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FA-112 / January Guide To Managing An Emergency Service Infection Control Program
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1 FA-112 / January 2002 Guide To Managing An Emergency Service Infection Control Program United States Fire Administration 2002
2 GUIDE TO MANAGING AN EMERGENCY SERVICE INFECTION CONTROL PROGRAM 2002 UNITED STATES FIRE ADMINISTRATION As an entity of the Federal Emergency Management Agency, the mission of the U.S. Fire Administration is to reduce life and economic losses due to fire and related emergencies through leadership, advocacy, coordination, and support. We serve the Nation independently, in coordination with other Federal agencies and in partnership with fire protection and emergency service communities. With a commitment to excellence, we provide public education, training, technology, and data initiatives.
3 PREFACE In 1992, the United States Fire Administration (USFA) developed the Guide to Developing an Emergency Service Infection Control Program in conjunction with the National Fire Academy (NFA) field course, Infection Control for Emergency Response Personnel: The Supervisor s Role. These two major Federal initiatives were designed to provide accurate information and guidance to the emergency services regarding communicable disease infection control. Both were developed with the support and assistance of the Centers for Disease Control and Prevention (CDC) and the Occupational Safety and Health Administration (OSHA), to coincide with the promulgation of 29 CFR Part , Occupational Exposure to Bloodborne Pathogens, Final Rule. Since the original publication, many advances have occurred in the field of infection control, and all emergency services should have some form of infection control program. The initial guide focused on the development of an infection control program. The new Guide to Managing an Emergency Service Infection Control Program updates relevant information from the original 1992 guide and focuses on the management of an infection control program. The guide is designed to meet or exceed all applicable Federal/national laws, regulations, standards, and guidelines in effect at the time of publication. Many of these are included in their entirety in Appendix B of the guide. The guide also contains Internet Web addresses for accessing those guidelines not included in their entirety. The principal development team for the guide included: Judy Janing, Ph.D., R.N., EMT- P, Emergency Program Specialist, IOCAD Emergency Services Group, Omaha, NE; Murrey Loflin, M.S., EMT-B, Battalion Chief, Virginia Beach Fire Department, Virginia Beach, VA.; Gordon Sachs, MPA, Director, IOCAD Emergency Services Group; Mike Grill, Captain, Sierra Vista Fire Department, Sierra Vista, AZ; David Barillo, M.D., Associate Professor of Surgery, Medical University of South Carolina, Charleston, SC. Sandy Bodgucki, M.D., Ph.D., Assistant Professor, Yale University School of Medicine, Department of Surgery, Section of Emergency Medicine, New Haven, CT. Members of the Technical Review Panel for the development of this guide were: Jonathan M. Lieske, M.D., M.P.H., International Association of Fire Fighters (IAFF); Richard Knopf, International Association of Fire Chiefs (IAFC), Health and Safety Committee; Philip Stittleburg, National Volunteer Fire Council; Decker Williams, Phoenix Fire Department; Richard Patrick, VFIS, Inc.; Scott Deitchman, M.D., Centers for Disease Control and Prevention (CDC); Ron Thackery, American Ambulance Association; and Susan McHenry, National Highway Transportation and Safety Administration (NHTSA). 3
4 TABLE OF CONTENTS Preface...3 Table of Contents...5 INTRODUCTION...7 SECTION 1: OVERVIEW OF INFECTION CONTROL...11 Chapter One: Technical Background...13 Introduction to Infection Control...15 Basic Concepts...16 Assessing Risk Potential...17 Bloodborne Diseases...18 Airborne Diseases...21 Infection Control Techniques...22 Summary...23 Chapter Two: Laws, Regulations, and Standards...29 Public Law...32 OSHA Regulations...34 National Fire Protection Association (NFPA)...37 Centers for Disease Control and Prevention...40 Summary...46 SECTION 2: COMPONENTS OF AN INFECTION CONTROL PROGRAM...47 Risk Management...49 Risk Management Model...50 Training and Education...53 Members...54 Health Maintenance...55 Roles and Responsibilities...56 Policies and Procedures...62 Exposure Control Plan...64 Standard Operating Procedures...65 Interactions with Other Departments...65 SECTION 3: VEHICLES, EQUIPMENT, AND SUPPLY CONSIDERATIONS 69 Vehicles...71 Personal Protective Equipment...76 Equipment and Supplies...81 Equipment Advances
5 Other Considerations...85 Summary...87 SECTION 4: FACILITIES CONSIDERATIONS...89 The Need for Facility Safety...91 Facility Issues...93 Summary...98 SECTION 5: ASSESSING EFFECTIVENESS: THE EVALUATION PROCESS..99 Overview Assessing Effectiveness Information Management Program Revision Action Plan Summary SECTION 6: SPECIAL SITUATIONS Overview The Training Environment Protecting the Patient Summary BIBLIOGRAPHY APPENDICES Appendix A: Glossary of Common Terms Appendix B: Laws, Regulations, and Standards Health Care Worker Needlestick Prevention Act (PL ) Occupational Exposure to Bloodborne Pathogens: Final Rule. (29 CFR Part ) Occupational Exposure to Bloodborne Pathogens: NeedlesticksAnd Other Sharps Injuries: Final Rule. (29 CFR Part ) Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV,And HIV and Recommendations for Postexposure Prophylaxis(June 29, 2001/MMWR 50 (RR11); 1-42.) Appendix C: Sources of Additional Information
7 INTRODUCTION SCOPE AND PURPOSE Since infection control requirements vary by agency type, local regulations, department size, etc., emergency response organizations cannot simply adopt a generic infection control program as their program. Therefore, this Guide is designed as a resource to help emergency response organizations tailor the requirements identified in regulations and standards to their own unique situations. The structure of the Guide facilitates its use for different purposes. The first section, Overview of Infection Control contains two chapters. Chapter 1: Technical Background summarizes basic terms and concepts, and describes the risks associated with various communicable diseases particularly relevant to emergency services. Chapter 2: Laws and Regulations summarizes applicable laws, regulations, and standards. The second section, Components of an Infection Control Program, covers the aspects of an infection control program that organizations need to address. These components include risk management, training and education, health maintenance, roles and responsibilities of department personnel, policies and procedures, standard operating procedures, and interactions with other departments. The third section, Vehicles, Equipment, and Supply Considerations, addresses issues related to vehicle design, decontamination of disposable and non-disposable equipment, equipment advances (including needleless systems), and considerations related to clothing/linen and volunteers responding from and returning to home or the primary workplace. The fourth section, Facilities Considerations, discusses infection control in relation to the various functioning areas of emergency services facilities. The fifth section, Assessing Effectiveness, provides a description of the evaluation process. A step-by-step approach for developing performance standards and compliance (evaluation criteria) for measuring effectiveness is described. Other aspects addressed include information management and program revision. The final section, Special Situations, provides a brief overview of infection control practices in the training environment and as they relate to protecting the patient. 9
8 INTRODUCTION In addition, the Guide also contains a bibliography of useful reference documents and several appendices: Glossary of Common Terms used in infection control. Text of major Laws, Standards, and Guidelines of interest to managers of infection control programs. Sources of Additional Information for special needs in infection control. The USFA Guide incorporates all requirements specified by applicable regulations and standards at the time of publication. However, users are encouraged to go beyond the information contained in the Guide to address specific needs. Managers also should remember that infection control is a rapidly evolving field. OSHA s Occupational Exposure to Bloodborne Pathogens, 29 CFR Part requires that the department s exposure control plan be reviewed and updated at least annually, and that the consideration and implementation of safer medical devices be documented. It is imperative to review new medical developments, consensus standards, and regulations. This will ensure that mechanisms exist to integrate that new information into a department's existing program. The goal of the infection control program is to provide the best protection available for members. 10
11 TECHNICAL BACKGROUND OVERVIEW This chapter provides an introduction to the basic principles of infection control in the emergency service environment. Technical terms are defined. The risk of occupational exposure to communicable disease is discussed. INTRODUCTION TO INFECTION CONTROL In the mid-1800 s in Vienna, Austria, a physician named Ignaz Semmelweis demonstrated the importance of hand washing in decreasing the incidence of infection in women following childbirth. He observed that medical students were conducting cadaver dissections in the morning and then delivering babies in the afternoon without wearing gloves or washing their hands. When the medical students were on vacation, the incidence of infection was reduced. Semmelweis traveled to other European cities to demonstrate that hand washing could reduce deaths related to infection. Even though he had reduced infection from 18 percent to 1 percent in the Vienna hospital, at the time the medical community did not take him seriously. Although hand washing remains the most fundamental measure for controlling infection, it is still not taken as seriously as it should be. Infection rates in patients, hospital personnel, and emergency responders continue to be a national problem, despite continuing improvements in medical technology. Infection control procedures have been developed and refined continuously over the years. Unfortunately, research on the incidence of infection, the spread of infection from patient to care provider, and the incidence of infection related to contaminated medical equipment continues to be limited almost exclusively to hospital-based studies. To date, there are few studies related to the incidence of disease in the emergency response environment. As a result, recommended practice and/or procedures for emergency responders are generally modifications of those established for in-hospital personnel. Without definitive data, it is difficult to demonstrate the need for infection control procedures specifically for emergency services. However, the U.S. Centers for Disease Control and Prevention (CDC) has classified emergency response personnel as being at high risk for exposure. They face the same potential for exposure as hospital personnel. 15
12 TECHNICAL BACKGROUND In many instances, the volatility and unpredictability of the emergency scene increases the level of risk. The Guidelines for Prevention of Transmission of Human Immunodeficiency Virus and Hepatitis B Virus to Health Care and Public Safety Workers (MMWR Vol. 38, No. 2-6, 1989) states The unpredictable and emergent nature of exposures encountered by emergency and public-safety workers may make differentiation between hazardous body fluids and those which are not hazardous very difficult and often impossible. For example, poor lighting may limit the worker s ability to detect visible blood in vomitus or feces. Therefore, when emergency medical and public-safety workers encounter body fluids under uncontrolled, emergency circumstances in which differentiation between fluid types is difficult, if not impossible, they should treat all body fluids as potentially hazardous. BASIC CONCEPTS An effective infection control program requires a basic understanding of key infection control concepts. Disease-Producing Organisms Viruses and bacteria are the organisms commonly responsible for the spread of disease. Viruses normally reside in a living host and cannot multiply outside of a living cell. However, viruses can spread disease through contact with inanimate surfaces that are contaminated with fluids/blood containing the virus. Bacteria can multiply outside the body, i.e., on surfaces or objects. Therefore, proper cleaning of equipment is critical. Infectious Versus Communicable Disease An infectious disease results from invasion of a host by disease-producing organisms, such as bacteria, viruses, fungi, or parasites. A communicable (contagious) disease is one that can be transmitted from one person to another. 16
13 TECHNICAL BACKGROUND Not all infectious diseases are communicable. For example, there are many cases involving people getting salmonella food poisoning from poorly prepared food containing salmonella bacteria. Salmonella is highly infectious, but it is not contagious. Chickenpox is an infectious disease that also is communicable. It can be transmitted easily from one person to another by airborne droplets. Infection control for emergency services is primarily, but not solely, concerned with communicable disease. Modes of Transmission A communicable disease can be spread directly or indirectly. Direct transmission occurs through direct contact with the blood or other body substances of an infected individual. Indirect transmission occurs without person-to-person contact; the disease-producing organism passes from the infected individual to an inanimate object. Another person comes in contact with the contaminated object and contracts the disease. Although a communicable disease may be transmitted by body fluids other than blood (e.g., cytomegalovirus), those of primary concern to emergency responders are those communicable diseases that are bloodborne or airborne. Bloodborne diseases are spread by direct contact with the blood or other body substances of an infected person. Bloodborne diseases of most concern to emergency responders include Human Immunodeficiency Virus (HIV), Hepatitis B, and Hepatitis C. Airborne diseases are spread by droplets of the disease-producing organism being expelled into the air by a productive cough or sneeze or by direct contact with infected bodily secretions. Airborne diseases include tuberculosis, meningitis, mumps, rubella, and chickenpox. ASSESSING RISK POTENTIAL Any exposure to a communicable disease carries a certain amount of risk. For bloodborne pathogens, an exposure occurs whenever there is contact with blood or other body fluids through open wounds, mucous membranes, or parenteral (by injection) routes. The degree of risk depends on the degree of exposure. Five factors are critical in assessing potential risk in any exposure situation: 17
14 TECHNICAL BACKGROUND Communicability Identification of the causative agent is critical. As noted previously, some disease-producing organisms are more readily communicable than others; some are capable of causing more serious effects. Dosage of the Disease-Producing Organism Dosage refers to the number of viable (live) organisms received during an exposure. Each illness requires that a certain number of infectious agents be present in order to cause disease. For example, one Hepatitis B virus in 1 milliliter of blood may be all that is needed to spread the infection, while 100,000 HIV viral particles may be needed. Virulence of the Disease-Producing Organism Virulence is the diseaseevoking power of the organism, in other words, the strength or ability of the organism to infect or overcome bodily defenses. Hardiness of the Organism Hardiness is the organism s ability to survive in the environment. This varies from one situation to another. In most cases, the organism must be one that survives outside the body. For example, the hepatitis B virus has been shown to live on a surface for days to weeks and still be infectious. Host Resistance Host resistance is the ability of the host to fight infection. Infection occurs as a result of an interruption in the body s normal defense mechanisms, which allows the organism to enter the body. Typically, the healthier you are, the less likely you are to become ill. BLOODBORNE DISEASES HIV/AIDS The number of new HIV cases reported in the United States has decreased slightly over the past decade. CDC reported 47,915 new cases of HIV (17.4 cases/100,000 population) in 1998 and 46,400 new cases (16.7 cases/100,000 population) in As of the 1999 report, there were 113,000 persons living with HIV and 290,542 persons living with AIDS in the United States. CDC reported twelve potential and no documented cases of HIV in emergency services personnel in This low number 18
15 TECHNICAL BACKGROUND can probably be attributed to the use of personal protective equipment, but it must be remembered that emergency services personnel remain in a high-risk group. Hepatitis B Hepatitis B virus (HBV) infection is the major infectious hazard for health-care personnel. The risk of HBV infection after percutaneous exposure varies from 2 percent if the patient is negative for the Hepatitis B early antigen (HBeAg) to 40 percent if HBeAg antigen is present. Overall, the estimated risk of HBV infection after an occupational exposure ranges from 20 to 30 percent. 1 During 1993, an estimated 1,450 workers became infected through exposure to blood and serum-derived body fluids, a 90 percent decrease from the number estimated to have been thus infected during This decline is partly due to widespread adoption of preventive immunization, increased adherence to universal precautions, and use of personal protective equipment by healthcare workers. Hepatitis B immunization is a critical preventative factor of an Emergency Medical Service infection control program. Hepatitis C Hepatitis C (HCV) is a leading cause of cirrhosis of the liver, liver cancer, and one of the major causes of the need for liver transplants. CDC estimates that the annual number of newly acquired HCV infections ranged from 180,000 in 1984 to 28,000 in Of these, an estimated 2-4 percent occurred among health-care personnel who were occupationally exposed to blood. After an unintentional needlestick from an HCVpositive source, the average risk for HCV infection is 1.8 percent. Transmission rarely occurs from mucous membrane exposures to blood, and no transmission has been 1 Swinker, M. (1997). Occupational Infections in Health Care workers: Prevention and intervention. American Family Physician, 56 (9), U.S. Department of Health and Human Services, Centers for Disease Control. (1997). Immunization of health-care workers: Recommendations of the advisory committee on immunization practices (ACIP) and the hospital infection control practices advisory committee (HICPAC). Morbidity Mortality Weekly Report; 46 (RR-18):
16 TECHNICAL BACKGROUND documented from intact or non-intact skin exposures to blood. 3 At least percent of persons who contract HCV infection become chronically infected, and half of those chronically infected develop cirrhosis or liver cancer. Up to 10 percent of parenterally transmitted hepatitis may be caused by other bloodborne viral agents not yet characterized. Hepatitis A Occupational exposure generally does not increase health-care workers risk for Hepatitis A virus (HAV) infection. 4 When proper infection control practices are followed, nosocomial HAV transmission is rare. Transmission of HAV from adult patients to health-care workers usually is associated with fecal incontinence in the patients. There is a vaccine for Hepatitis A. Currently it is recommended only for travelers and the military. Other Hepatitis Viruses There have been three additional Hepatitis viruses (E, F, and G) identified in addition to Hepatitis A, B, and C. Knowledge regarding these viruses is limited; however it is known that the mode of transmission for E is the fecal-oral route, for G is bloodborne, and F may be bloodborne. Risk of Infection Risk of infection from bloodborne diseases varies according to the type of exposure. The following list was published by the CDC to help evaluate risk levels. Risk decreases from top to bottom. 3 U.S. Department of Health and Human Services, Centers for Disease Control. (2000). Hepatitis C virus infection among firefighters, emergency medical technicians, and paramedics - Selected Locations, United States, Morbidity Mortality Weekly Report; 49 (29); U.S. Department of Health and Human Services, Centers for Disease Control. (1997). Immunization of health-care workers: Recommendations of the advisory committee on immunization practices (ACIP) and the hospital infection control practices advisory committee (HICPAC). Morbidity Mortality Weekly Report; 46 (RR-18):
17 TECHNICAL BACKGROUND Contaminated needle stick injury (large-bore, hollow needle carries more risk than small bore solid needle). Cuts with sharp objects covered with blood/body fluid. Blood/Body fluid contact with an open area of the skin. Blood/Body fluid contact to the mucous membrane surface of the eyes, nose, or mouth. Blood/Body fluid contact to intact skin. Although incidence of the major bloodborne diseases have decreased over the past several years, emergency service personnel remain at risk for contracting these diseases. If these declines are to be sustained, emergency service personnel must continue to adhere to protection strategies. AIRBORNE DISEASES Tuberculosis (pulmonary) The airborne disease of greatest concern to emergency services providers is tuberculosis (TB). Nationally, the number of reported cases of TB increased by 14 percent from 1985 to Consequently, concern about this disease increased, and more attention was focused on control measures. At the same time drug-resistant tuberculosis also increased, creating a serious concern. From 1982 to 1986, only 0.5 percent of new cases were resistant to both isoniazid and rifampin. By 1991, this proportion had increased to about 3.1 percent. Among recurrent cases, 3.0 percent were resistant to both drugs during the 1982 to 1986 period, but in 1991 this proportion had more than doubled, to 6.9 percent. The reported cases of TB began a decline in the years following this increase. There were 26,673 cases (10.5/100,000 population) in This decreased to 17,531 cases (6.4/100,000 population) in Of the cases reported in 1999, 2.5 percent occurred in health-care workers. Statistics specific to emergency services are not available, since CDC does not break out emergency services workers as a separate category in their TB surveillance program. 21
18 TECHNICAL BACKGROUND Drug-resistant cases also have decreased. In 1999, 12.2 percent of new cases and 8.4 percent of recurrent cases were resistant to isoniazid alone and 3.8 percent of new cases and 1.1 percent of recurrent cases were resistant to both isoniazid and rifampin. It is well known that the organism that causes TB dies when exposed to light and air, however there are factors that can affect the potential for infection from TB as well as other airborne diseases. These factors are duration of exposure and ventilation. Some diseases require prolonged exposure in order to contract the disease. Therefore shorter transport times can reduce risk potential. Risk potential also can be reduced by maximum ventilation. Ventilation systems for vehicles are addressed in depth in Section 3 of this Guide. On older vehicles without modern ventilation systems, personnel should open windows whenever possible. INFECTION CONTROL TECHNIQUES Hand washing is the most effective overall infection control measure, yet it is frequently ignored. Hands should be washed whenever gloves are removed, after all patient contacts, and after disinfecting equipment, as well as before eating and after using the bathroom. Hands should be well lathered with regular soap and scrubbed for at least 15 seconds before rinsing and drying. The towel should be used to turn off the faucet. Universal precautions is an infection control strategy developed by the CDC for hospital workers. Specific precautionary procedures are recommended for reducing potential exposure to bloodborne pathogens. Universal precautions are based on the concept that blood and certain body fluids (any body fluids containing visible blood, semen, vaginal secretions, tissues, cerebrospinal fluid (CSF), synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid, and amniotic fluid) of all patients should be considered potentially infectious for HIV, HBV, HCV, and other bloodborne pathogens. In 1996, CDC published standard precautions. Standard precautions synthesize the major features of body substance isolation and universal precautions and apply to isolation precautions in the hospital setting. Body substance isolation (BSI) goes beyond universal precautions and considers all body substances potentially infectious. Thus, in addition to those listed under universal precautions, feces, nasal secretions, sputum, sweat, tears, urine, and vomitus 22
19 TECHNICAL BACKGROUND also are considered potentially infectious. Such an approach obviously is safer in the emergency response environment, where medical histories are often incomplete or not known at all and differentiation between body fluids may be impossible. In effect, each emergency incident has exposure potential. BSI is generally accomplished through the barrier technique, using personal protective equipment (gloves, masks, protective eyewear, gowns, and resuscitation devices) to prevent personal contact with blood or other potentially infectious materials. Other infection control techniques include proactive preventive measures such as health maintenance, immunization programs, decontamination procedures, proper waste handling and disposal practices, and both initial and ongoing training. SUMMARY The intent of this chapter was to provide a brief overview of communicable disease and infection control principles, as background information for the rest of the Guide. Table 1-1-1, on the following pages, summarizes the most common communicable diseases encountered by emergency services personnel. It must be emphasized that a crucial component of an effective infection control program is learning as much as possible about various types of communicable disease and updating the infection control program as new knowledge becomes available. Organizations should capitalize on all available expertise by enlisting the help of local health and medical practitioners and/or infection control experts. Additional sources of information are provided in the References and Bibliography, and in Appendix C. 23
20 TECHNICAL BACKGROUND Table DISEASE INFORMATION FOR EMERGENCY RESPONSE PERSONNEL Disease/Infection Mode of Transmission Vaccine Available Signs/Symptoms Post-Exposure Treatment AIDS/HIV (Human Immunodeficiency Virus) Needlestick, blood splash into mucous membranes (e.g., eyes, mouth), or blood contact with open wound NO Fever, cough, night sweats, weight loss, Antiretroviral Regimen (see complete guidelines in Appendix B) Chickenpox (Varicella) Respiratory secretions and contact with moist vesicles YES Fever, rash, cutaneous vesicles (blisters) Vaccine Diarrhea: Campylobactor Cryptosporidium Giardia Salmonella Shigella Viral Yersinia Fecal/Oral NO Loose, watery stools None German Measles (Rubella) Respiratory droplets and contact with respiratory secretions YES Fever, rash Vaccine in 72 hours, immune globulin Hepatitis A (HAV) Fecal/Oral YES Fever, loss of appetite, jaundice, fatigue Immune globulin, vaccine Hepatitis B (HBV) Needlestick, blood splash into mucous membranes (e.g., eye or mouth), or blood contact with open wound. Possible exposure during mouth-tomouth resuscitation YES Fever, fatigue, loss of appetite, nausea, headache, jaundice Booster and/or immune globulin 24
21 TECHNICAL BACKGROUND DISEASE INFORMATION FOR EMERGENCY RESPONSE PERSONNEL (cont'd) Disease/Infection Mode of Transmission Vaccine Available Signs/Symptoms Post-Exposure Treatment Hepatitis C (HCV) Same as Hepatitis B NO Same as Hepatitis B None Hepatitis D (HDV) Same as Hepatitis B dependent on HBV (past or present) to cause infection NO Same as Hepatitis B None Hepatitis E,F, & G Several viruses with different modes of transmission NO Fever, headache, fatigue, jaundice None Herpes Simplex (Cold Sores) Contact of mucous membrane with moist lesions. Fingers are at particular risk for becoming infected. NO Skin lesions located around the mouth Herpes Zoster (Shingles) localized disseminated (See Varicella) Contact with moist lesions Varicella vaccine may be effective even if person has already had varicella Skin lesions, regional associated pain Influenza Airborne YES (changes yearly based on strains expected to cause infection) Fever, fatigue, loss of appetite, nausea, headache Antivirals (amantadine, rimantadine, zanamivir, and oseltamivir) 25
22 TECHNICAL BACKGROUND DISEASE INFORMATION FOR EMERGENCY RESPONSE PERSONNE L (cont'd) Disease/Infection Mode of Transmission Vaccine Available Signs/Symptoms Post-Exposure Treatment Lice: Head, Body, Pubic Close head to head contact. Both body and pubic lice require intimate contact (usually sexual) or sharing of intimate clothing. NO Severe itching and scratching, often with secondary infection. Scalp and hairy portions of body may be affected. Eggs of head lice (nits) attach to hairs as small round, gray lumps. Wash clothes, personal articles in hot water. Gamma benzene hexachloride shampoo (Kwell, Rid, etc.) if crawling lice or nits are noted close to the scalp. Measles Respiratory droplets and contact with nasal or throat secretions YES Fever, rash, cough See German Measles Meningitis: Meningoccocal Respiratory secretions contact YES Fever, severe headache, stiff neck, sore throat, may have distinctive rash Rifampin, Cephlosporin Haemophilus influenza (usually seen in very young children) Respiratory secretions contact YES (Same) Viral Fecal/Oral NO (Same) Mononucleosis Contact with respiratory secretions or saliva, such as with mouthto-mouth resuscitation NO Fever, sore throat, fatigue, swollen lymph nodes/spleen 26
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Unnayi Variyar
|This article does not cite any sources. (January 2009) (Learn how and when to remove this template message)
|Unnayi Warrier
Portrait of Unnayi Warrier
Unnayi Variyar (also Variar/Warrier/Warriar) was a poet, writer, scholar, dramatist who lived in Kerala, India during the later part of the 17th century. He gave immense contributions to the art of Kathakali, the classical dance-drama form of Kerala. He is widely renowned for his chef-d'oeuvre Nalacharitham aattakatha.
There are only sketchy details available regarding Unnayi Variyar's real name, exact date and place of birth, his family background and literary achievements. There is consensus among scholars that his family name was 'Akathoottu Warriam' and that he was a garland maker (traditional vocation of Warriers (Variar)) by profession at Irinjalakkuda Koodalmanikyam Temple. One tangible record available that throws light on his life and times is that his work Nalacharitham aattakatha - 2nd day was enacted during the festival season of Sree Padmanabhaswamy Temple at Thiruvananthapuram(Trivandrum) in 1752 AD. This for certain proves that Nalacharitham was authored by Variyar during the first half of 18th century or earlier. There is speculation that Ramapurathu Warrier was a disciple of Unnayi Variyar and as noted by Prof. Aimanam Krishna Kaimal in his celebrated work "Attakkatha Sahityam" it is reasonable to assume Unnayi Variyar lived between 1674 and 1754 C.E. Also, Prof. Kaimal infers that Unnayi's real name was 'Raman'. He arrives at this conclusion by presenting evidence that last sloka of another of Unnayi's works - 'Girijakalyanam' aatakatha mentions the author's name to be 'Raman'.
The most famous work of Unnayi Variyar is Nalacharitham Aattakkatha. The work is divided into four parts/days with each part designed in such a way as to be presented as an independent performance. Nalacharitham elevated the literary standards of Kathakali and is widely recognised to be path breaking and pioneering in its approach to make Kathakali a complete art form. Root story of Nalacharitham Kathakali song is based on the Mahabharata (chapters 52 to 79 of Aaranyaparvam). It is one of the stories told by sage Brihadaswan to Pandava prince Yudhishthira during the despondent times that Pandavas go through during their exile. Story revolves around the most righteous Nishada king Nala,his wife Damayanti and the troubles they undergo in spite of being pious and virtuous and how in the end they are absolved and restored to their previous glory and joy.By many accounts Nalacharitham is considered to be the complete aatakatha via its perfect storyline, masterly rendering and consistent aesthetics.
Fundamental influence that Unnayi Variyar has had on Kathakali is on the emergence of the importance of Rasa (aesthetics) as against a more dominant Bhava Bhava abhinaya. Also Variyar through his Nalacharitham is widely acknowledged to have raised the dramatic value of Kathakali as an art form.
- Ramapanchashathi
- Girijakalyanam
- Nalacharitham
- The Encyclopaedia Of Indian Literature (Volume One (A To Devo), Volume 1; Page:267. Author:Amaresh Datta; Publisher:Sahitya Akademi, 2006 . ISBN 9788126018031
- Aimanam Krishna Kaimal. Attakkatha Sahithyam (study). Chapter 4 - Nalacharitham. State Institute of Languages, Kerala, 1998.
External links[edit]
- Arts of Kerala
- Hindu poets
- Hindu scholars
- Hindu writers
- 17th-century Indian dramatists and playwrights
- Kathakali exponents
- Theatre in India
- Indian male dramatists and playwrights
- Malayalam-language dramatists and playwrights
- Malayalam-language writers
- Malayalam poets
- Writers from Kerala
- People from Irinjalakuda
- 17th-century Indian poets
- Indian male poets

subset: commoncrawl


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Reebok Omni Lite Cordura Delivery 2 Available Now
Sunday Feb 02 2014
Extending our delivery of the Omni Lite Cordura Pump, Reebok releases another dope colorway of the redesigned classic. Consisting of hues of grey, blue and orange, the fabrication is what makes this Pump separate from its predecessors. Made with tough Cordura material, these pumps will endure all of your rough daily activities with style. Grab a pair today! Phone Orders 702-463-3322 or firstname.lastname@example.com. International Shipping available.
- Francis Santos
[nggallery id=1475]
- Francis Santos
[nggallery id=1475]


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Hello everyone,
I apologise for not being active on this wiki for a while. I have recently become active again on wikia after a month or so, and have been editing on the Call of Duty Wiki. I'll begin editing and helping out to add to and maintain this wiki.
I will also do the news again, and since Awyman has announced that he is leaving the wiki in July, I'll try to do the news in his place (He was the only one doing it).
Thanks for reading.


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Log into your Fifth Third Bank account on the My Accounts homepage using the personal ID and password you created when you registered for online banking. To register for online banking you need your Fifth Third debit card number or your Social Security number.Continue Reading
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