DCs and Infectious Diseases
Ebola has put communicable diseases in the news lately, but MRSA, influenza and mosquito-borne illnesses are perhaps more likely to find their way into the practice of a chiropractic physician. Ebola, however, did raise awareness about public health, which is an important part of the chiropractic paradigm. (For more on “Ebola Virus and DCs,” see December 2014 ACA News, Page 4 or visit www.acatoday.org/Ebola
Karen Konarski-Hart, DC, DABCO, FACO, EMT, who is in private practice, president of ACA’s Council of Delegates and past president of the Arkansas State Board of Health, points to a moral obligation by doctors of chiropractic (DCs) to recognize there is an infectious disease in patients, so they can receive treatment early, and to protect employees, themselves and ultimately their families. “I’ve testified at the Arkansas legislature innumerable times and said we are primary care providers who can recognize a developing infectious disease, that we know the signs and symptoms and that we have the capability and responsibility to report it,” Dr. Konarski-Hart says.
Along with the moral component comes the legal obligation. For example, with the increase in immigration, many illnesses cross the border, requiring a broad knowledge of many types of infectious diseases. If your employees or other patients are exposed to an infectious disease, then you have legal responsibilities. “If there is something apparent in your office in a patient and you don’t recognize it, there is negligence if you don’t address it with the patient,” says Dr. Konarski-Hart. A related complication is that, of course, you and your staff can catch the disease and even die.
According to A. Carlo Guadagno, BSc, DC, CCSP, clinical science instructor at National University of the Health Sciences Florida Campus and chairman of ACA’s Public Health Committee, it is precisely due to the nature of the chiropractic profession that DCs need to protect themselves from infectious diseases. “We are a touchy-feely profession, and we get our bare hands traditionally on people,” Dr. Guadagno says. “We are not using personal protective equipment and are almost embarrassed to use gloves when seeing patients because some believe it takes away from the adjustment.”
While Dr. Guadagno agrees that all DCs should be aware of Ebola, he says to look at the probability of someone with Ebola coming into your office. Unless you have a practice in an area where there are many travelers coming in, especially from West Africa, you probably aren’t going to see it. “More than likely, you are going to deal with a patient with a chronic situation from a previous infection that is experiencing joint pain, perhaps polyarthritis,” he says.
Part of the problem with identification of infectious diseases is that many start out as issues for which your patients normally would see you. “Symptoms of most infectious diseases are aches and pains, headaches, malaise, feeling rotten and sometimes you see respiratory issues, but usually it’s just feeling bad and the patient calls his or her chiropractor,” says Dr. Konarski-Hart. She adds that you may be the first line of defense. “I occasionally see trends in the flu starting up in the community by the number of patients coming in with muscle aches and low-grade fever,” she says.
Dr. Guadagno points out that every year the Centers for Disease Control and Prevention (CDC) issues a new list on emerging infections. Infections in 2014 included Ebola, but more likely to be seen in your office were the enterovirus D68, which is a respiratory disease and the influenza virus H5N7. Chikungunya also emerged, a mosquito-borne illness, prevalent in the Caribbean and Central America and is showing up in the United States associated with travel. But in 2014, Florida was the only state in which 11 cases were found to be locally acquired. DCs need to be aware of its signs, especially acute onset of fever (i.e., typically greater than 102 degrees) and joint pain (e.g., bilateral, symmetric, often disabling).
Every year, there are new emerging infections on the CDC list, and Dr. Guadagno advises that the best way for chiropractic physicians to keep up is to sign up with Health Alert Network (HAN), run by the CDC (see box, Health Alert Network). You can sign up for a myriad of topics; for example, if you’re interested in what’s going on with fishing, hunting, vaccines or anything to do with public health, you’ll be alerted when a contagion is coming to your area.
Dr. Konarski-Hart cautions to watch out for the antibody-resistant diseases like MRSA.1 She knows a DC who discovered MRSA in a patient and was able to quickly refer the patient for treatment. “MRSA is very dangerous, so we need to watch out for chronic presentations of infections, and these are what DCs are more likely to see,” she says.
Dr. Konarski-Hart is also an EMT and notes in that environment there is much talk about body substance isolation and protective clothing. “But the emphasis isn’t on what you think of like HIV or SARS (severe acute respiratory syndrome) but is on diseases that are more subtle; there was a big scare here with hepatitis C, which has the potential of developing into cancer,” she says. “People were disabled because of it, so you lose your livelihood, your family loses its head of household and ultimately you can expose your family.”
Protect Patients and Yourself
“The first point is to learn all you can,” says Dr. Konarski-Hart. “Go to the Occupational Safety and Health [OSHA] website, look at resources, know what rules and regulations apply, know clinical hygiene and appropriate infectious disease protocols.” If new rules and regulations are enacted, you need to know them.
Part of gaining basic awareness, according to Dr. Konarski-Hart, is if you don’t remember infectious disease information from when you took microbiology in chiropractic college, then review it. She recommends learning about forms of transmission, whether blood-borne, fluidborne, respiratory-borne or vector-borne, such as mosquito transmission.
Learn the signs and symptoms of infectious diseases and the various treatments. “You really need to be able to read and analyze, with a clear scientific mind, the literature and the research about infectious diseases,” Dr. Konarski-Hart says. “This is not a philosophical discussion; this is about what are available treatments. Patients will ask you, and you need to formulate a clear opinion and know what you are going to tell them.”
Part of the discussion involves giving patients information on where to find resources, such as local health departments, the CDC or any appropriate source. “There is much in our natural healer literature that is anecdotal at best, and I know a lot of things work for some people some of the time and nothing works all of the time; but if you are going to promote something to combat infectious diseases, you need to have your homework done,” says Dr. Konarski-Hart. “Otherwise you need to at least say, ‘I don’t know everything there is to know about it, but I can tell you what I do know and where you can find more information.’”
Dr. Konarski-Hart says the same kind of thinking has to apply when DCs go on mission trips or serve in inner-city free clinics. Consider the situations of those patients. “These people have no backup – no nutritional support, no continued healthy living support and questionable sanitation. Is your advice appropriate to those conditions?”
With respect to your own family, “Think about protocols before you are faced with a crisis,” Dr. Konarski-Hart advises. “But if there is a new disease that emerges such as Ebola, you may want to reconsider your own personal outlook in the face of something your body may not be equipped to handle even with the best immune system.”
Dr. Guadagno says DCs can protect themselves and their patients by using universal precautions or standard precautions (see box, Standard Precautions), which is something DCs should always have in mind whether or not they know a patient is infected. He points to the need for good hand hygiene,1 clean office equipment 2 and personal protective equipment. “Some doctors do phlebotomy, so they need safe handling of equipment and to use common sense,” Dr. Guadagno says. “After contact with wound dressing, bodily fluids or preparing an injection and even after taking gloves off, use an alcohol-based disinfectant.”
Another part of protection is to hold a practice drill with your staff so they know what they’re going to do if a patient arrives with an infection.
“The American Academy of Family Physicians suggests you have a response plan in place,” Dr. Guadagno says. He advises all DCs to develop a response plan for the office and be prepared to use infection-control practices. He adds to be aware of proper post-exposure management for patients and health care staff and to know the requirements for proper laboratory support.
Finally, Dr. Guadagno says to “develop skills and resources for counseling patients to minimize the psychological consequences from possible infectious diseases.”
DCs’ Roles in Epidemics
Being a first line of defense means reporting what you’re seeing. It’s very important to know who your local health officers are. “We can’t send people to the CDC every time we suspect an infection,” says Dr. Guadagno. Instead, he advises you make a report to your local health department. “In every community, you need to know who that local health officer is and sign up for the health action network from the CDC so you know what emergent health infections are turning up in your community.”
Ebola in 2014 was an epidemic in the parts of Africa that it affected, just as the seasonal flu becomes an epidemic in the United States at times. But infectious diseases can become pandemics affecting people globally, such as the influenza pandemic of 1918-1919, which the U.S. Department of Health and Human Services estimates killed as many as 30 million to 50 million people around the world and an estimated 675,000 Americans.
Chiropractic physicians could be the earliest point of patient contact to notice that something unusual is happening, which marks the start of an epidemic. If the hospital or major medical facility in your area becomes quarantined or limited in how many patients it can take in, DCs could experience an influx of patients.
“You my be asked to handle what is called the secondary or satellite medical facility if there is a pandemic, where you would get the average patients, while the infectious disease is handled at the hospital,” says Dr. Konarski-Hart. “If there is a pandemic, you may be asked to go and work in the shelter where they are quarantining people, so you may serve in that capacity. You are not necessarily going to be the ones dealing directly with the infected patient. You may be treating the nurse, EMTs or whoever is caring for the infected people,” she adds.
American Public Health Association
It’s important for DCs increasingly to become part of the healthcare community and not be isolated from it. “Too many times we don’t participate with the greater health care community and we need to come together,” says Dr. Guadagno. He explains that an immediate priority within ACA’s public health committee is to try to push its members to become more involved with the American Public Health Association (APHA). “Within APHA, there is the chiropractic section, and the more of us that are part of that public health section, the stronger it is,” Dr. Guadagno says. “Then we have a voice in all these public health issues, not just what directly affects us, but what affects our populations in our communities. The duty of being a physician implores us to be aware of these practices to take care of our patients correctly.”
1 Green BN. Johnson CD. Egan JT. Rosenthal M. Griffith EA. Evans MW. Methicillin-resistant Staphylococcus aureus: an overview for manual therapists. J Chiropr Med
2012 Mar;11(1):64-76. doi: 10.1016/j.jcm.2011.12.001
2 Evans MW Jr. Ramcharan M. Floyd R. Globe G. Ndetan H. Williams R. Ivie R. A proposed protocol for hand and table sanitizing in chiropractic clinics and education institutions. J Chiropr Med
2009 Mar;8(1):38-47. doi: 10.1016/j. jcm.2008.09.003.
3 Evans MW Jr. Campbell A. Husbands C. Breshears J. Ndetan H. Rupert R. Cloth-covered chiropractic treatment tables as a source of allergens and pathogenic microbes. J Chiropr Med
2008 Mar;7(1):34-8. doi: 10.1016/j.jcme.2007.10.003.
Health Alert Network
The CDC allows you to sign up with its Health Alert Network (HAN) to be notified of threats as part of its emergency preparedness and response system. There are four HAN message types:
provides vital, time-sensitive information for a specific incident or situation; warrants immediate action or attention by health officials, laboratorians, clinicians and members of the public; and conveys the highest level of importance.
provides important information for a specific incident or situation; contains recommendations or actionable items to be performed by public health officials, laboratorians and/or clinicians; may not require immediate action.
provides updated information regarding an incident or situation; unlikely to require immediate action.
provides general public health information; unlikely to require immediate action.
To sign up for HAN, go to emergency.cdc.gov/han/updates.asp.
The Centers for Disease Control and Prevention (CDC) defines the standard precautions as the minimum infection prevention practices that apply to all patient care, regardless of suspected or confirmed infection status of the patient, in any setting where health care is delivered. Standard precautions include: 1) hand hygiene, 2) use of personal protective equipment (e.g., gloves, gowns, masks), 3) safe injection practices, 4) safe handling of potentially contaminated equipment or surfaces in the patient environment and 5) respiratory hygiene/cough etiquette.
Download the guide at www.cdc.gov/HAI/settings/outpatient/outpatient-care-gl-standared-precautions.html.
Public Health Online
Public Health Online is a non-commercial organization, launched in 2013 to provide public health resources to those considering a career in public health or currently employed in the industry. It offers free materials and tools on topics such as jobs and careers, educational program options and financial aid, pre-professional experience and state and local government public health resources.
Many career fields in public health require a master’s degree or higher. Public Health Online’s data analysts and higher education experts created a new resource for students pursuing a master’s in public health. Access the free guide and rankings of Best Online MPH Programs 2014-15: www.publichealthonline.org/degree-programs/masters
Ebola Virus Disease Information
Amid widespread media coverage of the Ebola virus, it’s important for the public and health care workers, in particular, to have the facts about this serious infectious disease. ACA provides links to information to help you better understand the Ebola virus and its symptoms, how it is transmitted and what steps can be taken to prevent infection. Go to www.acatoday.org/Ebola.
Proposed OSHA Standard
OSHA is considering enacting an economically significant, far-reaching standard that would apply to almost all healthcare workers, including those in physicians’ offices, clinics embedded in non-healthcare facilities, such as schools and prisons, hospices, laboratories, home health care settings and mortuaries. The draft standard is in the prerule stage and requires a comment period but is expected to become law in some form in 2015. It would not apply to workers who provide first aid only, veterinarians and workers performing tasks not covered under the framework (e.g., teachers, prison guards and athletic trainers).
OSHA’s reasoning is:
Employees in health care and other high-risk environments face longstanding infectious disease hazards, such as tuberculosis (TB), varicella disease (chickenpox, shingles) and measles (rubeola), as well as new and emerging infectious disease threats, such as severe acute respiratory syndrome (SARS) and pandemic influenza. Healthcare workers and workers in related occupations, or who are exposed in other high-risk environments, are at increased risk of contracting TB, SARS, methicillinresistant Staphylococcus aureus (MRSA) and other infectious diseases that can be transmitted through a variety of exposure routes. OSHA is concerned about the ability of employees to continue to provide health care and other critical services without unreasonably jeopardizing their health. OSHA is considering the need for a standard to ensure that employers establish a comprehensive infection control program and control measures to protect employees from infectious disease exposures to pathogens that can cause significant disease. (29 CFR 1910 )
OSHA’s proposed program standard would address worker exposure to infectious diseases transmitted by routes (i.e., contact, droplet, airborne) other than the bloodborne route, which is already covered by the Bloodborne Pathogens standard (29 CFR 1910.1030).
If enacted, many requirements would be imposed, starting with a written worker infection control program (WICP), which would need to be developed, implemented and updated annually. OSHA does state that the rules would be flexible and not one-size-fits-all. All employers would be required to develop SOPs for at least the following:
• Infectious agent hazard evaluations (to promptly identify suspected or confirmed sources of infectious agents) and communication of hazard evaluation results;
• Hand hygiene;
• Restricting food and cosmetics;
• Engineering, administrative and work practice controls and personal protective equipment;
• Handling, containerization, transport or disposal of contaminated materials;
• Occupational health services;
• Exposure incident investigations;
• Signage and labeling/color-coding;
• Notification of occupational exposure during transfer, transport, shipping or receipt of samples of infectious agents.
Employers who provide direct patient care would also develop SOPs for:
• Patient scheduling and intake/admittance;
• Standard, contact, droplet and airborne precautions;
• Patient transport;
• Medical surge procedures.
The regulatory framework would require that vaccinations and associated vaccination regimens (e.g., doses, intervals) be made available consistent with recognized and generally accepted good infection control practices relevant to the occupational exposures encountered during the job tasks of the employee. The employer would, at a minimum, need to make the following vaccinations available:
• Influenza (seasonal and pandemic);
• Measles, mumps and rubella (MMR);
• Tetanus, diphtheria and pertussis (Tdap);
• Varicella; and
• Any other vaccination(s) that is specified in the employer’s WICP or determined by a PLHCP to be medically appropriate for a particular employee (e.g., the meningococcal vaccine).
Vaccinations would not need to be made available to an employee with occupational exposure if the employer has documented that the employee’s vaccination is up-to-date, antibody testing has revealed that the employee is immune or a vaccine(s) is contraindicated for medical reasons.
In addition, employers would need to provide training on vaccinations prior to an employee’s initial job placement and offer required vaccinations after the training has been provided. A worker could decline a vaccination(s), but the employer would need to ensure that the worker completes a vaccine declination form (a sample of which is included with the regulatory framework), and if that worker decided at a later date to accept the vaccine(s), the employer would need to make the vaccine(s) available at that time.
Follow-up testing (e.g., antibody titer) would need to be provided according to generally recognized and accepted good infection control practices. OSHA preliminarily expects that all employers of workers in facilities where direct patient care is provided would need to make an annual flu shot available to their workers.
The entire proposed draft standard is at www.osha.gov/dsg/id/tab6.pdf.