TB disease. Some people develop TB disease soon after becoming infected (within weeks) before their immune system can fight the TB bacteria. Other people may get sick years later when their immune system becomes weak for another reason.

TB disease: people are sick from TB germs that are active, multiplying and destroying tissue in their body. They usually have symptoms of TB disease. People with TB disease of the lungs or throat are capable of spreading germs to others. They are prescribed drugs that can treat TB disease.

Severity

A person with TB can die if they do not get treatment.

Prevalence

Varies by country

One third of the world’s population is infected with TB (over 2 billion people).

In 2013, 65% of all TB cases and 90% of multidrug–resistant TB cases in the United States occurred among people born in other countries.

Nearly 50% of these individuals were born in just five countries.
9,582 TB cases (a rate of 3.0 cases per 100,000 persons) were reported in the United States in 2013

High risk factors

For people whose immune systems are weak, especially those with HIV infection, the risk of developing TB disease is much higher than for people with normal immune systems.

Once a person is infected with TB bacteria, the chance of developing TB disease is higher if the person: has HIV infection; been recently infected with TB bacteria (in the last 2 years); has other health problems, like diabetes, that make it hard for the body to fight bacteria; abuses alcohol or uses illegal drugs; or was not treated correctly for TB infection in the past.

Transmission

TB germs are put into the air when a person with TB disease of the lungs or throat coughs, sneezes, speaks, or sings.

These germs can stay in the air for several hours, depending on the environment. Persons who breathe in the air containing these TB germs can become infected; this is called latent TB infection

TB is not spread by

  • Shaking someone’s hand
  • Sharing food or drink
  • Touching bed linens or toilet seats
  • Sharing toothbrushes
  • Kissing

Prevention

  • Prompt detection and referral of suspected infectious patients;
  • Airborne precautions;
  • Treatment of people who have suspected or confirmed tuberculosis (TB) disease.

The most critical risk for healthcare-associated transmission of M. tuberculosis in healthcare settings is from patients with unrecognized TB disease who are not promptly handled with appropriate airborne precautions.

Travelers and high risk environments Avoid close contact or prolonged time with known TB patients in crowded, enclosed environments (for example, clinics, hospitals, prisons, or homeless shelters).

Travelers who will be working in clinics, hospitals, or other health care settings where TB patients are likely to be encountered should consult infection control or occupational health experts. They should ask about administrative and environmental procedures for preventing exposure to TB.

Once those procedures are implemented, additional measures could include using personal respiratory protective devices.

Travelers who anticipate possible prolonged exposure to people with TB (for example, those who expect to come in contact routinely with clinic, hospital, prison, or homeless shelter populations) should have a tuberculin skin test (TST) or interferon-gamma release assay (IGRA) test before leaving the United States. If the test reaction is negative, they should have a repeat test 8 to 10 weeks after returning to the United States. Additionally, annual testing may be recommended for those who anticipate repeated or prolonged exposure or an extended stay over a period of years.
If you think you have been exposed Contact your health care provider or local health department to see if you should be tested for TB. Be sure to tell the doctor or nurse when you spent time with someone who has TB disease.

Concern

Multi-drug resistant tuberculosis (MDR TB) exists and, rarely, extensively multi-drug resistant tuberculosis (XDR TB). Drug resistant TB is a public health challenge.

Additional information available:
CDC TB 101 for Health Care Workers
http://www.cdc.gov/tb/webcourses/TB101/intro.html

CDC TB Factsheet “General” information http://www.cdc.gov/tb/publications/factsheets/general/tb.htm

CDC TB Factsheet “Infection Control in Healthcare Settings” http://www.cdc.gov/tb/publications/factsheets/prevention/ichcs.htm

http://www.cdc.gov/tb/publications/factsheets/general/tb.htm
http://www.cdc.gov/tb/topic/basics/default.htm
http://www.cdc.gov/tb/topic/globaltb/default.htm
http://www.cdc.gov/tb/statistics/
http://www.cdc.gov/tb/topic/basics/default.htm
http://www.cdc.gov/tb/topic/basics/default.htm
http://www.cdc.gov/tb/publications/factsheets/drtb/mdrtb.htm
http://www.cdc.gov/tb/publications/factsheets/prevention/ichcs.htm

Influenza (seasonal influenza, the flu)

Last updated: 12/09/2014

For updated information please visit the Center for Disease Control Influenza site
http://www.cdc.gov/flu/index.htm

Cause

Caused by influenza viruses, which infect the respiratory tract (i.e. nose, throat, lungs)

Unlike other viral respiratory infections, such as the common cold, the flu can cause severe illness and life-threatening complications in many people

There are several influenza viruses such as the swine flu (H1N1, and H3N2), and the avian flu (H5N1, H7N9, and the highly pathogenic H5N1 with only sporadic human infections).

Note: other respiratory viruses can also circulate during flu season and cause symptoms and illness similar to those seen with flu infections. Non-flu viruses include rhinovirus (one cause of the “common cold”) and respiratory syncytial virus (RCV, more common in children).

NEED TO KNOW

Elective dental care on patients suspected of infection with known highly infectious disease (such as influenza) should not be performed until the person’s symptoms have resolved.

Use standard infection control

  1. Wash hands thoroughly and frequently. And use alcohol-based hand sanitizers.
  2. Contain your coughs and sneezes. Cover your mouth and nose when you sneeze or cough. Cough into a tissue or the inner crook of your elbow to avoid contaminating your hands.
  3. Avoid crowds.
  4. When you are sick, stay at home so you do not infect others.

Assess patients for evidence of infectious disease

  1. Health history questionnaire
  2. Direct health interview
  3. Signs and symptoms (fever, cough, sore throat, etc. – see below)
  4. Faculty consult and patient assessment
  5. Refer for medical evaluation when appropriate
  6. Avoid working on patients who are sick.

Symptoms

  • Fever or feeling feverish/chills
  • cough
  • sore throat
  • runny or stuffy nose
  • muscle or body aches
  • headaches
  • fatigue (tiredness)
  • some people may have vomiting and diarrhea, but this is more common in children

Transmission factors

Spread to others up to about 6 feet. Most experts think the flu virus are spread mainly by droplets made when people with flu cough, sneeze, or talk. These droplets can land in the mouths or noses of people who are nearby or possibly be inhaled into lungs. Less often, a person might also get flu by touching a surface of object that has flu virus on it and then touching their own mouth or nose.
Most people with the flu have mild illness and do not need medical care or antiviral drugs. If you get sick with flu symptoms, in most cases, you should stay home and avoid contact with other people except to get medical care.

  •  You can get the flu from patients and coworkers who are sick with the flu.
  • If you get the flu, you can spread it to others even if you don’t feel sick.
  • By getting vaccinated, you help protect yourself, your family at home, and your patients.
    Severity Flu is unpredictable and how severe it is can vary widely from one season to the next depending on many things, including:

    • what flu viruses are spreading,
    • how much flu vaccine is available,
    • when vaccine is available,
    •  how many people get vaccinate, and
    • How well the flu vaccine is matched to flu viruses that are causing illness.

Influenza (the flu) can be a serious disease that can lead to hospitalization and sometimes even death. Anyone can get very sick from the flu, including people who are otherwise healthy.

Prevalence

It is estimated that each year on average 5% to 20% of the population gets the flu and more than 200,000 people are hospitalized from seasonal flu-related complications

Flu seasons are unpredictable and can be severe.

Over a period of 30 years, between 1976 and 2006, estimates of flu-associated deaths in the United States range from a low of about 3,000 to a high of about 49,000 people.

Some people, such as older people, young children, pregnant women, and people with certain health conditions are at high risk of serious flu complications.

Incubation time

Most healthy adults may be able to infect other people beginning 1 day before symptoms develop and up to 5 to 7 days after becoming sick. Children may pass the virus for longer than 7 days.

Symptoms start 1 to 4 days (average 2 days) after the virus enters the body. That means that you may be able to pass on the flu to someone else before you know you are sick, as well as while you are sick.

Some people can be infected with the flu virus but have no symptoms. During this time, those persons may still spread the virus to others.

High risk factors

Anyone can get the flu (even healthy people), and serious problems related to the flu can happen at any age.

  • Some people are at high risk of developing serious complications:
  • Children younger than 5, especially younger than 2 years old
  • Adults 65 years and older
  • Pregnant women
  • American Indians and Alaskan Native seem to be at increased risk.
  • People of any age with certain chronic medical conditions such as:
    • Asthma
    • Neurological and neurodevelopmental conditions (including disorders of the brain, spinal cord, peripheral nerve, and muscle such as cerebral palsy, epilepsy (seizure disorder), stroke, muscular dystrophy, spinal cord injury)
    • Chronic lung disease (chronic obstructive pulmonary disease (COPD) and cystic fibrosis
    • Heart disease (congenital heart disease, congestive heart failure, coronary artery disease)
    • Blood disorders (such as sickle cell disease)
    • Endocrine disorders (such as diabetes mellitus)
    • Kidney and liver disorders
    • Metabolic disorders (inherited metabolic disorders, mitochondrial disorders)
    • Weakened immune system due to disease or medication (people with HIV or AIDS, cancer, or those on chronic steroids).
    • People younger than 19 years of age who are receiving long-term aspirin therapy
    • People who are morbidly obese (Body Mass Index, or BMI of 40 or greater).

Prevention

Every day precautions

Follow general every day precautions that help prevent the spread of germs that cause respiratory illness:

  • Practice hand hygiene. Wash your hands often with soap and water, especially after you cough or sneeze. Alcohol-based hand cleaners are also effective.
  • Cover your nose and mouth with a tissue when you cough or sneeze. Throw the tissue in the trash after you use it.
  • Avoid touching your eyes, nose or mouth. Germs spread this way.
  • Try to avoid close contact with sick people.
  • If you get sick with influenza, the U.S. Centers for Disease Control and Prevention recommends that you stay home from work or school and limit contact with others to keep from infecting them.

Additional information on infection control in healthcare settings can be found at: CDC “Healthcare-associated infections”  http://www.cdc.gov/hai/prevent/ppe.html

CDC “Guidelines for Infection Control in Healthcare Personnel, 1998” http://www.cdc.gov/hicpac/pdf/InfectControl98.pdf

Please note that previous “Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare settings, 2007” has been replaced by the:

CDC “Infection Prevention and Control Recommendations for Hospitalized Patients with Known or Suspected Ebola Virus Disease in US Hospitals”  http://www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.html

Prevention

Vaccination

The best way to prevent seasonal flu is by getting a flu vaccination each year.

The CDC Advisory Committee on Immunization Practices (ACIP), and the Healthcare Infection Control Practices Advisory Committee (HICPAC) recommend that all U.S. health care workers get vaccinated annually against influenza.

Everyone 6 months and older should get vaccinated against the flu every year. Get vaccinated soon after vaccine becomes available in your community, ideally by October. Immunity set in about two weeks after vaccination.

Flu season in the United States occurs in the fall and winter. The peak of flu season has occurred anywhere from late November through March.

Additional information available:

CDC Hand Hygiene in Healthcare Settings: http://www.cdc.gov/handhygiene/

Hand Hygiene Basics: http://www.cdc.gov/handhygiene/Basics.html
http://www.cdc.gov/flu/about/qa/disease.htm
ttps://www.cdc.gov/flu/index.htm
http://www.cdc.gov/flu/professionals/acip/clinical.htm
http://www.cdc.gov/flu/about/disease/high_risk.htm
http://www.cdc.gov/flu/healthcareworkers.htm

 

APPENDIX B:

CDC Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis

CDC Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis

 

 

APPENDIX C

ADA Statement on the Treatment of Patients with Infectious Diseases of Uncertain Transmission

The American Dental Association considers the delivery of necessary dental care to patients to be the fundamental responsibility of every practicing dentist. This obligation is expressed in the principles of beneficence and justice in the ADA Principles of Ethics and Code of Professional Conduct.

Occasionally, a dentist may be called on to provide care to a patient with an infectious disease for which there are no recommended infection control procedures to prevent or reduce the risk of disease transmission within an otherwise adequately equipped dental operatory. For example, during the outbreak of severe acute respiratory syndrome (SARS) in 2003, many questioned whether a dentist could safely treat an infected patient without endangering himself or herself, other patients or members of the dental team.

To maintain patient and provider safety in the delivery of oral health care, the dentist and the dental team should be adequately trained in infection control measures as recommended by the U.S. Centers for Disease Control and Prevention (CDC). When concerned about uncertain transmission of infectious disease, dentists are encouraged to consult the recommendations of appropriate public health authorities, such as the CDC. Dentists can also check with the local or state health department for the latest epidemiological information for their community.

In most circumstances, the decision to treat a patient with a suspected infectious disease depends primarily on the particular infectious organism and whether recommended infection control procedures will allow the dentist to treat the patient without compromising the safety of dental health care workers and other patients. For example, in the case of patient with suspected active tuberculosis, elective dental treatment should be deferred until a medical evaluation confirms that the patient is not infectious. Consulting with the patient’s current treating physician and/or facility to review the course and outcome of treatments rendered may inform the dentist as to the appropriate and safe time for providing dental treatment. In the case of a dental emergency, treatment of such a patient should be provided in a facility equipped with the capacity for airborne infection isolation.

As is the case with all patients, when an individual is suspected of having an infectious disease of uncertain transmission where effective infection control procedures have not been identified or scientifically supported, dentists should balance the needs of the patient with the safety of other individuals to arrive at an appropriate treatment decision. If it is believed that the patient may have an undiagnosed disease that poses a significant public health risk, the dentist should, while balancing and respecting the patient’s privacy rights, consider contacting the proper public health authorities.

Adopted by the Council on Scientific Affairs and the Council on Ethics, Bylaws and Judicial Affairs April 2012.

[i] http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/distribution-map.html#areas

[ii] http://www.cdc.gov/vhf/ebola/symptoms/index.html

[iii] http://www.cdc.gov/vhf/ebola/transmission/qas.html

[iv] http://www.cdc.gov/vhf/ebola/hcp/ed-management-patients-possible-ebola.html

[v] http://www.cdc.gov/vhf/ebola/hcp/ed-management-patients-possible-ebola.html

[vi] http://www.cdc.gov/vhf/ebola/treatment/index.html

[vii] http://www.cdc.gov/vhf/ebola/symptoms/index.html

[viii] http://www.cdc.gov/vhf/ebola/hcp/procedures-for-ppe.html

[ix] http://www.cdc.gov/vhf/ebola/prevention/index.html

[x] http://www.cdc.gov/coronavirus/mers/risk.html

[xi] http://www.who.int/csr/disease/coronavirus_infections/faq/en/

[xii] http://www.cdc.gov/coronavirus/mers/

[xiii] http://www.cdc.gov/coronavirus/MERS/about/symptoms.html

[xiv] http://www.cdc.gov/coronavirus/mers/about/transmission.html

[xv] http://www.cdc.gov/coronavirus/MERS/risk.html#peninsula

[xvi] http://www.cdc.gov/sars/infection/index.html

[xvii] http://www.cdc.gov/tb/publications/factsheets/general/tb.htm

[xviii] http://www.cdc.gov/tb/topic/basics/default.htm

[xix] http://www.cdc.gov/tb/topic/globaltb/default.htm

[xx] http://www.cdc.gov/tb/statistics/

[xxi] http://www.cdc.gov/tb/topic/basics/default.htm

[xxii] http://www.cdc.gov/tb/topic/basics/default.htm

[xxiii] http://www.cdc.gov/tb/publications/factsheets/drtb/mdrtb.htm

[xxiv] http://www.cdc.gov/tb/publications/factsheets/prevention/ichcs.htm

[xxv] http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5417a1.htm?s_cid=rr5417a1_e

[xxvi] http://www.cdc.gov/tb/topic/infectioncontrol/default.htm

[xxvii] http://www.cdc.gov/flu/about/qa/disease.htm

[xxix] http://www.cdc.gov/flu/professionals/acip/clinical.htm

[xxx] http://www.cdc.gov/flu/about/disease/high_risk.htm

[xxxi] http://www.cdc.gov/flu/healthcareworkers.htm

APPENDIX D

HIPAA Privacy in Emergency Situations

Patient rights to privacy are protected under HIPAA federal and state privacy laws.  UW School of Dentistry faculty, staff, students, and volunteers are required to follow legal protocols to safeguard patient privacy, as detailed in the School’s Notice of Privacy Practices brochure, online at: http://dental.washington.edu/compliance/hipaa/

Protocols include:  Never sharing protected health information (PHI) unless permitted to do so, and never accessing that information unless it is required to treat the patient.  In addition, a general prohibition on disclosing information about an Ebola patient is r the patient or the patient’s personal representative has signed a valid HIPAA authorization/consent form.

According to the Department of Health and Human Services, disclosure of patient PHI is permitted for treatment and payment purposes, at the request of a public health authority for purposes of controlling disease, or to a person who may have been exposed to a communicable disease who is at risk of spreading it.  Reference: November 2014; U.S. Department of Health and Human Services, Office for Civil rights; BULLETIN: HIPAA Privacy in Emergency Situations[xxxi]

[xxxi]

http://dental.washington.edu/compliance/pgp/hipaa-privacy-policies/