The document provides information and guidance for reporting notifiable diseases from the emergency department setting. It lists diseases that should be reported including new and emerging infections, outbreaks, and infections that put vulnerable groups at risk. The document also discusses the criteria for pyrexia of unknown origin, malaria, and managing animal and human bites. It provides the rabies risk assessment form and outlines tetanus immunization guidance and HIV exposure management.

1. Up to date ID
for
ED Doctor
CESR Educational day
25/11/2022
Rashid Abuelhassan
MBBS, FRCEM,EMRTP

2. About this session
• No conflict of interest
• No fire drill today
• Keep your phone handy but silent
• Fast pace
• Lots of tools for you to scan and keep

3. Scan this QR code to participate

5. Content
Notifiable diseases * IC5
Pyrexia in travelers & PUO IP2, IC6
Malaria * IC7
Influenza * IC1
Human and Animal Bites
HIV & Infections in Immuno-Suppressed patients IC2, IC6
Exposure to infections during pregnancy Chicken Pox
/ Measles *
ObC3
Needle Stick / Exposure to Blood Borne viruses IP4.
Infestations IC3

6. Notifiable Duty /Rule in ED
*

8. What to
report?
1.Chemical exposure (e.g. CO, lead, mercury)
2.Radiation exposure
3.New and emerging infections (e.g. new strains
flu)
4.Part of an outbreak/ cluster (e.g. c. diff,
norovirus)
5.infections where vulnerable are at risk: e.g.
infection in a HCW, VZ exposure in pregnant or
immunocompromised persons
*2

14. *

17. The triage nurse approached you.
She has a 35 year old male, returned from
Ghana, presenting with muscle pain,
headaches, a history of fever and
diarrhoea.
What is your next question for her ?

18. Pyrexia in
travelers
What is the cause ? *4

23. Travel onset
• Time & Pattern
Activities
• Freshwater, Saltwater, Caves,
Barefoot, Animal contacts
Room and Board
• Urban vs rural
• Local food; dairy; water
• Mosquito nets; screens
Vaccination/pre travel preparation
• Vaccines?
• prophylaxis and compliance
Exposure
• Med care; infections or transfusions
• Sick contacts within three months
• Tattoos
Location
• Exact itinerary
• Duration in each
• Stopovers

24. *

28. *

35. Next to be seen is a 35 year old male,
returned from Ghana, presenting with
muscle pain, headaches, a history of
fever and diarrhoea.
What do you think?
*

39. Malaria

41. Severe Malaria Presentations
• Impaired consciousness : GCS <11 in adults or a Blantyre coma score <3 in children
• Acidosis : base deficit of >8 meq/l or HCO3 <15 or lactate >5. ? respiratory distress (rapid, deep and
laboured)
• Hypoglycaemia : glucose <2.2 mM (<40 mg/dl)
• Hyperparasitaemia: according to the level of malaria transmission.
• Severe malarial anaemia: Hb <5 g/dl or HCT <15% (adults) Or <7 g/dl
• Renal impairment : serum creatinine >265 μM (3 mg/dl) or blood urea >20 mM
• Jaundice : bilirubin >50 μM (3 mg/dl)
• Pulmonary oedema: Radiologically confirmed, or SpO2 <92% on RA OR RR >30/min +/- crepitation on
auscultation
• Significant bleeding: Inc. recurrent or prolonged bleeding from nose gums or vein puncture sites
• Shock:
• Compensated shock : cap refill ≥3 s or tempe gradient on leg (mid to proximal limb), but NO
hypotension.
• Decompensated shock : sys BP <70 mm Hg in children or <80 mm Hg in adults with evidence of
impaired perfusion
*

44. PUO
Criteria:
•Temperature >38.3°C on several occasions.
•3 weeks of illness.
•Failure to reach a diagnosis after one week of
inpatient investigation.
New modification :
• patients diagnosed after two outpatient visits
or three days in hospital.
• Nosocomial PUO in hospital patients.
• Neutropenic PUO, fever as above + <1 x
109 neutrophils.
• HIV-associated PUO, HIV +ve + fever as
above for 4wks as outpatients or 3d
inpatients,

45. ▪ Infections
▪ SBE
▪ TB
▪ Device –related infections
▪ Deep seated infections
• Diverticular abscess
• Liver abscess
• Spondylo-discitis
• Osteomyelitis
▪ Tropical
• Malaria
• Leishmaniasis
• Brucellosis
• Enteric fever
• Amoebic liver abscess
• Melioidosis
▪ Viral /atypical
• HIV-related
• CMV / EBV
• Atypicals / q-fever
▪ Malignancies
– Lymphoma
– Leukaemia / myeloma
– Renal cell Ca
– Disseminated malignancy
▪ Connective tissue / other
– Connective tissue disease
(RA/MCTD)
– Vasculitis / PMR
– Still’s disease
– Sarcoid
– Crohns
– Drug fever
– Factitious fever

46. *
Your junior approached you and told you that his patient may have Rabies.
How will you respond ?

48. Rabies
Is there any Rabies in Europe ?

49. Rabies
Risk by countries

50. Rabies
Rabies post exposure risk assessment
form and calendar

51. Managing a bite
• Encourage bleeding.
• Removal of any foreign bodies.
• Thorough irrigation with warm, running water.
• Debridement?
• Analgesia.
• ABX
• Human bite: If skin is broken + drawn blood or involves
high-risk areas or pt. at risk of wound infections. +
?consider risk of HIV or hepatitis B.
• Animal bite: if a cat bite has broken the skin and the
wound could be deep or a dog or other animal bite has
penetrated vital tissues, caused significant tissue
damage or is contaminated or involves high-risk areas of
skin or the person is at risk of wound infections.
• ? Tetanus and rabies prophylaxis.
The full guideline

53. Tetanus-prone wounds include:
• puncture-type injuries acquired in a contaminated environment and likely
therefore to contain tetanus spores e.g. gardening injuries
• wounds containing foreign bodies
• compound fractures
• wounds or burns with systemic sepsis
• certain animal bites and scratches - although smaller bites from domestic pets
are generally puncture injuries animal saliva should not contain tetanus spores
unless the animal has been routing in soil or lives in an agricultural setting
High-risk tetanus-prone wounds include:
• heavy contamination with material likely to contain tetanus spores e.g. soil,
manure
• wounds or burns that show extensive devitalised tissue
• wounds or burns that require surgical intervention that is delayed for more than
six hours are high risk even if the contamination was not initially heavy
Tetanus

54. Immunisation Status Immediate treatment Later treatment
Clean
wound
Tetanus Prone High risk
tetanus prone
Those aged 11 years and over, who
have received an adequate priming
course of tetanus vaccine2 with the
last dose within 10 years
Children aged 5-10 years who have
received priming course and
preschool booster Children under 5
years who have received an adequate
priming course
None required None required None required Further doses as
required to
complete the
recommended
schedule (to
ensure future
immunity)
Received adequate priming course of
tetanus vaccine2 but last dose more
than 10 years ago Children aged 5-10
years who have received an adequate
priming course but no preschool
booster
Includes UK born after 1961 with
history of accepting vaccinations
None required Immediate
reinforcing dose of
vaccine
Immediate reinforcing
dose of vaccine One
dose of human tetanus
immunoglobulin3 in a
different site
Further doses as
required to complete
the recommended
schedule (to ensure
future immunity)
Not received adequate priming course
of tetanus vaccine2 Includes uncertain
immunisation status and/ or born
before 1961
Immediate
reinforcing
dose of
vaccine
Immediate
reinforcing dose of
vaccine One dose
of human tetanus
immunoglobulin3
in a different site
Immediate reinforcing
dose of vaccine One
dose of human tetanus
immunoglobulin3 in a
different site
Further doses as
required to complete
the recommended
schedule (to ensure
future immunity)

55. ID Quick reference
The Green Book
*

58. Is the fluid involved significant?
Was the nature of the exposure significant?
•Deep injury.
•Visible blood on the device involved.
•Injury from a needle that has entered the source’s blood vessel.
•Terminal HIV-related illness in the source.
Is the source high risk?
•Intravenous drug user.
•Sex industry worker.
•Originally from sub-Saharan Africa.
•Regularly has unprotected sex with any of the above.
•If the source is a child, they are high risk if their mother has HIV.
•The source has, or is under investigation for, an AIDS defining illness.
If the source patient is unknown, then the usual approach is to assume a low risk
exposure.

59. Advice on discharge from the ED & Follow up
• Use barrier contraception.
• Avoid sharing razors and toothbrushes.
• Not donate blood until results are back.
• Healthcare workers can continue to undertake procedures
with PPE.
• HCW should be encouraged to contact their OH ASAP to
arrange further follow up.

61. New HIV diagnoses,AIDS at diagnosis, and all-cause deaths in the UK:
2000 to 2019

62. New HIV diagnoses in the UK: all persons by probable exposure route,
2010 to 2019

63. NumberofpeopletestedforHIVbyservicetypeatallSHS:England,2015
to2019

64. 10 Infection Latent Phase Symptomatic HIV & AIDS
Spike in viral load = Most
infectious period
Often associated with a
seroconversion illness
Can we identify these
patients?
Variable length – years to
decades with low vial loads,
a falling CD4 count and no
symptoms
Should we screen? More
later with the CEM guidance.
As CD4 count falls patients
become more
immunodeficient & thus
susceptible to infections
Progressing to opportunistic
infections and death

66. 1. HIV testing should be performed in the emergency department (ED) setting when it influences immediate clinical
management and improves patient care.
2. The HIV seroprevalence rate in the catchment population should be known before any HIV testing program is
introduced into the emergency department. Strong recommendation.
3. Consider offering routine ED HIV testing where the local diagnosed HIV prevalence is 2/1000 or greater, providing that
appropriate funding, and systems are in place to support this. Emergency Departments are not a suitable environment
for ad hoc screening programs where local prevalence rates are uncertain or below 2/1000. Strong recommendation.
4. Safeguards are required before introducing routine ED HIV or blood borne virus testing. These safeguards include: a
systems-wide approach; adequate resources for training and education of staff, testing and follow up; and, the
development of robust protocols for the transfer of patient care with reactive or positive results to appropriate care and
support services. Strong recommendation.

67. Exposure to
Chicken Pox
during pregnancy

69. References