By KATHERINE WEST and JAMES R. CROSS
In 1990, the Ryan White Comprehensive AIDS Resources Emergency Act, Public Law 101-381, was enacted into law. Although this law deals primarily with funding for HIV/AIDS programs throughout the country, Subpart B contains key provisions for fire/EMS personnel regarding notification of possible exposure to communicable diseases. This portion of the law, often referred to as the Ryan White Notification Law, requires every emergency response entity in the country to have a designated infection control officer (DICO) to serve as the liaison between emergency responders involved in exposure incidents and medical facilities to which the source patients in the exposures are transported. This covers emergency responders including firefighters, EMTs, paramedics, police officers, and volunteers. The law also outlines the role and responsibilities for this individual, which are extensive and comprehensive. Since this individual is charged with the postexposure follow-up and deals with infection control issues, the DICO title seemed appropriate.
The law requires medical facilities to provide the disease status of source patients as soon as possible and no later than 48 hours after an exposure has been reported to the facilities by the DICO of the responder involved in the exposure. The law also requires that medical facilities contact the DICO of the transporting entity that delivered a patient suspected for or diagnosed with pulmonary tuberculosis. This essentially ended a dual standard of care for postexposure medical follow-up that had existed across the country for many years. The law also afforded coverage to fire/EMS agencies that were not covered under the Occupational Safety and Health Administration’s (OSHA’s) Bloodborne Pathogen Standard (29 CFR 1910.1030). The Centers for Disease Control and Prevention (CDC) was charged under the law with developing a list of diseases that must be reported by medical facilities to DICOs. The list includes bloodborne diseases [HIV and hepatitis B (HBV)], airborne diseases (tuberculosis), and uncommon or rare diseases (rabies, meningitis, plague, hemorrhagic fevers, and diphtheria).
Because the Ryan White Notification Law provided federal funding for HIV/AIDS programs, the U.S. Congress was required to pass reauthorizations periodically to appropriate funds. There have been several reauthorizations since the law was passed in 1990; each included the emergency response provisions of the law. However, these provisions were stricken from the 2006 reauthorization. After much work by a coalition of emergency response organizations, including the International Association of Fire Fighters, the International Association of Fire Chiefs, the National Association of Emergency Medical Technicians, the National Volunteer Fire Council, and the National Association of State Emergency Medical Services Officials, the law’s emergency response provisions were reinstated in its reauthorization on October 1, 2009.
The emergency response section of the Ryan White law is included in the 2009 version as Part G—Notification of Possible Exposure to Infectious Diseases. Since this section of the law was stricken and then later reinstated, the U.S. Congress has interpreted it to mean that it, in effect, became a new law. Therefore, the CDC was charged with developing a new list of diseases, which eventually numbered 12, covered by the law. The list primarily adds diseases transmitted by the airborne and droplet method. It also adds hepatitis C (HCV), which was omitted from the initial CDC list, and clarifies that syphilis is also to be covered (Table 1). This new list reflects the diseases that have risen in large numbers over the past few years—diseases essentially deemed to have been eliminated by vaccine and immunization programs. For example, in 2010, there were 27,550 cases of pertussis (whooping cough) and more than 15,000 cases of chickenpox reported in the United States.
Many departments fail to see that, to have a fully comprehensive exposure notification and medical follow-up program, the Ryan White Law needs to be combined with OSHA’s Bloodborne Pathogens Standard and the 2005 CDC Tuberculosis Guidelines (being enforced by OSHA). Also missed is the term “medical facility,” which refers to more than just hospitals—it includes all facilities that the fire/EMS department transports patients to and from such as long-term care facilities, correctional health units, and clinics.
Selection of the DICO is very important; it should be based on interest in the role—not just membership in the department—and on established criteria. For example, this individual should be self-motivated in staying current on medical information, laws, and regulations. The individual should also develop a working budget for vaccines/immunizations and postexposure evaluation costs not covered by workers’ compensation. He also must have the department membership’s trust. This role requires good organization skills to set up an effective working communication system.
Being a DICO is a 24/7 responsibility. Select an individual who is truly interested in assuming this role and the responsibility that goes with it. There is much more involved than just sending a potentially exposed employee to the medical facility. In fact, the exposed employee does NOT need to go to the emergency department for evaluation and does NOT need immediate baseline testing for exposure. The DICO must be aware of the current standard of care for postexposure medical follow-up, which begins by testing the source patient, not the exposed employee. Knowing that an exposed employee does not need to go to the medical facility and have baseline blood testing is science-based and saves the department $1,000 to $1,600. The science basis tells us that the source patient results will determine the need for any employee testing. In addition, the DICO should know that the department is responsible for paying for source patient testing. OSHA states that the patient should not be charged for blood testing performed on the behalf of an exposed employee.
A truly knowledgeable DICO will assist in ensuring proper care if an exposure occurs and will assist management with liability and cost reduction. However, administrations of many departments do not appear to understand this role’s duties and responsibilities; they simply designate a person and do nothing more to develop a good working program such as making sure the person is trained in what is and is not an exposure, which body fluids do and do not pose a risk, and proper postexposure care and counseling. Departments do this at their own peril; OSHA states that the “employer” is responsible to ensure that proper care and counseling are afforded to the exposed employee. If care is not proper, it is the employer—not the physician or health care provider—who will be held responsible.
ROLE OF THE DICO
The Ryan White Notification Law lists three persons to be involved in an exposure event: the DICO, the exposed employee, and a medical facility representative (usually the treating physician). In essence, this position bucks the historic chain of command, for three very good reasons. First, the DICO makes the initial determination of whether or not an exposure has occurred. If not, the employee does not need to go to the medical facility, and no paperwork or costs are to be processed. Second, the DICO ensures that the postexposure follow-up process is completed in an expedited manner. Time is important because all testing begins with the source patient; the best opportunity to test patients is when they are at the medical facility. Third, the DICO maintains confidentiality of the source patient AND the exposed employee. When an employee is exposed, he has become a patient and has the right to privacy.
When a bona fide exposure has occurred, the employer DICO is responsible for contacting the medical facility where the source patient was transported to request source patient testing. HIV testing is subject to the law of the state in which the exposure occurred. Therefore, the DICO must know the provisions of his state’s HIV testing law. Each state’s law differs in provisions governing the need for consent to test. Some states require patient consent for HIV testing; others do not. Some states have exceptions that allow testing even if the patient refuses to give consent. With knowledge of the provisions of the state law, the DICO can ensure that the law is followed on behalf of the exposed employee. The DICO must also be aware that consent is not needed to test a source patient for HBV, HCV, or syphilis; state testing laws address only the need to test for HIV.
The DICO must establish an effective system for exposure notification; timely source patient testing; and where an exposed employee will receive postexposure testing and counseling, if needed. These take time to establish and require ongoing relationships with each medical facility that the department routinely transports to and from. Meeting these individuals and developing good working relationships are essential to an effective program. When a DICO reports an exposure, the medical facility must begin the source patient testing process, and its laboratories must offer “rapid testing” to expedite testing on behalf of the exposed employee. Presently, there is reliable and accurate rapid testing available for HIV, HCV, meningitis, and tuberculosis (TB). Rapid test results for each of these diseases are available in one hour, except for TB, which takes six hours. Rapid testing can offer great relief to an exposed care provider if testing is negative. In addition, confirmation that a source patient is HIV negative using rapid testing provides the necessary information to avoid inappropriate administration of antiretroviral drugs, which are very expensive and often make the employees who take them very sick, requiring time off from work for several days.
Today’s rapid tests are no longer the primitive antibody tests used in the past. Newer tests screen for viruses and are more accurate than previous testing methods. Rapid testing, if positive, can jump-start postexposure medical treatment, if needed. Unfortunately, many laboratories are not currently offering rapid testing. This is contrary to the 2001 CDC postexposure guidelines, which state: “Testing to determine the HBV, HCV, and HIV infection status of an exposure source should be performed as soon as possible. Hospitals, clinics, and other sites that manage exposed HCP should consult their laboratories regarding the most appropriate test to use to expedite obtaining these results.” OSHA is enforcing CDC postexposure guidelines. This is an area where administrative support and legal input may be needed if rapid testing is not being used by medical facilities.
The DICO also has a role in education; he can conduct one-on-one education regarding what is and is not an exposure and provide scientific information to back up such decisions. The DICO can also do initial education and training regarding risk in an exposure event and explain the postexposure medical follow-up and counseling, if indicated. The DICO also documents all aspects of this very important function, which supplements new hire and annual update training. All exposure information is collected to develop a year-end report detailing the number of exposures, broken down to form sharps and TB risk assessments for the department. This information is then given to the department’s trainer for inclusion in annual update training.
According to the Ryan White Notification Law, medical facilities must notify the DICO if a crew has transported a patient suspected for or diagnosed with an airborne/droplet transmitted disease. This disease notification list will expand greatly with the new diseases to be included (Table 1). The DICO must stay up-to-date on this information to ensure that medical facilities uphold their responsibilities. Again, it is important to establish a timely notification system in advance, which must work from the DICO to the medical facility and vice versa.
The DICO must also stay current on changes in laws and regulations and CDC guidelines applicable to his department. Therefore, self-motivation and the skill set to access knowledge of scientifically sound reference sites are additional factors to consider when selecting a DICO. The DICO also needs to maintain credibility when sharing information and interacting with medical facility representatives and department members (Table 2). Ultimately, the DICO is your direct link to Plan B; when all else fails and an exposure occurs, the DICO will be there to ensure that proper care is given to prevent contracting the disease to which an employee was exposed.
Chiefs and administrators must ensure their departments support science and research as the driving forces for this role. Evidence-based practice mirrors the medical and nursing worlds and will assist the fire service in ensuring proper postexposure follow-up care and, at the same time, offer significant cost savings in a time of major budget constraints.
Ryan White CARE Act, 2009, Notification of Possible Exposure to Infectious Diseases, Part G. Sec. 2695.
CPL 02-20.069, Enforcement Procedures for the Occupational Exposure to Bloodborne Pathogens, November 27, 2001.
Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005, December 30, 2005.
KATHERINE WEST, BSN, MSEd, CIC, is an infection control consultant who has worked with Fire and EMS since 1978. She lectures nationally and internationally and has authored books, videos, and articles on infection control issues. West has served as a consultant to the Centers for Disease Control and Prevention, the National Institute for Occupational Safety and Health, the U.S. Public Health Service, and Federal Occupational Health. She is also an education specialist for the National Institutes of Health and authored the Infectious Disease Handbook for Emergency Care Personnel. West was honored as a “Hero in Infection Control & Prevention” in 2006 for her work in the field of infection control and EMS by the Association for Professionals in Infection Control & Epidemiology.
JAMES R. CROSS, JD, is an attorney and a legal, regulatory, and legislative consultant and trainer. He has made presentations to the emergency response community on the legal aspects of infection control since 1992. Cross is the editor of “The Source,” a periodic publication for infection control officers in fire/rescue, EMS, and law enforcement. Cross is also president of Crossroads Mediation Services in Manassas, Virginia.