BYJOANN R. GURENLIAN, RDH, PhD
In the recent months, our country has been challenged by two major infections - non-polio enterovirus and ebola virus disease (EVD). Both diseases are cause for concern as health-care providers may be exposed prior to recognizing the symptoms, including while working in dental practice settings.
EVD is a severe and often fatal illness. The virus is transmitted from wild animals and spreads through human-to-human transmission via direct contact with blood, secretions, organs and bodily fluids of infected people, and with contaminated surfaces such as bedding and clothing. Fatality rates average around 50%. Originally, EVD occurred in remote villages in Central Africa; however, the most recent outbreak has occurred in West Africa, with cases now occurring in the United States.
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EVD can only be spread to others after symptoms begin, which can appear within two to 21 days after exposure. Symptoms of EVD include fever (greater than 101.5 degrees F), severe headache, muscle pain, diarrhea and vomiting, abdominal pain, and unexplained bruising or bleeding. Treatment includes supportive care such as rehydration and symptomatic management. Vaccines for EVD are being investigated.
Non-polio enteroviruses include coxsackieviruses A and B, echovirus, and enterovirus D68 (EV-D68). These viruses cause 10 to 15 million infections in the United States annually. The viruses can occur in any individual, but tend to occur more often in infants, children, and teenagers because they do not have the immunity from previous exposures to the viruses. Most recently, EV-D68 has resulted in fatality due to severe respiratory illness.
EV-D68 can be found in respiratory secretions, including saliva, nasal mucus, or sputum. This virus spreads from person to person through sneezing, coughing, and touching surfaces touched by an infected individual. Symptoms of EV-D68 can be mild to severe. Mild cases include fever, runny nose, sneezing, coughing, and body and muscle aches - easily confused with flu. Severe symptoms include wheezing and difficulty breathing. Children with asthma are particularly vulnerable to severe infection. There is no specific treatment for EV-D68, nor is there a vaccine available to prevent this type of infection.
As health-care providers, we come in contact with patients on a regular basis who present with cold and flu-like symptoms. We are familiar with the patients who faithfully attend their appointments even though they know they are sick. Rather than stay home to treat their illness, they bring it to our offices, potentially infecting us, staff, and other patients in the reception area. What can we do to enhance protection and prevention during these viral attacks?
First, add questions to the health history to try to discern infectious potential. For example, ask patients if they have been traveling recently and whether or not they have been to West Africa specifically, Liberia, Sierra Leone, or Guinea in the last 21 days. Ask if they have been near an area where there has been an Ebola outbreak and if they have been exposed to someone diagnosed with this virus. Ask about any symptoms associated with EVD. If the patient responds affirmatively, defer treatment and refer them for further medical care. For those patients with flu-like symptoms, inquire about the length and severity of symptoms, and whether or not they have been exposed to others with EV-D68. The CDC and ADA recommend delaying routine oral health care for those patients until 21 days have elapsed from their trip.
For those patients who answer yes to having traveled to West Africa and have been exposed to someone diagnosed with EVD, it is recommended that the dental office team members immediately protect themselves by:
• Using standard precautions with physical barriers
• Immediately calling 911 on behalf of the patient
• Notifying the appropriate state or local health department authorities
• Asking the health department to provide the dental office with the most current guidance on removing and disposing of potentially contaminated materials and equipment, including the physical barriers
Next, take vital signs, including temperature. It is not that common for us to take body temperature in a dental office setting, but elevated temperature alerts us to signs of infection. As a general rule, normal body temperature ranges from 96 degrees to 99.5 degrees. Postponing treatment and referral for further medical care is warranted for any patient who presents with an elevated temperature.
Further, practice pristine infection control. This includes
wiping down operatories and any items in the reception area, especially children's toys. Ask patients to cover their mouth and nose with tissues or a shirt sleeve when sneezing and coughing, and encourage them to wash their hands with soap and water for 20 seconds. And, encourage patients to stay home when they are sick by not incurring charges for cancellations due to illness. If you are firm on this practice, patients are less likely to share their illness with you.
Lastly, protect yourself by getting vaccines. By now you should have received a yearly flu vaccine. If you are in the sixth decade of life, you may also need a pneumococcal vaccine and a shingles vaccine. Further, if you have flu-like symptoms, stay home until you are fully recovered. You do not garner extra points for bringing infection to the workplace.
EV-D68 has traversed the U.S. and who knows how far EVD will spread. Do take the time to protect yourself and the practice wherein you work. RDH
JOANN R. GURENLIAN, RDH, PhD, is president of Gurenlian & Associates, and provides consulting services and continuing education programs to health-care providers. She is a professor and dental hygiene graduate program director at Idaho State University, and president of the International Federation of Dental Hygienists.