key: cord-007583-owxcokge
authors: Kohn, William G.
title: Emerging and re-emerging infectious diseases: Be prepared
date: 2014-12-26
journal: J Am Dent Assoc
DOI: 10.14219/jada.archive.2010.0002
sha: 
doc_id: 7583
cord_uid: owxcokge

nan

Be prepared E ach time a new infectious agent or variant emerges, the public and health care providers struggle to understand how to stay safe. In the case of health care providers, we have the added responsibility for the safety of our patients, staff members and families. In the past 30 years, we have responded to a litany of diseases and organisms with exotic names, such as hepatitis B virus (HBV); human immunodeficiency virus (HIV); hantavirus; Lyme disease; variant Creutzfeldt-Jakob disease and prion diseases; severe acute respiratory syndrome/coronavirus; avian influenza (bird flu); West Nile virus; human papilloma virus; Escherichia coli O157:H7; methicillin-resistant Staphylococcus aureus; and, of most recent concern, 2009 H1N1 influenza. There also are potential threats from deliberate exposures with uncommonly seen yet virulent agents such as anthrax, plague, tularemia and viral hemorrhagic fevers. In these circumstances, it is almost impossible for a clinician to stay fully informed about the variety of signs, symptoms, routes of transmission, virulence and other important factors related to risk of transmission.

When considering how to apply infection control practices to emerging infectious diseases, it might be best to consider the Boy/Girl Scout motto: "Be prepared." "Be prepared for what?" someone once asked Robert Baden-Powell, the founder of Scouting. "Why, for any old thing," he replied. The most important thing we, as clinicians, can do is to be informed and prepared-for any old or new thing that comes our way.

Preparation would be a daunting task if each agent required a special set of infection control practices, particularly when infected patients can be asymptomatic or unaware they are infected. Fortunately, dental health care workers follow a set of standard infection control precautions. In 1985, the Centers for Disease Control and Prevention (CDC), Atlanta, established "Universal Precautions," a set of infection control practices based on the concept that all blood and bodily fluids that might be contaminated with blood

The most important part of being prepared is to have a written plan and to train staff members in executing the plan.

viruses. dPost signs in languages appropriate to your patient population with instructions to patients and accompanying family members or friends to report immediately symptoms of a respiratory infection as directed. dApply source-control measures such as covering the mouth and nose with a tissue when coughing and disposing of used tissues. Use a mask on a coughing person when it can be tolerated and is appropriate. dConduct hand hygiene after every contact with respiratory secretions.

dUse spatial separation, ideally three feet or more, of people with respiratory infections in common waiting areas when possible.

It is worth noting that the Occupational Safety and Health Administration (OSHA) recently posted regulatory controls that health care employers should be using to protect workers from exposure to the 2009 H1N1 influenza virus. 2 These general principles are intended to follow CDC guidance. In addition, CDC 3 recently posted specific guidance for dental health care: dEncourage all dental health care personnel to receive vaccinations for seasonal influenza and 2009 H1N1 influenza. dUse patient-reminder calls to identify patients reporting influenzalike illness and resched-ule nonurgent visits until after the patient is free of fever for 24 hours without the use of feverreducing medicine. dIdentify patients with influenzalike illness at check-in; offer a face mask or tissues to symptomatic patients; follow respiratory hygiene and cough etiquette 4 and reschedule appointments for patients needing nonurgent care; separate ill patients from others whenever possible if evaluating for urgent care. dUrgent dental treatment can be performed without the use of an airborne infection isolation room because transmission of 2009 H1N1 influenza is thought not to occur across longer distances through the air, such as from one patient room to another. dUse a treatment room with a closed door, if available. If not, use one that is farthest from other patients and personnel. dWear recommended personal protective equipment before entering the treatment room. dDental health care personnel should wear a disposable N95 respirator fit-tested by the National Institute for Occupational Safety and Health when entering the operatory and when performing dental procedures in patients with suspected or confirmed 2009 H1N1 influenza. dIf N95 respirators and/or fit testing is not available despite reasonable attempts to obtain them, non-fit-tested disposable N95 respirators or surgical face masks can be considered as a lower level of protection for personnel at lower risk of exposure or lower risk of experiencing complications resulting from influenza until fit-tested N95 respirators are available. dMinimize spray and spatter should be treated as infectious. These were designed to prevent transmission of HIV, HBV and other bloodborne pathogens in all health care settings. In 1996, CDC expanded this guidance into "Standard Precautions," a standard of care designed to protect health care personnel and patients from pathogens that can be spread by blood or any other bodily fluid, excretion or secretion. Standard Precautions are the foundation of a comprehensive infection control program and include a group of infection control practices that apply to all patients, regardless of suspected or confirmed infection status, in any setting in which health care is delivered, including dental settings.

At press time, we are in the middle of the 2009 H1N1 influenza pandemic. Exposure to 2009 H1N1 influenza virus occurs in household, community and occupational settings, and transmission is thought to occur through droplet exposure of mucosal surfaces; through indirect contact, usually via the hands, with respiratory secretions from an infectious patient or contaminated surface; and through inhalation of small-particle aerosols in the vicinity of the infectious person. In theory, any measure that limits the dispersal of respiratory droplets should reduce the opportunity for transmission. An important element added to Standard Precautions in 2007 was respiratory hygiene/cough etiquette. 1 Basic principles of this etiquette include the following: dEducate staff members, patients and visitors regarding the importance of containing respiratory secretions to help prevent the transmission of influenza and other respiratory In theory, any measure that limits the dispersal of respiratory droplets should reduce the opportunity for transmission of infection. when possible (for example, use a dental dam and a high-volume evacuator).

Despite the economic and ethical pressure to keep working despite illness, dental personnel should take action to prevent the transmission of 2009 H1N1 influenza in their practices. Among these actions are the following: dSelf-assess daily for symptoms of febrile respiratory illness (fever plus one or more of the following: nasal congestion/runny nose, sore throat or cough). dDo not report to work with fever and respiratory symptoms. dRemain at home until at least 24 hours after being free of fever (100°F/37.8°C), or signs of fever without the use of feverreducing medications. dIf a family member is diagnosed with 2009 H1N1 influenza, you still can go to work but should monitor yourself for symptoms.

All aspects of preparedness planning for pandemic influenza must allow for flexibility and real-time decision making that take new information into account as the situation unfolds. CDC provides updated infection control guidance as necessary. The most important part of being prepared is to have a written plan and to train staff members in executing the plan. Excellent sources of information exist to help in developing an influenza plan, including a CDC checklist and action steps for 2009 H1N1 influenza planning and response for outpatient facilities. [4] [5] [6] [7] When considering infection control guidelines and infectious disease transmission in caring for our patients, we also might do well to remember another Scout guideline-"Leave no trace" (after camping or other outdoor activities)-or, in our own Hippocratic terms, "First, do no harm." ■

Centers for Disease Control and Prevention. Respiratory hygiene/cough etiquette in healthcare settings

OSHA instruction: enforcement procedures for high to very high occupational exposure risk to 2009 H1N1 influenza

Infection control in dental settings: prevention of 2009 H1N1 influenza transmission in dental health care settings

Department of Health & Human Services

Department of Health and Human Services, Medical offices and clinics pandemic influenza planning checklist

Centers for Disease Control and Prevention. 10 steps you can take: actions for novel H1N1 influenza planning and response for medical offices and outpatient facilities

Department of Health and Human Services. HHS pandemic influenza plan: supplement 4 infection control