THE NEWSLETTER OF THE BUREAU OF HEALTH SERVICES • COUNSELING SERVICES UNIT • FDNY December 2007

2007 BIOPOD Summary

On Friday, November 6, 2007, FDNY Bureau of Health Services conducted its annual bio preparedness drill. In this city wide drill, all on duty members, fire and ems were directed to 12 PODS (points of distribution). The drill ran from 0800 hours to 2400 hours.

During the drill members were offered the flu (influenza) vaccine. This exercise does provide a recommended vaccine to our members. However, it is designed to ensure that FDNY can respond to a biological emergency.

Biological threats can be from nature (pandemic flu) or from terrorist threat (anthrax attack). As a Department, we must be able to respond quickly to protect our members. As first responders, on the front lines, the protection and safety of our members is critical. The services that FDNY provides to the city must continue, uninterrupted, in the face of emergency.

In the BioPod exercise, many bureaus of the FDNY came together to develop and refine this response: DISPATCH, COMMUNICATIONS, BTDS, ETC.

In this year’s exercise, changes were made to further improve our program. The drill ran from 0800 hours to 2400 hours, ensuring that both the day and night tour for on duty fire and for all three tours of EMS could be vaccinated.

The day and night timeframes provided the challenge of moving members to the 12 sites with different traffic patterns.

The sites of the PODS were selected to utilize both Fire and EMS facilities while ensuring that FDNY response remained in place. Deployment consisted of 11 stationary PODS and 1 Mobile POD.

At headquarters, in the auditorium, both the on duty civilian workforce along with on duty FIRE and EMS responded to this POD site.

Visitors from NYPD, DOHMH and NYS Homeland Security viewed the drill. An exercise of this undertaking has attracted national attention.

The computer programs utilized to compile the immunization data is recorded real time. It is automatically entered into the individual immunization record maintained for all our members. This program was developed to meet FDNY needs with the Katrina deployment to ensure that all members were protected with needed vaccinations before departure to New Orleans.

The numbers of individuals who were seen at the 12 PODS are impressive: 516 civilians, 4,371 firefighters/officers and 968 EMS personnel were seen.

Unfortunately less than 50 percent of our workforce chose to be immunized. The flu vaccine remains a safe vaccine that provides recommended protection to our FDNY members.

BioPOD 2007 was successful in its mission to keep FDNY prepared. If a true biological exposure occurred, the lessons learned from this drill would be utilized in responding to that emergency. This exercise is not just a day of giving out the flu shots; this drill is a critical exercise in remaining prepared. Thanks to all the individuals who helped make this a success.
BE WELL AND STAY SAFE ON EVERY RUN.

MRSA Questions and Answers

Both the FDNY in partnership with the NYC Department of Health wish to address questions that have been posed to us by members in the field. We wish to specifically answer these questions to give you the most up to date information we have with regard to the transmission of this infection along with the guidelines set forth by the CDC that we all must take to protect ourselves.

Community Acquired Methicillin Resistant Staph Aureus (CA-MRSA) infection presents most commonly as relatively minor skin and soft tissue infection, but severe invasive disease, including necrotizing pneumonia, necrotizing fasciitis, severe osteomyelitis, and a sepsis syndrome with increased mortality have also been described in children and adults, as recent media has shown. MRSA colonized patients more frequently develop symptomatic infections. How safe is it for a colonized patient to be in an environment such as the firehouse?

Answer:
There are no studies that we are aware of that measure risk of infection of coworkers in this setting.

In most cases Staph infections of the skin remain localized skin infections. In the rare cases with more invasive disease, the host (patient) is often very young, very old or there are underlying medical conditions or immunity issues. For example, recent hospitalization for a surgery or illness, diabetes, etc.

Resistance to infection is based on many variables. Would a FF be more susceptible to contracting MRSA after a strenuous job, with a cold, minor cuts/abrasions? What about similar conditions for a colonized patient?

Answer:
Resistance to infection means the ability of an individual to defend against an infection. Anything that impairs the immune system might affect resistance, such as influenza.

Any open cut or wound can get infected. Wounds should be cleaned and covered to prevent infection. Whether the patient is colonized or not, the care of the wound remains the same.

Transmissions within hospitals of MRSA strains first described in the community are being reported with increasing frequency. Changing resistance patterns of MRSA (according to tracking from 1992- 2003) provide additional evidence that the new epidemic MRSA strains are becoming established. Have any studies been conducted regarding transmission in an environment such as the firehouse?

Answer:
None found in recent review of the published medical literature. Staph has shown resistance to antibiotics since the 1970’s. Initially, it became resistant to the penicillin family, and alternative antibiotics were given. MRSA means methicillin resistant. Therefore, once again, alternatives must be given. Resistance occurs with increased usage of antibiotics as bacterial strains develop new forms that become more difficult to fight. The MRSA infections that were once seen primarily in hospitals are now seen in the communities where we live: our schools, our playgrounds, ball fields and even our firehouses. The means of transmission relate to open wounds and cuts with close body contact and shared environmental conditions, close contact, shared personal items, etc. FDNY firefighters/ officers when on medical leave are seen at BHS before return to duty. This allows us to follow patterns of illness and injuries. There have been cases of MRSA. BHS has worked with the NYC Dept of Health/Mental Hygiene and the State Dept of Health to review our policies and protect our work force. The numbers of cases have been small. The lateral transmission of cases has not been seen. Members are not returned to work until there is no evidence of infection and with clearance by an Infectious Disease specialist.

Recent media has demonstrated that it is possible to have a skin infection and a physician not recognize it as MRSA. How does BHS determine if an infection is MRSA?

Answer:
Recognition of MRSA infections remains a challenge for the medical community. The continued education of both the public and our medical physicians is ongoing. The absolute way to confirm a MRSA infection is by cultureopening the wound or pustule to obtain this culture.

If someone in the firehouse believes that they may have MRSA, what action should be taken?

Answer:
Members who believe they have an active MRSA infection should go see their own physician or come to BHS for evaluation. Stopping the transmission of illness or infection to others is important. Early treatment and evaluation may prevent worsening of an infection.

Is a person with a first degree burn (sunburn) more likely to get MRSA?

Answer:
Any disruption of the skin’s integrity could make one more susceptible to infection with MRSA or any organism.

Prior strategies to curb outbreaks of MRSA in other environments (hospitals, schools) have included improvement/ adherence to hand hygiene, isolation, environmental cleaning, and temporary unit closure. We are aware of the importance of good hygiene pertaining to MRSA. How feasible are these courses of action for the firehouse?

Answer:
Good hygiene remains the cornerstone of prevention and reduction of transmission. Removing the actively infected member/patient from the work environment is helpful until the infection has cleared completely. Keeping wounds covered prevents infection. Maintaining individual personal items such as towels and razors, toothbrushes and soap is helpful. Washing sheets after personal use is helpful. Maintaining of a clean environment with regularly scheduled washing of bathrooms and kitchens is helpful.

Contact precautions are routinely taken in hospitals to prevent transmission either directly or indirectly, providing single patient rooms and wearing a gown and gloves due to contact with the patient or potentially contaminated areas, even with the disinfecting of surfaces. Under the right environment, MRSA can live on surfaces for quite some time. Given these factors, how likely is it that MRSA could be brought out of the firehouse?

Answer:
MRSA is everywhere we live. It should be presumed to be anywhere. Every day in the paper, we are made aware that in every level of society, every age group, every play, home and work environment, people can get MRSA.

Although MRSA can survive in the environment, it is not likely that this plays a major role in transmission. Person to person contact is the more likely mechanism. Prevention of transmission whether at the firehouse or home is the same: attention to personal hygiene.

Once a person is colonized with MRSA, can they be decolonized? Are they more likely to get re-infected?

Answer:
People who are colonized with MRSA in their mucous membranes, documented by nasal cultures, can be treated with intranasal antibiotic ointment/cream to treat this colonization. This may need to be repeated but methods to decolonize do not always work.

In addition, changes in behavior that may create skin infections (body shaving, body piercing) are addressed, with use of washing substances such as phisohex. These changes may reduce the likelihood of recurrences.

Anyone can get re-infected. Bacterial infections do not provide lifetime immunity. A person can get recurrent bacterial infections. Once colonized, the risk of re-infection with those bacteria remains. Reducing infections with good wound care and attention to hygiene remains essential. Currently there is research investigating a vaccine to prevent staph infections. It is not available at this time.

Once a person has had MRSA, is it a good idea to have routine cultures taken?

Answer:
No, it is not necessary unless there are recurrences.

If a FF known to be colonized with MRSA requested a transfer to an Engine company that responded to an average of 1100 CFR-D runs a year, (many of them in overcrowded apartments, contact with homeless people, shelters, and/or AIDS facility) would this be a concern to his/her safety, since he/she may be considered at risk to have an outbreak?

Answer:
On each and every run, universal precautions should be utilized. Following each run, members should wash their hands using liquid soap or the alcohol based sanitizers. Each day nurses, physicians, medical care providers and Emt/Paramedics as well as CFR-D responders take care of individuals with multiple medical problems and risk factors. They are able to safely do their job, and return to their homes safely by using universal precautions.

A recent study (Roline, CE, Crumpecker, C, Dunn, TM). Can Methicillin-Resistant Staphylococcus Aureus Be Found In an Ambulance Fleet? Pre-hospital emergency Care.2 007;11:241-244) found that 47.6% of ambulances tested positive for MRSA. Would a FF with MRSA be safer working in a company that doesn’t routinely do CFR-D duties?

Answer:
This study highlights the prevalence of these bacteria in our environment. Placement of members in engines versus ladders would not change the standards utilized to prevent infections.

As the concern for CA MRSA grows, and firefighters, who share close living quarters and equipment, is the job considering classifying it as a work related hazard?

Answer:
Each case is reviewed on an individual basis. MRSA remains a part of the community in which we live. Certainly, with secondary infections from work related lacerations, surgeries and burns, those infectious complications have been covered as service connected.

Are there any legal ramifications if a member’s child tests positive for MRSA, and it is found that the child’s parent works with a known colonized MRSA FF?

Answer:
Currently, this infection has been found in school age children, young adults playing team sports, professional athletes, family members, hospitalized patients, nursing home patients, and all ages, sexes, ethnicities, socioeconomic groups. Every person must assume that the persons that we live with, work with and interact with could have this infection and we must use precautions as outlined.

According the NYS Dept of Health Website, there is a strain of MRSA that is resistant to vancomycin. If a FF is found to have this strain, can he/she work in the firehouse?

Answer:
The standard of return to duty includes: no active infection, and evaluation and clearance by an infectious disease specialist. CDC guidelines are followed and we will continue to follow their recommendations for return to duty as well as those of the NYC Dept of Health/Mental Hygiene.

Currently this strain of MRSA has only been seen in hospitalized patients.

According the NYS Dept of Health Website, some people can carry MRSA for days to many months, even after their infection has been treated. Does FDNY verify that the person doesn’t carry MRSA before they are returned to the firehouse?

Answer:
We will continue to follow the recommendations of CDC as well as the Dept.of Health/Mental Hygiene. The current standard is no evidence of active infection and clearance by an infectious disease specialist.

According to the NY State Health Dept, outbreaks nationwide and in NYS are being reported with increasing frequency in a variety of community settings, especially where there is close physical contact or close living conditions, as well as the dormitory setting. In fact, it was just reported (11/06) that 2 more FDNY FFs were diagnosed with MRSA. Is FDNY concerned now that CA-MRSA is becoming more common, especially among emergency personnel?

Answer:
It is a concern that is being addressed. The recommendations for firehouses and ems stations have been sent out again (see HEALTHCONNECTIONS). BHS and Dept. of Health have partnered in sharing information and advice. I have addressed the UFA general membership meeting along with Dr. James Mellius. I have made site visits to several firehouses, with Dept of Health and the Union leadership. Recommended additions to the firehouses include liquid antibacterial soap for the kitchen and bathrooms with alcohol hand sanitizers for the apparatus floor were made. This remains an ongoing situation with new recommendations and monitoring of the situation. Safety for our members is of critical importance. Fair treatment of our members is also important.

Our number of members with MRSA infections remains small; our mutual goal must be prevention.

Since MRSA is difficult to diagnose (as evidenced by recent media), in a firehousemember be penalized if he/she goes sick because they think they might have contracted MRSA?

Answer:
No

According the NYS Dept of Health Website, NYC Dept of HMH will soon ask NYC Board of Health to make MRSA a reportable condition in NYC. The concern with strains showing reduced susceptibility is genuine. Does FDNY share this view? (Is there a concern given the environment in the firehouse?)

Answer:
As a reportable condition, it will be easier for the Dept of Health to track patterns of illness or outbreaks.

For members who have contact with an ill patient, who is later discovered to have had MRSA, NO PROPHYLAXIS is required. Unlike meningitis, exposure to this infection does NOT require prophylactic or preventive medication.

On each and every run, utilize universal precaution and wash after each run.

If a member contracts MRSA, does he/she have to notify FDNY?

Answer:
Members on medical leave for illness do notify FDNY. They should notify us of the nature of the illness, such as MRSA.

How often is routine hand washing recommended in an environment known to have a colonized MRSA patient?

Answer:
Routine hand washing is recommended after direct patient contact, before eating, after using the bathroom and when hands are soiled. Hands should be washed before preparing food and after touching raw foods such as meat, fish, eggs and poultry. When in doubt, wash up.

Since the first reported episode of MRSA infection in the US reported in 1968, there has been a significant increase in reported cases. Formerly limited primarily to patients in hospitals or long-term care facilities, recent reports of CA-MRSA infections raise concern. Have studies been conducted within FDNY or EMS to determine if there should be similar concern within the department?

Answer:
As discussed, this infection is of concern to the community at large, certainly including FDNY/EMS. BHS monitors medical leave patterns.

If a FF comes down with MRSA, what is FDNY’s procedure? Does an infectious control physician determine the status of the patient?

Answer:
Each member has an individual evaluation, depending on the presentation of their infection. Before clearing to return to duty, a member would have to show no signs of active infection or skin problem, and a note for clearance by an infectious disease specialist. The guidelines of the CDC remain in place as will be followed as we continue to monitor our members.

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WTC Treatment Sites

The FDNY WTC Treatment sites are now open in all the satellite locations.

TO MAKE AN APPOINTMENT, CALL OUR TREATMENT APPOINTMENT STAFF AT 718 999 1858

ALL ACTIVE AND RETIRED MEMBERS CAN BE SEEN FOR EVALUATION AND TREATMENT OF WTC CONDITIONS WITH FREE MEDICATIONS FOR THESE CONDITIONS.

Conditions of participation include a WTC Monitoring Medical/Annual after July 2005.

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