Message: #2661 - BPI Tech Brief #7
Date: 22 Mar 94 16:25:57 EST
From: Mike Darwin <>

22 March, 1994
Copyright 1994 by Biopreservation, all rights reserved.

     As with Tech Brief #6 on assessment and identification 
of human cryopreservation patients this Tech Brief is a 
reprint of a chapter from our Level I Transport Manual.  It 
is presented here both for criticism and comment and to 
serve as a starting point for the generation of community-
wide standards for infection control during transport 

Infection Control In the Standby and Transport Setting

By Michael Darwin and Steven B. Harris, M.D.


        Infectious  disease is any illness which can be 
transmitted from organism to organism. All infectious 
diseases fall into the class known as parasites: they live 
at the expense of the host organism by extracting energy and 
materials from the host's body.  Disease organisms which are 
poorly adapted to their hosts rapidly kill or quickly 
provoke immunity (neutralization) in the host, and thus 
require a large population of susceptible individuals to 
infect in order to propagate and survive.  Such diseases 
usually must spread rapidly and are known as epidemic 
diseases.  Examples of epidemic diseases are polio, 
smallpox, Plague (Black Death), and the childhood diseases 
such as chicken pox and measles. The causes or "etiologic 
agents" of an infectious illness may be broadly divided into 
four classes:

1) Viruses and associated sub-viral particles (virion) of 
DNA and RNA;  instructional material inside the cell's 
nucleus which in effect "tells the cells what to do.".  
Examples of viral etiologic agents (to name a very few) are 
influenza, polio, hepatitis A, B, and C, and the human 
immunodeficiency virus (HIV) the cause of  Acquired 
Immunodeficiency Syndrome (AIDS).  An example of  a "sub-
viral" etiologic agent is the Delta Particle which is a 
small piece of nucleic acid which is harmless alone, but 
when present  in an individual suffering from Hepatitis B 
virus infection, greatly exacerbates the morbidity and 
mortality associated with the illness.

Viruses and virions, unlike the other etiologic agents 
discussed below, are not capable of reproduction without a 
living host cell, in other words, they rely upon a host to 
provide most or all of the machinery for their reproduction. 
In fact, a virus is often nothing more than a carefully 
packaged set of instructions for making more virus (there 
are many exceptions to this generalization: the smallpox 
virus is large enough to see by "eye" with a high powered 
light microscope and contains many enzymes and complex 
structures which it uses to take over the host cell).  The 
"package," consisting of an outer coat of specialized lipids 
or proteins, is designed to allow the virus to attach itself 
to, enter, and take control of the cell's metabolic 
machinery subverting  it to the purposes of producing 
thousands of additional copies of the virus  (usually 
resulting  in the death of the infected cell).

2) Bacteria, protozoa,  and fungi  are capable of 
reproduction outside of living cells of other organisms .  
These organisms use the host's structure and nutrients as a 
food source to further their multiplication.  Illnesses 
caused by these microorganisms are responsible for an 
enormous range of  human disease and suffering.  Leprosy, 
tuberculosis, the Plague , bacterial pneumonia, malaria, 
syphilis, and gonorrhea are but a few.

3)  Multicellular parasites are more complex organisms such 
as mites (arthropods) and worms (helminths such as the 
Cestodes, Trematodes and Nematodes) which can also infect 
human beings and cause illness. Examples of such organisms 
encountered in the Developed Western World are scabies, and 
head, body, and public lice among the arthropods, and 
pinworm (enterobiasis),  trichinosis and filariasis among 
the helminths.  While illness caused by such muliticellular 
parasites is less common in developed countries than it was 
even a few decades ago, it is still common enough to be of 
some concern to the Transport Technician and to merit 
discussion of symptoms, and prophylaxis and treatment.

Transmission of  Infection

        Infectious agents may be found in many places in both 
the animate and inanimate environment which surrounds us.   
Transmission of infectious disease requires three factors: a 
source of infecting organisms (or reservoir), a means of 
transmission of the organism, and a susceptible host.  These 
three factors may be imagined as three overlapping circles:

*Illustration not included.

Figure 15-1: Elements of infection.

Source (Reservoir)

        Infectious agents may survive in a reservoir but may or 
may not multiply.  Three common sources or reservoirs of 
infection are: people, fomites, and animals:

People:  The source of etiologic agents may be patients and 
may include persons with acute disease, persons in the 
incubation period of the disease, or persons who are 
colonized by infectious agents but who have no apparent 
disease.  Patients may also become infected with their own 
microbial flora (such as bacteria normally present in the 
gut, on skin, and on mucous membranes).  This is called 
endogenous infection.

Fomites: The inanimate environment can also serve as a 
source of etiologic agents.  Bedding, work surfaces, 
contaminated medical devices, door handles, and so on, can 
all carry infectious agents from viruses to insects.

Animals and Insects: Fleas may transmit the Plague, ticks 
may transmit Rocky Mountain Spotted Fever, and skunks and 
bats serve as reservoir animals for rabies.  Generally, 
animals and insects are not considered of any significance 
as a mode of disease transmission to the Transport 
Technician at this time, although acquisition of infestation 
with several species of insects from patients (scabies and 
the body louse) are of slight concern.


        Transmission is the mechanism for transfer of an 
infectious agent from the source (reservoir) to a 
susceptible host.  There are four main routes of 

Contact Routes:

1) Direct Contact: This involves direct physical transfer 
between an infected or colonized individual and a 
susceptible host.  Examples of this are when a transport 
technician touches, intubates, suctions, surgerizes, or 
performs other procedures which put him/her in direct 
contact with the patient.

Indirect Contact:  This occurs when there is contact between 
the susceptible host with a contaminated object (usually 
inanimate) such as instruments, clothing, linens, dressings 
and so on.

Droplet Contact:  The occurrence of droplet contact is as a 
result of the production of aerosols of body fluids which 
are expelled or propelled from the source (usually the 
infected person)  and which come into contact with the , 
skin, , conjunctivae, or other mucous membranes of  a 
susceptible host.  This mode is considered direct 
transmission since the droplets are usually large particles 
which settle out of the air on environmental surfaces within 
no more than three feet of the source.  Examples of sources 
of aerosols are coughing, suctioning, operation of 
respiratory equipment, and aerosolization of body fluids 
mixed with air (such as  bloody foam being withdrawn from an 
extracorporeal circuit) being discharged from a syringe into 
an open waste container.

*Illustration not included.

Figure 15-2: Transmission Via Droplet Contact: 
Aerosolization of infectious material during a sneeze.  Note 
the mucous strings and relatively coarse particle size.

Vehicle Route 

        The vehicle route transmits infectious agents or their 
toxins through the following media:

        Food - as in salmonella and staph infections
        Water - as in giardia and legionellosis or Hepatitis A
        Drugs and IV Fluids - as in septicemia secondary 
                to administration of a contaminated parenteral product.
        Blood: as in HIV, or Hepatitis B or C.

Airborne Transmission

        Transmission of etiologic agents by the airborne route 
involves the creation of droplets or dust particles which 
are less than 5 microns in diameter.  These particles are 
small enough to remain in the air currents in the ambient 
environment and get onto or into the susceptible host 
(conjunctiva, skin, or contact by inhalation).

Volume of Innoculum

      The quantity of etiologic agent which is transferred 
usually affects the liklihood of subsequent infection.  This 
will vary greatly from etiologic agent to etiologic agent.  
For instance, it is estimated that a single smallpox virus 
is capable of routinely causing infection.  By contrast, 
many, many HIV particles are typically required to cause 

Vector-borne Transmission

        This route of transmission involves an infectious agent 
which is transmitted to the susceptible host by an arthropod 
(insect).  This is not a serious or common mode of disease 
transmission in the developed world.


        The so far unmentioned but by no means unimportant 
final element in the process of infection is the susceptible 
host.  Susceptibility to a given infectious disease can and 
does vary greatly between hosts.  Some hosts will easily 
become infected.  Others will be resistant to infection.  
Still others will become infected and will experience mild 
or not clinically obvious illness.  Others may become 
infected and serve as asymptomatic carriers of the disease.  
Age, general health, the presence of stress, trauma, wounds, 
nutritional status, and many other factors alone or in 
combination all may act to impact the host's susceptibility 
to a given etiologic agent.  Finally, the genetic make-up of 
the host and past history of exposure to the etiologic agent 
or its antigens (such as vaccination) can have a profound 
effect on the likelihood of infection as well as on the 
course of the illness if infection occurs.

Prevention of Infection

        Transmission of  etiologic agents can only be inhibited 
by "breaking the chain" of events which lead to infection.  
Logically, the best place to do this is at the weakest link 
in this chain.

1)  Patients with known infections should be identified 
promptly and their diseases assessed for the need for 
special precautionary measures.  Inanimate sources of 
pathogens associated with caring for the patient can be 
addressed through disinfection or sterilization.  In all but 
rare instances (which will be discussed briefly below)  
standard "Universal Precautions" which isolate the Transport 
Technician from  contact with the patient's blood, 
secretions, and other body fluids will be sufficient to 
"break" the link at its weakest point, the point of 

With the emergence of HIV with its long, asymptomatic period 
and its unusual feature of infectivity throughout all 5 
phases of the illness, it has become imperative to presume  
that  all patients are HIV infected or carry other diseases, 
both blood borne and respiratory, which may not be 
clinically apparent at the time of  standby or transport 
(such as Hepatitis B, C, or tuberculosis (TB)).

2) Interrupting the mode of transmission is the most 
frequently employed method of preventing the spread of 
infectious disease.  Hand washing, wearing  of masks, gloves 
and gowns, and disinfection of surfaces, linens and 
instruments are all examples of interrupting transmission.

3) Hand washing has consistently been shown to be the most 
effective single means of preventing transmission of 
etiologic agents.  All personnel should wash their hands 
both before and after patient contact regardless of whether 
or not gloves have been worn.

4) Manipulation of the host's susceptibility is one of the 
more difficult factors to control.  Vaccination and 
administration of products conferring passive immunity (such 
Hepatitis B immune globulin), and  the use of 
chemotherapeutic prophylaxis (such as the administration of 
Ribavirin to personnel Transporting and perfusing HIV cases) 
may help boost host defenses.  Proper nutrition and stress 
reduction are also important considerations and will be 
discussed in greater detail later..  However, these are 
downstream interventions and the best place to prevent 
infection is to prevent contact of the infectious agent with 
the host.

5) Isolation in the form of  Universal Body Substance 
Precautions (UBSI) is to be practiced at all times during 
patient contact since they are the best way to break the 
chain of infection.  The isolation precautions mandated in 
this manual are predicated on this concept.

Diseases of Concern in the Standby/Transport  Setting

        From the moment the Transport Technician first has 
contact with the patient it is important to be aware of the 
patient's medical history and to pay particular attention to 
the following diseases which are of special concern:

(AIDS) Human Immunodeficiency Virus Infection.  HIV is a 
lipid coated retrovirus (an RNA virus) which is transmitted 
through intimate contact with body fluid containing the 
virus.  Examples of such contact which are of special 
concern to the Transport Technician are contact of mucosa or 
open wounds with blood or body secretions,  needle sticks or 
cuts with instruments contaminated with infected blood or 
body fluid, conjunctival contact with blood or body fluid 
during suctioning, catastrophic rupture of the 
extracorporeal circuit, or aerosolization of 
blood/secretions during Thumper support in the presence of 
fulminating pulmonary edema, or contact with circulating 
water in the Portable Ice Bath (PIB) which is contaminated 
with body fluids.

        HIV is a disease with 6 stages beginning with infection 
and ending with complete compromise of the host's immune 
system and death.  This first stage of the disease 
(infection) is sometimes (though not always) accompanied by 
flu-like symptoms; fever, malaise, sore throat...  The 
disease infects T-lymphocytes, in particular "helper" T-
lymphocytes either killing them or rendering them 
ineffective.  When the population of helper T-cells drops 
below 400 per cubic mm of blood or about 1/2 of normal the 
infected individual becomes increasingly susceptible to 
attack by bacteria, viruses and malignancies which are 
normally kept in check by this arm of the immune system.  
Infection with single or multiple etiologic agents ensues 
eventually resulting in death from failure of one or more 
organ systems.   HIV may also infect other body cells such 
as those in the central nervous system  and gut, causing 
dementia and 

*Illustration not included.

Figure 15-3:  The Walter Reed Classification System chart 
show the progression of patients from exposure to HIV (WR-0) 
through stages of progressive immunocompromise ending with 
complete collapse of T4 cell function and death.  The 
criteria by which patients are staged are shown in the 4th 
and 5th columns from the left and consist of T4 cell count 
and  decay of the delayed hypersensitivity response (skin 
anergy: in other words failure of the patient to develop a 
local inflammatory response on the skin after cutaneous 
administration of common disease antigens such as measeles, 
mupms and so on).  The chart below shows WR staging versus 
both T4 cell count and associated clinical changes (i.e., 
lymphadenopathy, opportunistic infections, etc.). 

intestinal failure.  The mean incubation period for AIDS 
(the final stage of HIV disease) is believed to be 10.25 
years.  However, individuals have been to known to die of 
AIDS as early as 12 months after infection and to have 
remained healthy for as long as 17 years.  

        Because HIV compromises the arm of the immune system 
most responsible for protecting the individual against 
tuberculosis (TB), this disease is epidemic amongst HIV 
infected individuals in the 3rd through 5th stages of the 
disease.  Unlike HIV, TB is a highly communicable disease.  
TB will be discussed in great detail below, however it is 
worth mentioning here that all AIDS patients must be 
presumed to have concurrent TB infection since AIDS destroys 
the immune response used to detect the presence of TB 
infection.  It is estimated that between 1/4th to 1/3rd of 
all AIDS patients are infected with TB; an increasing number 
with a strain of TB which is resistant to most antibiotics 
known to be effective at treating TB (so-called multi-drug 
resistant TB (MDR-TB)). 

        HIV has been found in virtually all body fluids but is 
present in the highest concentration in semen, blood and 
cervical secretions.  Although not common, it is a 
theoretical possibility that HIV may be transmitted through 
contact with any body fluid such as urine, saliva, tears, 
cerebrospinal fluid, peritoneal fluid, pericardial fluid, 
pleural fluid, synovial fluid, amniotic fluid and breast 
milk.  While HIV has been found in saliva there are no 
documented cases of transmission by this route.  Extensive 
studies involving the use of shared eating utensils, tooth 
brushes, and intimate oral contact between infected and 
uninfected persons have failed to demonstrate theses routes 
as a means of transmission.  Because  HIV is a lipid coated 
virus it is very fragile and does not survive long on 
environmental surfaces.  Furthermore, its lipid coating 
makes it very susceptible to destruction by soaps and 
detergents.  Thus, cleansing of environmental surfaces with 
detergents and disinfectants and hand washing are very 
effective at destroying the virus.

*Illustration not included.

Figure 15-5: Typical  patient clinical course and T4 cell 
count as staged using the Walter Reed staging classification 
for HIV infection.  Approximately 3 months after exposure 
the patient shows significant levels of virus in the blood.  
The T4 cell count drops and then rebounds in response to 
initial antibody production  by the host. By about 9 months 
lymphadenopathy develops.  At approximately 36 months after 
infection the T4 cell count has declined to below 400.  At 
68 months the patient became symptomatic with oral thrush.  
Twevele months later the patient experiences multiple 
opportunistic infections and at 83 months death occurs with 
a T4 cell count of essentially zero. (From Scientific 
American 259:4, 1988.)

Risks Of Transmission

        Of  special concern to the Transport Technician is the 
risk of acquiring HIV infection as a result of incidents of 
exposure or "breaks" in technique which may occur during the 
course of transport operations.  The "good" news is that HIV 
is not very infectious compared to most other epidemic viral 
illnesses and in particular in comparison to Hepatitis A, B, 
and C.  The Hepatitis viruses are by comparison thousands of 
times more infectious than HIV.

        The bad news is that HIV infection is generally 
presumed to carry a mortality rate of  100%.  Thus, it is of 
paramount importance that the Transport Technician not 
become infected with HIV during the course of delivering 
cryopreservation care.  The unbreached application of UBSI 
Precautions to be described below will virtually guarantee 
protection from transmission of  HIV to transport staff.  

*Illustration not included.

Figure 15- 4: The graphic above shows the wide variety of 
tissues which are currently known to be infected with the 
Human Immunodeficiency Virus (HIV).  All cells which can be 
infected with HIV carry the CD4 molecule on the surface of 
their cells. 

        However, accidents can and do happen and it is 
important that staff be aware of the risks they face in the 
event of  an incident of exposure.  While there is no way to 
know what the response of a given individual will be to 
exposure, the risks for statistical populations are known 

and they are as follows:

1) Needle Sticks/cuts with HIV contaminated sharp objects: 
This is by far the most serious and common source of 
exposure.  It is estimated by the CDC that the risk of 
infection from this route is roughly 1 in 250.  In other 
words, for every 250 people who experience this kind of 
contamination 1 will become infected with HIV.

*Illustration not included.

Figure 15-6:  Recapping needles is strictly forbidden 
because of the obvious risk of needle-stick.

2) Conjunctival/Respiratory Contact With Aerosols or Blood:  
Good numbers for this route of transmission are not known.  
Personal communication with infectious disease physicians 
experienced in this area place the risk for conjunctival 
contact at between 1 in 500 and 1 in 1,000.  The risk for 
respiratory contact is not known.

3) Blood Contact  With Open Wounds (cuts, abrasions, etc.):  
Risks are not well established here although there have been 
several documented cases of transmission by this route 
amongst health care workers.  

        It should be noted that the CDC has stated that the 
risk of infection from needle sticks is low.  The author 
believes this statement to be hypocritical since the risk of 
acquiring HIV from needle sticks,  puncture, or incision by 
other contaminated sharps,  is the same as quoted for 
unprotected anal intercourse with an infected partner: a 
practice which the CDC  defines as very high risk.

Universal Body Substance Isolation

        Universal body substance isolation precautions (UBSI) 
are called "universal" for the simple reason that you must 
assume that all patients you care for are infected with HIV 
or one or more other blood or airborne pathogens.  

        Since medical history, testing , and examination cannot 
reliably identify all patients infected with HIV and TB the 
following blood/body fluid and airborne disease precautions  
must be consistently used for all patients:

  From the time Standby begins all Transport Technicians who 
will have contact with the patient including being present 
in the room where the patient is being cared for must wear a 
mask at all times.  Gloves must be worn for touching blood 
and body fluids, mucous membranes, tissues or non-intact 
skin of all patients.  Gloves must be latex, not vinyl.  
Vinyl gloves are easily torn and rapidly develop microscopic 
holes which allow more than two times the penetration of 
bacteria and viruses than do latex gloves.  

*Illustration not included.

Figure 15- 7: The Human Immunodeficiency Virus.

   Once transport operations begin all transport personnel 
must wear the following protective items at all times during 
transport operations:

o  Hand/skin protection consisting of nitrile glove liners 
with latex exam or surgical over-gloves.  Personnel who will 
not be doing surgery must wear heavy-duty minimum 12 mil 
nitrile gloves with latex over-gloves.  Surgical or other 
personnel requiring good "feel" or touch sensitivity may 
wear sheer 5 mil nitrile liners with surgical or latex exam 

o Respiratory protection consisting of either tie-on or cup-
type surgical  masks.  

o Eye protection consisting of goggles or full face shields.  
Personnel involved in perfusion operations or surgery must 
wear full face shields.

o Body skin protection consisting of Tyvek suits which cover 
arms, trunk and legs. 

o  Shoe covers must be worn to prevent contamination with 
ice water contaminated with body fluid which may accumulate 
on the floor during PIB leaks or movement of the patient out 
of the PIB.  If the Tyvek clothing has integral shoe covers 
these are acceptable.

  Hands and other skin surfaces should be washed thoroughly 
with soap and water if contaminated with body fluids or 
blood.  Hands should also be washed immediately after 
removal of gloves.  Nitrile liner gloves should also be 
washed while on the hands (and left in place) if there is a 
need to discard the latex over-glove (such as when exiting 
the transport or operating area to a "clean" area or working 
on clean equipment).  If possible all hand washing and skin 
cleansing should be carried out with an antimicrobial soap.

   Extreme care should be taken to avoid sticks or  cuts 
from scalpels, needles or other sharp objects both during 
and after procedures and when cleaning instruments.  To 
prevent needle-stick injuries needles should never be re-
capped, purposely bent, or broken by hand, removed from 
syringes, or otherwise manipulated by hand.  Immediately  
after use needles, scalpel blades, syringes and other 
disposable sharp objects must be placed in rigid walled, 
puncture resistant  "sharps containers" for disposal.  
Locate the sharps container as close to the point of use as 
possible.  Never lay a used needle or sharp down on any 
surface for any reason.  Sharps must disposed of promptly.

   Transport Technicians who have lesions or weeping 
dermatitis should refrain from all direct patient contact 
and from handling contaminated patient care equipment until 
the condition is gone.

  Where possible Transport Technicians who are pregnant 
should refrain from involvement with invasive aspects of the 
procedure and should exercise special care to protect 
themselves during discharge of their duties.  While pregnant 
women are not known to be at increased risk of contracting 
HIV in a healthcare or transport setting, the fact remains 
that  if infection does occur their is significant risk of 
its prenatal or natal transmission  to the fetus/infant.

  Although saliva has not been known to be responsible for
HIV transmission it is capable of transmitting Hepatitis
and other infectious agents.  For this reason bag-valve 
resuscitators or other ventilation equipment  providing 
isolation for the Transport Technician should always be 
available for use during transport operations.

HIV Chemoprophylaxis and Surveillance

        Transport personnel involved directly in invasive 
surgical operations employing sharps under field conditions 
should be prophylactically treated with Ribavirin (Vilona) 
obtained from Mexico.  While this drug is not an effective 
treatment for HIV infection because of its failure to cross 
the blood-brain barrier, it is the prophylactic agent of 
choice at this point.  Zidovudine (AZT) should probably not 
be used for prophylaxis since most AIDS patients have 
received this drug during their illness and thus harbor 
Zidovudine resistant virus.  The HIV  chemotherapeutic 
agents ddI and ddC are unacceptable for prophylaxis due the 
high incidence of both mild (GI disturbances) and serious 
(pancreatitis) side effects.  By contrast, Ribavirin, used 
for the short period of  transport operations, and a brief 
window beyond, is very unlikely to produce serious side-
effects.  The following protocol of  Ribavirin prophylaxis 
is indicated for surgical personnel involved in transport:

  When the patient becomes frankly agonal, at-risk team 
members should take a dose of 400 mg of Ribavirin (Vilona).

   Thereafter doses of 400 mg  should be administered at 8 
hour intervals for 48 hours after transport operations or 
other risk of exposure ceases.

   In the event of  needle stick or other contamination or 
break in technique Ribavirin therapy should be continued for 
14 days.  Follow up serologic examination should then be 
conducted at 90 days, 6 months, and 12 months to rule out 
the possibility of infection.

   All  Transport Team Members must  have routine 
surveillance for the presence of HIV infection at 90 days 
and 6 months following transport operations when it is 
documented that HIV infection was present in the patient. 
(NOTE: all patients are serologically evaluated for the 
presence of HIV antibodies following cryopreservation..)

*Illustration not included.

Figure 15-8:  Ribavirin for use in prophylaxis against HIV 

        Transport personnel with known exposure to HIV should 
continue Ribavirin prophylaxis for at least 2-weeks.  The 
Technician should then be tested for HIV antibody at 6 
weeks, three months, six months and one year.  Until HIV 
seronegativity is firmly established (antibody 
seronegativity by ELISA at 1-year and/or antigen negativity 
by PCR at 6 months)  the exposed individual should be 
counseled to avoid unprotected sexual contact and operate 
under the assumption that they are HIV infected and act to 
protect their sexual partners accordingly.  Similarly, 
exposed individuals should refrain from blood, blood 
component, or semen donation, and females should defer 
pregnancy until  absence of infection can be determined. 

Hepatitis A, B, and C

        Hepatitis A is a highly infectious form of hepatitis 
(liver inflammation/injury) which is transmitted primarily 
through oral-fecal contact (as in lack of or improper hand 
washing during food preparation) or by blood or salivary 
contact.  It is most often a childhood disease with a peak 
incidence between the ages of  5-14 years.  It has a short 
incubation period (15 to 50 days) usually causes little 
morbidity (though this is variable) and is only rarely 
associated with mortality (<0.5%).  However, several caveats 
apply in this regard: pregnant  and post menopausal women 
appear to have a more severe course of the illness and the 
morbidity rises for both males and females the later in life 
that infection occurs.

        The incidence of Hepatitis A is somewhat seasonal 
occurring mostly in Autumn or Winter.  The clinical course 
is one of abrupt onset with anorexia, fever, nausea, 
vomiting, lassitude and sometimes right upper quadrant 
abdominal pain.  Symptoms persist for several days to a week 
after which time jaundice (yellowing of skin and the whites 
of the eyes) appears if it is going to occur.  Once jaundice 
occurs fever and associated symptoms usually decrease in 
severity.  Jaundice is frequently accompanied by dark urine, 
and light or white colored stools.  The onset of jaundice 
usually signals the beginning of recovery.  The patient is 
infectious throughout the illness and often into 
convalescence which may be prolonged (lasting several weeks 
to months).   The usual course of the disease is benign and 
recovery is almost always complete.  Comparatively rarely 
the disease may become fulminant and the patient experience 
significant morbidity or even mortality.

        Patients recovered from Hepatitis A are  believed to 
have lifetime immunity and do not develop carrier state.

 Hepatitis B and C

        Hepatitis B and C will be discussed together since the 
clinical course of both illnesses is roughly the same and it 
is believed that the incubation period, mortality and 
morbidity are also comparable.  

        There are several important differences between 
Hepatitis B and C and Hepatitis A.  The onset of B and C is 
slower, indeed often insidious, and the incubation time is 
far longer: 45 to 160 days.  Not infrequently the first 
appearance of the disease is jaundice.  However, fatigue, 
malaise, changes in urine color, and occasional febrile 
illness accompany initial manifestation of the illness.  
While the onset of  Hepatitis B and C is slower with 
patients often being afebrile, the clinical course is much 
more serious than with Hepatitis A.    Hospitalization is 
frequently necessary and the mortality may approach 10 % to 
20% in some outbreaks.  The symptoms of the illness: 
jaundice, malaise, anorexia, fever, white or cream-colored 
stools, and dark urine are much the same as with Hepatitis A. 

        It should be noted that many individuals in the 
population have had Hepatitis A, B and/or C  and have never 
manifested clinical symptoms.  In the case of Hepatitis A it 
is believed that the ratio of asymptomatic (undiagnosed) 
cases to symptomatic cases is 10 to 1.  For  Hepatitis B and 
C the ratio is lower, possibly as low  as 2 to 1 or 3 to 1.

        While the clinical course of  Hepatitis B and C may run 
the gamut from virtually no symptoms to death, it is an 
unfortunate reality that the less severe the course of the 
illness, the more likely the illness is to become chronic 
and/or to result in carrier status for the infected 
individual.  The chronic active form or Hepatitis B and C 
has a high mortality both from liver failure as a result of 
the direct action of the virus and from liver cancer 
associated with the chronic presence of the virus.  
Similarly, carriers of the B and C viruses have an 
approximately 100-fold greater risk of developing primarily 
carcinoma of the liver and of course they are a life-long 
source of infection to those with whom they come into 
intimate contact, or with whom they share needles or blood 

        The primary routes of transmission of Hepatitis B and C 
are sexual contact,  intimate personal contact (shared tooth 
brushes, or other hygienic utensils),  contaminated needles 
or sharps (such as those used in IV drug abuse, ear 
piercing, and tattooing) and blood products.  

Hepatitis Precautions

        The UBSI techniques discussed above for use with HIV 
are also effective at protecting against all three varieties 
of Hepatitis.   It is important to point out that unlike 
HIV, Hepatitis B is easily transmitted through routine 
contact such as bed bathing, kissing, and so on.  Thus, 
Transport Technicians present in standby operations 
(particularly long standbys) who become involved in routine 
patient care should be especially vigilant when dealing with 
individuals infected with Hepatitis.  The use of gloves, 
masks and cover gowns is required during all patient handing 
operations including turning, bathing, suctioning, and 
handling of  linens soiled with body secretions.

Hepatitis Prophylaxis

        A very safe and highly effective vaccine is available 
against Hepatitis B (HB vaccine).  It is required that all 
transport personnel be immunized against hepatitis B using 
either of the commercially available vaccines (Recombivax or 
Engerix-B). Following vaccination the Transport Technician 
should be evaluated for  anti-hepatitis B antibodies (anti-
HBs) to ensure the presence of a sufficient titer of 
antibody to confer protection.

        In the event of documented exposure to Hepatitis A, a 
single dose of pooled gamma globulin (0.02 to 0.04 ml of 16% 
solution per kilo of body weight) should be administered 
intramuscularly as soon as possible after exposure.  Exposed 
personnel must then be followed by the Suspension Team 
Medical Director or their own physician and development of 
any disease documented and reported as required by law. 

*Illustration not included.

Figure 15-9:  Hepatitis B vaccine is a safe, highly 
effective and nearly side-effect free product for protection 
against Hepatitis B.

        Personnel with documented exposure  to Hepatitis B 
should  be treated with Hepatitis B Immune Globulin (Hyper-
Hep).  The usual dose for adults is 1 ml administered 
intramuscularly.  Simultaneously, the Team Member should be 
evaluated for anti-HB titer and if the titer is inadequate a 
booster dose of HB vaccine given.

        Personnel exposed to Hepatitis A or C should refrain 
from intimate contact with others (including sexual contact 
with or without use of a condom) until seronegativity for 
the antigen can be established or the maximum common 
incubation period has passed without evidence of 
seroconversion or illness.

Mucocutaneous Herpes 

        Herpes infections of the skin and/or mucous membranes 
are common in patients suffering immunocompromise from  HIV, 
cancer, chemotherapy or advanced age.  UBSI precautions 
should used to protect against transmission of these agents. 
The Herpes viruses cause a wide range of human illness but 
have a predilection for tissues derived from the embryonic 
ectoderm, usually infecting the  skin and/or the nervous 
system. Herpes viruses are lipid coated but can persist for 
clinically relevant times on environmental surfaces.  A 
rather unpleasant, albeit fascinating aspect of Herpes 
viruses, is their ability to establish latent infection 
after the initial invasion of the host.  This characteristic 
can result in repeated symptomatic outbreaks of the illness 
even decades after initial infection. A brief  summary of 
the most common Herpes viruses responsible for human 
diseases of concern to the Transport Technician is discussed 

Herpes Simplex viruses are the class of etiologic agents 
responsible for cold sores, and genital herpes.  H. Simplex 
may infect the eyes, lips, mouth, anus, vagina, and 
occasionally the central nervous system.  Infection with one 
or more varieties of H. Simplex is almost universal.  UBSI 
precautions should be used when caring for patients with H. 
Simplex.  The illness does not usually cause significant 
mortality except in immunocompromised hosts.

Cytomegaloviruses (CMV) are among the most ubiquitous 
viruses infecting man.  It is estimated that in the United 
States 60 % to 80% of the population is infected with one or 
more strains of CMV.  The CMVs can cause a wide array of 
illness most of which are not serious.  CMV mononucleosis is 
common.  More serious forms of CMV such as CMV disease of 
the liver (CMV hepatitis), central nervous system,  liver, 
kidneys, and lungs most often occur in immunocompromised 
hosts.  CMV is not highly infectious and requires contact 
with body fluids.  UBSI should be effective in preventing 
transmission of CMV in most cases.

Epstein-Barr Virus (EBV) is the primary causative agent of 
infectious mononucleosis.  The exact mode of transmission of  
EBV is unknown however, like CMV and the other herpes 
viruses, infection with EBV is ubiquitous.  Certain strains 
of EBV in certain susceptible individuals seem to be 
responsible for, or at least closely associated with,  
several malignancies: including Burkitt's lymphoma,  and 
carcinoma of the post-nasal space.  While the route of 
transmission of EBV is as yet not well established (although 
it is often referred to as the "kissing disease"; an 
unproved theory!) it is clear that EBV is not very 
infectious, rarely results in serious illness, and with the 
use of UBSI precautions presents little risk to the 
Transport Technician.

Varicella-Herpes Zoster is more commonly known as 
chickenpox, a benign disease of the skin usually seen in 
childhood.  It commonly causes pustular eruptions on the 
skin  and runs its course in 7-10 days.  The incubation time 
is quite consistently between 15 and 18 days. 

        In many individuals infected with H. Zoster the 
infection re-emergence late in life as shingles: an acutely 
painful lesion of the skin confined to the path of  the 
infected underlying nerve and characterized by the same kind 
of papule with the same crusting progression observed in 
chickenpox.  The exudate from these lesions is highly 

        UBSI should be used in handing individuals exhibiting 
active H. Zoster  disease.  Typically H. Zoster is not a 
major concern for the Transport Technician since most have 
been previously infected and are thus immune to acute re-
infection.  The exception to this rule is adults who have 
not had previous H. Zoster infection (i.e., chickenpox).  In  
the case of such immunologically naive individuals transport 
of patients with active H. Zoster infection should be 
avoided since infection with H. Zoster in the adult is more 
serious and can occasionally result in significant morbidity 
and even (rarely) death.  While UBSI precautions should be 
used in H. Zoster infections it should be noted that in 
patients with extensive lesions these precautions may well 
fail to protect the immunologically naive Transport 
Technician; H. Zoster, much like smallpox, is highly 
infectious and even the slightest exposure to the etiologic 
agent  is likely to produce disease (witness the near 
universality of infection in the global human population).

        Alternatively, the immunologically naive Transport 
Technician may choose to transport such a patient  accepting 
the likelihood of subsequent infection and choosing to 
undergo therapy with Acyclovir (an oral antiviral of low 
toxcicity which is effective against Herpes viruses)  to 
moderate the course of the illness.  Prophylaxis with 
Acyclovir is also a possible option and may be decided upon 
by the Transport Technician and the Medical Director.


        Influenza is an acute, highly contagious disease that 
is almost always associated with fever and profound fatigue.  
Severe headache, myalgia and malaise accompanied by 
(usually) relatively mild respiratory symptoms is typical.  
The outcome is usually benign with the notable exceptions 
being the very young, the very old, and the 
immunocompromised.  The usual cause of morbidity and 
mortality in these groups is viral and/or bacterial 
pneumonia with a few individuals succumbing to acute 
cardiomyopathy with resultant congestive heart failure.

        There are three types of influenza: A, B and C each of 
which is antigenically distinct and unrelated to the other.  
All three are lipid coated viruses all three are susceptible 
to chemotherapy with the antiviral Ribavirin.   
Additionally, early influenza  A infection can be treated 
with two other antivirals, amantadine and rimantadine. A 
bivalent vaccine for influenzas A and B exists and it is 
recommended that transport personnel be immunized against 
influenza annually.

                Influenza is of particular concern to the 
Transport Technician for the following reasons:

1) It is highly infectious and UBSI precautions may fail to 
check its spread to staff caring for the patient.  It is not 
inconceivable that most or all of the staff may contract the 
illness at once making patient care delivery problematic to 
say the least!

2) It has a very short incubation time (24-48 hours) so that 
staff may become ill with it before the end of standby, 
during transport, or during subsequent cryoprotective 
perfusion and cool down.

3) It is a prostrating and incapacitating illness which 
demands inactivity and bed rest.  It cannot be "worked 
through".  Failure to get adequate rest can result in 
exacerbation of the illness and serious complications.

4) It is a common cause of death in the elderly and 
immunocompromised patient; the  prime  patient population 
for cryopreservation.

5) Infection of Transport and Perfusion staff with influenza 
from a cryopreservation patient has already occurred and has 
resulted in serious compromise of key personnel to perform 
effectively in a patient safety  threatening  emergency 
which immediately followed the patient's cryopreservation.

        For these reasons Ribavirin and amantadine 
hydrochloride (another prophylactic chemotheraputic agent 
effective against influenza A) are maintained in the 
Transport Team Leader's ONK and may dispensed at the 
discretion of the Medical Director in the event that 
vaccination and UBSI fail to prevent staff infection.


        Meningitis with or without accompanying encephalitis 
may be caused by a wide range of viral and bacterial 
infections.  Of most concern here are those caused by 
communicable viruses and the meningicocci.  The virulence of 
these etiologic agents varies considerably.  UBSI 
precautions as described above should be used.  
Chemoprophylaxis or Bioprophylaxis should be determined by 
the etiologic agent and the judgment of the Cryopreservation 
Team Medical Director as to their appropriateness.

        While the occurrence of an outbreak of meningicoccal 
meningitis in an institutional setting (camp, prison, 
military barracks) is often the cause of near hysteria, the 
fact is that the overall risk of transmission is very low 
and lower still in a medical setting where respiratory 
protection is in place.  Most patients who have had 24 to 48 
hours of  antibiotic therapy for the disease will present no 
risk of transmission.  Prophylaxis in the form of  
minocycline and rifampin (or other suitable agents) may be 
initiated by the Medical Director at his/her discretion 
based upon the virulence of the organism and the degree of 
exposure of the staff.

        Vaccination against several  strains of meningicoccal 
meningitis is also an option and may be administered at the 
discretion off the Medical Director and Transport Team 

Pneumococcal Pneumonia and Meningitis were  until recently 
of little concern to the Transport Technician in the 
Transport setting.  However this has begun to change with 
recent emergence of several strains of pneumococcus which 
are resistant to almost all antibiotics including the third 
generation cephalasporins, pennicillin and streptomycin.  
The only antibiotic effective in some cases against these 
organisms has been vancomycin administered in high doses.  
At such doses vancomycin is both nephro- and oto- toxic.  
There have been several deaths from these strains of 
pneumococcus and almost uniform severe morbidity (due 
largely to delays in diagnosis as a result of the failure of 
the illness to respond to conventional antibiotic therapy).

        Transport Technicians are at special risk of acquiring 
antibiotic resistant pathogenic pneumococcal organisms as a 
result of their contact with the elderly nursing home 
patients who have often had repeated courses of antibiotics 
for pneumococcal pneumonia.  There is thus the risk that the 
Transport Technician may become carrier for such organisms 
and later succum to infection with antibiotic resistant 
pneumonia or meningitis.  It is for this reason that  all 
Transport Technicians are required to be vaccinated for 

Tuberculosis (TB) was once the leading cause of death in the 
United States and was  known as the White Plague.  It 
devastated generations of Americans.  It is still the 
leading cause of death worldwide.  The causative organism is 
Mycobacterium Tuberculosis a non-motile bacillus which is 
transmitted primarily by the airborne route.  Humans are 
very susceptible to TB.  In epidemics of TB resulting from 
contact with an open case of pulmonary tuberculosis  (such 
as in a classroom or  homeless shelter setting) 50 % to 70% 
of the exposed individuals will become infected although 
only a few will develop clinical disease during the first 
few years after infection.  The age at which infection 
occurs has a significant relationship to the time at which 
subsequent active disease is likely to develop.

        While most associated with its pulmonary manifestations 
the disease may affect many organ systems.  Tubercular 
disease located elsewhere than in the lung is referred to as 
miliary TB.  Organs or tissues affected by miliary TB may 
include (but are not limited to): bones, joints, skin, 
bladder, kidneys, liver/gallbladder, lymphatic system, 
cervix, and most devastating, the brain and meninges.  

        TB was once thought a thing of the past in U.S. and was 
of little concern to either the general population or to 
health care workers.  Changes in the handling of the 
mentally ill (with the resultant creation of "street 
people") and the emergence of large numbers of 
immunocompromised individuals as a result of HIV infection 
have changed all that.  The incidence of TB is climbing 
rapidly in the United States and, what is more troubling, 
there has emerged several strains of the organism which are 
resistant to virtually all currently available (and so far 
to all experimental) chemotheraputic agents.  It is now 
estimated that as many as 10% of all TB infections in AIDS 
patients are of the multi-drug resistant variety.  This is 
a very serious public health issue which, in this author's 
opinion, is not being addressed well in the United States.  

        The U.S. strategy to controlling TB has long relied on 
surveillance with a skin test of tuberculin antigen (PPD or 
tine)(originally developed by the Bacilli's discoverer 
Robert Koch) to identify infected individuals and then treat 
them with a combination of drugs (usually Isoniazid and 
Rifampin) most commonly administered over a 12-month period.  
Unfortunately, due to poor or nonexistent follow-up on the 
part of U.S. public health authorities, particularly among 
the lower socioeconomic classes and "street people" has lead 
to the emergence of  strains of the organism which are 
completely resistant to all currently available 
chemotheraputic protocols.

        Another distressing development is the growing 
population of immunocompromised individuals in whom active 
tubercular disease cannot be easily detected  with the skin 
test.  Unfortunately, tubercule bacilli are notoriously 
difficult to culture and this procedure is not only costly 
but not very effective in identifying active cases.  These 
three developments: the resurgence of TB,  the emergence of 
multi-drug resistant TB, and the presence of a growing 
reservoir of undetectable hosts for TB make it imperative 
that the Transport Technician protect his/herself against 
tuberculosis by every means available.

*Illustration not included.

Figure 15-10: A 12-year follow-up on children infected by a 
single school teacher (From: Hyge. Danish Med. Bull., 4:13, 

        This is especially true since a significant percentage 
of patients presenting for cryopreservation have done so 
because of HIV infection.  In fact, using the Alcor 
Foundation  (the largest cryopreservation organization) 
experience as representative, 18% of all patients who have 
presented for cryopreservation after the beginning of the 
AIDS epidemic  did so because of HIV disease.  As has been 
previously noted, AIDS patients constitute a significant 
reservoir of TB. 

TB Precautions

        TB is spread by airborne particles (droplets or dust) 
and  thus respiratory protection is of paramount importance.  
Masks should be worn by transport personnel at all times 
when caring for or standing by in the home of any patients 
with known tubercular disease or HIV.  UBSI precautions 
should be used during transport.

TB Prophylaxis

        It is urged that all Transport Technicians be 
vaccinated against TB with  Bacillus Calmette Guerin (BCG).  
This vaccine is a live bacillus which is inoculated into 
excoriated or punctured skin. It confers immunity to 
subsequent TB infection in approximately 80% of those 
vaccinated with no prior history of TB.

*Illustration not included.

Figure 15-11: The effectiveness of BCG in preventing TB 
infection.  An 80% rate of protection can be expected.

        In cases where prolonged contact with the patient is to 
occur (as during a lengthy standby in the patient's home) 
with a TB infected or likely TB infected individual  
Isoniazid in doses of 100 mg three times a day may be given 
during the period of standby, transport and for a minimum of 
two weeks following the conclusion of transport as 
prophylaxis against infection.

Measles, Mumps, and Rubella are not normally serious 
concerns during transport of  cryopreservation patients.  
Most Transport staff will have either had these childhood 
illnesses or been vaccinated against them.  If the Transport 
technician believes s/he might not have had these illnesses 
NOW is the time to get vaccinated.

Scabies, head and body lice are normally of  little concern 
in the transport setting.  Most patients presenting for 
cryopreservation will have been under medical care and will 
come from a socioeconomic background where such arthropod 
infestation is uncommon.  

        The use of UBSI precautions is very effective in 
inhibiting transmission of these arthropods.   If 
transmission does occur pediculosis (lice) may be treated by 
the application of any of a variety of inexpensive, highly 
effective over-the-counter preparations such as A-200.  
Scabies may be easily and effectively treated by any of 
several prescription insecticides such as Kwell.

The Pregnant Transport Technician

      Because of  the risk to both the mother and fetus 
posed by both the infectious agents, and chemotherapy to 
treat infection, pregnant women should be excluded from 
transports where there exists reasonable possibility of 
exposure to infectious disease.

Disinfection and Cleaning of Equipment and Environmental Surfaces

   The first and most important rule in disinfection and 
cleaning of equipment and instruments is: avoid having to do 
it in the first place.  Wherever possible use disposable 
equipment; particularly where such equipment will contact 
blood or be used in invasive procedures.

   Disconnect any disposable equipment from non-disposable 
equipment (suction lines, extracorporeal tubing, etc.) while 
wearing gloves, a mask, gown and shoe covers; sanitize or 
sterilize the non disposable equipment according to the 
guidelines following this Chapter, and properly dispose of 
the rest.

   Non critical items that do not ordinarily touch the 
patient or that touch only intact skin (such as blood 
pressure cuffs) rarely, if ever, transmit disease.  Simple 
sponging, wiping, or washing with regular detergent is 
usually all that is required.  Rinse with clear water and 
allow to air dry thoroughly.  Wash the PIB, Thumper, and 
similar equipment with hot soapy water.

   All pieces of equipment that are first to be disinfected 
or sterilized should first be thoroughly cleansed to remove 
all organic matter (blood, tissue, saliva) and other residue.

   Patient care equipment that enters normally sterile 
tissue or that touches mucous membranes must be sterilized 
before each use and subjected to high level disinfection.  
Chemical sterilants that are registered with the U.S. 
Environmental Protection Agency (EPA) as "sterilants" may be 
used either for sterilization or for high-level 
disinfection.  Also acceptable is a solution of household 
bleach diluted in water (concentrations ranging in 1:10 to 
1:100) to disinfect equipment and surfaces.  Clean all 
organic matter and other debris off of the equipment before 
disinfecting, and follow the manufacturer's instructions for 
disinfecting any equipment.  Be sure to clean any visible 
blood and secretions out of all cracks and crevices.

Disinfection and Cleaning of the Ambulance

        Extraordinary attempts to disinfect and/or "sterilize" 
the interior surfaces of the ambulance are unnecessary and 
liable to result in damage to upholstery and equipment.  The 
environmental surfaces of the vehicle are rarely associated 
with transmission of disease.  The most important aspect to 
minimizing the risk of disease transmission in the ambulance 
is general cleanliness, good housekeeping and organization.  
Do not allow trash in the form of  medical disposables 
wrappers to accumulate.  Keep working surfaces uncluttered 
and promptly clean up spills of any kind.  Where body fluids 
have spilled use a Body Fluid Spill Clean Up Kit and wipe 
the surface down with a commercial disinfectant or bleach 

        Following completion of a transport the ambulance 
interior should be cleaned with soap and water and 
environmental surfaces wiped down with 1:100 solution of 
household bleach.  Keep the vehicle well ventilated during 
cleaning.  The following guidelines are recommended for 
cleaning the vehicle interior following completion of a 

   Wear disposable gloves and eye protection during all 
cleaning and decontamination procedures.  

   Remove any blood, body fluids, or other matter with paper 
towels or disposable linens; dispose of these properly and 
immediately.  Whenever  blood is found clean with a 
disinfectant or bleach solution.

Transport Technician Prophylactic Health Recommendations

        Before  the Transport Technician begins active duty 
s/he should:

   Receive a PPD skin test for tuberculosis, unless the 
individual has documentation of a previous significant 
reaction or vaccination with BCG.  Persons with significant 
reactions on initial  PPD screening should be followed in 
accordance with American Thoracic Society Guidelines.  
Contact the local Department of Health Services for further 
information and notify the staff  physician.

   Show evidence of immunity to the following diseases:

a) Measles by proof of appropriate immunization or history 
of disease or infection, or serologic evidence.

b) Hepatitis B by proof of appropriate immunization or 
history of disease or infection, or serologic evidence.

c) TB (if PPD  negative) by  immediate vaccination with BCG 
or proof of prior vaccination with BCG.

d) Rubella by proof of appropriate immunization or serologic 
evidence of past disease. (History of disease is not 

e) Tetanus, diphtheria and polio by proof of prior 
immunization. (Prior disease does not impart immunity).

f) Influenza by vaccination.

   Be counseled on the importance of  good nutrition and 
judicious micronutrient supplementation in improving 
resistance to infectious disease.  It is especially 
important for any health requirements such as ongoing 
vitamin/mineral supplementation, prescription medications, 
and so on to be available and continued throughout  
transport operations.  

        Transport of cryopreservation patients almost 
invariably results in marked stress both psychological and 
physiological to the Transport Technician.  Interruptions in 
normal sleep-wake cycles and sleep deprivation are common.  
Dietary alterations (reliance on fast food or foodstuffs not 
commonly eaten  at home), confinement for extended periods 
with colleagues and strangers, often in an alien home 
setting, the psychological demands of the terminally ill 
patient and family, plus the not infrequently present added 
stress of familial hostility and medical/legal complications 
all contribute to both physiological and psychological 
stress.  It is now well understood that both these kinds of 
stress result in secretion of adrenalcorticoids and related 
steroid hormones which are markedly immunosuppressive even 
in the healthy individual, and further that such stress 
results in depletion of micronutrients due to both their 
increased metabolism and excretion (for instance serum 
levels of both vitamin C and the B vitamins decline markedly  
in humans and animals under stress.  It is thus of added 
importance that the Transport Technician continue 
uninterrupted any nutritional or medical regime s/he is 
normally on during the period of Transport operations.

Nutritional Supplementation Recommendations

        It is the recommendation of the Cryopreservation Team 
Medical Director that all transport personnel follow the 
supplementation regime recommended below during the course 
of standby and transport operations, or an equivalent regimen:

o  1 capsule of  Daily One multivitamin/multimineral 
supplement manufactured by Twinlabs, Inc.  Females of  
reproductive age should use the iron containing version of 
this product.
o  1,000 mg of vitamin C (time release is not necessary).  
It is recommended that this be acquired in single dose, 
film-tab or coated tablets, to ease consumption under field 
o  400 I.U. vitamin E.
o 500 elemental magnesium in the form of magnesium oxide.

        The above supplements are available without a 
prescription from most health food stores and pharmacies.  
The Transport Team Leader will maintain a modest supply of 
these nutrients for distribution to team members, however it 
is urged that each team member maintain their own supply.  
Further, it is strongly urged that as a minimum Transport 
Team members carry on a program of nutritional 
supplementation such as the one outlined above on an ongoing 
basis since when an emergency is going to occur (inside or 
out of human cryopreservation activities) can never be 

Recommended Immunizations For Transport Technicians

        Before you participate in Transport Operations you must 
be immunized against the following infectious diseases.  
Immunization against TB is optional, however if immunization 
is declined a TB skin test (tine test) is required annually.

o Hepatitis B vaccination (3 doses over 6 months).

o Influenza vaccination (annually).

o DPT (diphtheria/pertussis/tetanus) with a DT  booster 
every 10 years.

o Polio immunization.

o Rubella (German Measles) vaccination.

o Measles vaccination.

o Mumps vaccination.

o Pneumococcal pneumonia vaccination

o Meningicoccal Meningitis vaccination.

General Guidelines For Preventing the Transmission of 
Infectious Disease

        In  addition to the specific precautions outlined 
above, the following  general guidelines should be observed  
when transporting patients for human cryopreservation:

   Wash your hands thoroughly after the completion of your 
patient handling duties.  If running water is not available, 
use a commercial germicidal hand rinse to clean your hands.  
If you need to clean or disinfect any equipment in the 
vehicle, thoroughly wash your hands again afterwards.

   Whenever possible, use disposable equipment and supplies, 
particularly on patients with known infectious disease.  
When you have finished, double-bag all used equipment in a 
red Biohazardous Waste Bag (red bag), seal it to prevent 
leakage, and transport it to the Biopreservation facility, 
hospital, mortuary or other facility which is authorized to 
dispose of biohazardous wastes.

   Maintain at hand a supply of disposable gloves, masks, 
hats, gowns and shoe covers at all times.  Follow the 
procedures outlined above to dispose of any soiled gloves, 
masks, gowns or shoe coverings.

   Always wear disposable gloves when working with or 
cleaning up blood.

   Never retain disposables for clean-up and use in 
teaching, training or for any other purpose.  Disposables 
are to be thrown away at the end of the transport with the 
only exception being in the case of equipment (disposable) 
malfunction where the device may need to be retained for 
subsequent medicolegal investigation.

   In the case of a device being retained for investigation 
of malfunction it should be double red bagged and returned 
to the facility for disinfection.  If there is to be a delay 
in return the device should be refrigerated on ice taking 
care not to allow water to enter the red bags.  The cooler 
the device is in should be clearly labeled with a 
Biohazardous Materials Trefoil.  If refrigeration is not 
practical or possible, call the facility for an appropriate 
protocol of on-site disinfection (such as treating the 
device with Cidex or Sporocidin).

   Disassemble and disinfect all non disposable equipment 
after every use.  Thoroughly clean equipment first to remove 
blood, vomitus, or other organic soil; then wash in a strong 
disinfectant and let the disinfected equipment soak (i.e., 
Cidex or Sporocidin).

   Bag all tissues, dressings, and other disposable paper 
items in double red bags and seal to prevent leakage (tie 
the bag or use a cable tie).  

   If  your  clothing becomes soiled with body fluids remove 
it as soon as possible, bag it and label it, take a hot 
shower and wash with germicidal soap.  Rinse thoroughly.  
Your clothing should be washed for at least 25 minutes in 
hot water containing a germicide which will not damage the 
fabric (Sanisol  or other benzyl ammonium chloride 
containing detergent is acceptable).

   Dump any secretions, blood, or vomitus from suction 
devices down the drain, hopper or toilet at the hospital 
mortuary or Biopreservation facility (as appropriate) and 
wash thoroughly into the sewer system.  If disposing of such 
wastes at Biopreservation they must first be admixed with 
bleach in an approximately 1:10 concentration (i.e., 1 
volume bleach to 10 volumes liquid waste).

   Remove all equipment and linens from the ambulance and 
wash all ambulance surfaces contacted by the patient with 
Sanisol or similar product.  Wipe down the vehicle walls 
with 1:100 bleach solution.  Let the ambulance air-dry and 
restock it with clean supplies.

   After you have finished all cleaning of equipment and the 
ambulance, wash your hands again thoroughly.

   Document in the ambulance log-book that cleaning was 

   Promptly report any suspected exposure, including the 
date and time of exposure, the type of fluid involved, the 
amount of fluid, and details of the exposure  using the 
Exposure Incident Investigation Form. 

Disposal of Biohazardous (Infectious)  Waste

        Federal and State law mandate stringent guidelines for 
the disposal of Biohazardous waste.  It is very important to 
understand that the liability for such waste is perpetual , 
that it originates with the generator of the waste, and that 
the liability cannot ever be transferred.  Thus, if an 
individual is injured by a sharp generated by 
Biopreservation 100 years after the sharp was generated, 
Biopreservation (if it is still in existence) is fully 
liable for any damages.  Furthermore, this liability cannot 
be given away or bought by others.  Thus, if you hand over a 
bag of Biohazardous waste to a hospital or mortuary and they 
improperly dispose of it (even after agreeing to dispose of 
it properly) Biopreservation and/or the Transport Technician 
are fully liable.

*Illustration not included.

Figure 15-12:  Universal biohazard symbol: the Biological 
Hazard Trefoil.  The biohazard trefoil must be present on 
all biohazardous/infectious waste containers.

        For this reason Biopreservation deals with a licensed 
and heavily insured Biohazardous waste hauler (TCI of 
Colton, Ca) to dispose of Biohazardous wastes.  In the event 
the Transport Technician relies on a hospital or mortuary to 
dispose of such waste it is critical that it be determined 
that the waste will be handled appropriately.  Sharps 
(except in out-of-state cases) must never be disposed of by 
handing off to a mortuary or hospital.  All sharps must be 
transported back to Biopreservation for incineration with 
TCI.  Transport is to be carried out in the ambulance in 
sealed sharps containers (use duct tape to close double 
close the lid, then place the sharps container inside two 
red Biohazardous waste bags and label appropriately).

   Bulk blood, suctioned fluids, excretions, and secretions 
can be carefully poured down a drain connected to a sanitary 
sewer.  If it is possible and safe to do so, such wastes 
should first be mixed with bleach in a  1:10 ratio per the 
instructions above.  Always wear a face-sheild whendisposing 
of such waste, in addition to gloves, gowns shoe covers and 
so on.

*Illustration not included.

Table 15-1:  Comparison Of The Relative Effectiveness of 
Various Chemical Sterilants and Disinfectants

Selected Bibliography

1) Comstock WG, et al: A controlled trial of community-wide 
isoniazid prophylaxis in Alaska. Amer Rev Resp Dis. 

2) Occupational Health and Safety Administration: 
Occupational exposure to blood-borne pathogens final rule: 
29 CFR Part 1910.1030. Washington D.C.  Federal Register 

3) Gerty RJ, ed: Hepatitis B. New York: Academic Press. 

4) Green WC:  AIDS and the immune system. Scientific 
American 1993;269:99-105.

5) Haffen BQ, Karren KJ, eds: Pre-Hospital Emergency Care 
and Crisis Intervention. Englewood Cliffs, New Jersey: 
Prentice Hall. 1992.

6) Joklik WK, Smith DT, eds: Zinsser Microbiology: 15th 
Edition. New York: Appleton-Century-Crofts. 1972: 454-469.

7) Pantaleo G, et al: HIV infection is active and 
progressive in lymphoid tissue during the clinically latent 
stage of the disease. Nature 1193;362:355-358.

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