Solution Manual for Basics of Anesthesia, 6th Edition

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TEACHAnswer KeyMILLER:Infection Control and Management of Hazardous Materials for the Dental Team,6th Edition1Scope of Microbiology and InfectionControlANSWER KEYChapter Review Questions1.C2.D3.A4.B5.C6.B7.A8.B9.C10.A11.C12.C

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TEACHAnswer KeyMILLER:Infection Control and Management of Hazardous Materials for the Dental Team,6th Edition2Characteristics of MicroorganismsANSWER KEYChapter Review Questions1.D2.D3.C4.B5.C6.B7.D8.D9.C10.B11.D12.B13.B14.A15.A

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TEACHAnswer KeyMILLER:Infection Control and Management of Hazardous Materials for the Dental Team,6th Edition3Development of Infectious DiseasesANSWER KEYCase ScenarioDisease SpreadPotential Consequences:The winter season is the most prominent time for colds and influenza. Peopleinfected with an influenza virus shed virus and may be able to infect others from 1 day before getting sickup to 5 to 7 days or more after. Some people can be infected with an influenza virus and have nosymptoms but may still spread the virus to others. Influenza viruses are spread when infectious dropletsdirectly contact mucous membranes, by inhalation of aerosol particles and by indirectly touchingrespiratory droplets on contaminated surfaces.June touched the outside of her mask with bare hands and then rubbed her nose before any handhygiene was performed. Remember,the outside of masks worn at chairside are commonly contaminatedwith patients’ oral fluids. Also June removed some of her contaminated protective equipment in thebreak/locker room where there may have been food, personal items, and nonclinical surfaces that couldhave become contaminated.Prevention:It’s essentially impossible to determine if a given patient is carrying pathogenic microbes thatcan make you sick. Patients with detectable symptoms such as coughing or sneezing become suspect.The latter can and do shed microbes. Thus,we have to consider ALL patients, as well as ourselves,potential carriers of pathogenic microbes and apply our infection-control protocols universally.In regard to the scenario presented, don’t touch your body with contaminated hands. Avoid thosehands-to-nose and hands-to-eyes motions. Whenever you remove your gloves, wash your hands or usean alcohol hand rub, and do the same if your bare hands become contaminated with patient materials.Remove masks by touching the elastic bands or ties, which are less likely to be contaminated.Some Related Regulations and Recommendations:•“Remove barrier protection, including gloves, mask, eyewear and gown before departing work areas(e.g., dental patient, instrument processing, or laboratory areas)” (CDC).•“When personal protective equipment is removed it shall be placed in an appropriately designatedarea or container for storage, washing, decontamination or disposal” (OSHA).Reprinted with permission from: Miller CH. Special series on consequences: The spread of diseases.Infect Contrl in Pract2010; 9(1):1-2.Chapter Review Questions1.D2.A3.A4.D5.D6.C7.A8.C9.A10.C11.A12.B13.D14.B15.A

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TEACHAnswer KeyMILLER:Infection Control and Management of Hazardous Materials for the Dental Team,6th Edition4EmergingDiseasesANSWER KEYChapter Review Questions1.A2.C3.A4.C5.B

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TEACHAnswer KeyMILLER:Infection Control and Management of Hazardous Materials for the Dental Team,6th Edition5Oral Microbiology and Plaque-Associated DiseasesANSWER KEYChapter Review Questions1.D2.A3.D4.C5.A6.B7.B8.D9.A10.A

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TEACHAnswer KeyMILLER:Infection Control and Management of Hazardous Materials for the Dental Team,6th Edition6Bloodborne PathogensANSWER KEYCase ScenarioHepatitis BPotential Consequences:Hepatitis B is an occupational hazard of nonimmune health care personnelwho have a potential for exposure to human body fluids. Unvaccinated members of the dental team areabout 2 to 5 times more likely to become infected with the hepatitis B virus than the general population.Hepatitis B virus carriers who are also positive for HBeAg are more highly infectious than carriers who areHBeAg negative. The risk of acquiring clinical hepatitis from a needle contaminated with HBsAg-positivebut HBeAg-negative blood was found to be 1% to 6%. With both HBsAg-positive and HBeAg-positiveblood, the risk jumped to 22% to 31%. It’s not clear why Jenna originally refused the hepatitis Bvaccination when in school. Ideally the school had Jenna sign the required OSHA Vaccine Declinationform for its protection. Also, ideally, the school greatly emphasized to Jenna the importance of avoidingexposure to potentially infective body fluids since she had not been immunized against hepatitis B. Asometimes unrecognized consequence of being exposed to a patient’s body fluid is the anxiety related towaiting for the results of blood tests.Prevention:Jenna needed to take action to stay healthy. There are two approaches to preventing virusdiseases. One is to become immunized against the disease (if the appropriate vaccine exists), and theother is to avoid exposure. Sometimes we simply cannot avoid exposure, for example when we interactwith an asymptomatic carrier of a disease. Fortunately there is a vaccine for the prevention of hepatitis B.Maybe if Dr. D had asked for proof of Jenna’s immunization at the time of hiring, he could have providedher with training that would have helped her make an informed decision about the vaccination. Of coursehindsight is always more clear. Jenna could have told Dr. D that she had not been immunized but wouldlike to receive the vaccination series so she would not become infected and possibly pass on the diseaseto his patients. This type of language would be more positive than saying, “Yes, I want to be protectedfrom getting hepatitis from your patients.”PS: Thank goodness Jenna did not develop hepatitis B. She apologized to Dr. D for lying.Some Related Regulations and Recommendations:•“Hepatitis B vaccination shall be made available after the employee has received the required trainingand within 10 working days of initial assignment to all employees who have occupational exposureunless the employee has previously received the complete hepatitis B vaccination series, antibodytesting has revealed that the employee is immune, or the vaccine is contraindicated for medicalreasons” (OSHA).•“The employer shall assure that employees who decline to accept hepatitis B vaccination offered bythe employer sign the Vaccine Declination statement” (OSHA).•“Develop a written comprehensive policy on immunizing dental healthcare personnel (DHCP),including a list of all required and recommended immunizations” (CDC).•“Develop policies for work restriction and exclusion that encourage personnel to seek appropriatepreventive and curative care and report their illnesses, medical conditions, or treatments that mayrender them more susceptible to opportunistic infection or exposures; do not penalize DHCP with lossof wages, benefits, or job status” (CDC).Adapted from: Miller CH. Special series on empowerment: Take action to stay healthy.Infect Contrl inPract2011; 10(1):3-4.

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Chapter6:Bloodborne Pathogens2TEACHAnswer KeyMILLER:Infection Control andManagement of Hazardous Materials for the Dental Team,6th EditionChapter Review Questions1.A2.B3.B4.D5.D6.A7.B8.C9.A10.B11.B12.D

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TEACHAnswer KeyMILLER:Infection Control and Management of Hazardous Materials for the Dental Team,6th Edition7Oral and Respiratory DiseasesANSWER KEYCase ScenarioEye InfectionPotential Consequences:A pitfall of not wearing proper protective eyewear can be the development ofacute infectious conjunctivitis (also known aspinkeye). This can be caused by viruses (e.g., adenovirus,enterovirus, coxsackievirus) or bacteria (e.g.,Chlamydia trachomatis,Haemophilus influenzae,Staphylococcus aureus,Streptococcus pneumoniae,Moraxella lacunata). It is spread through contactwith contaminated respiratory fluids and hands. Health care workers with conjunctivitis should berestricted from patient contact and contact with patients’ environments. Conjunctivitis usually subsides in2-5 days without treatment. Antibiotics are sometimes prescribed. While pinkeye can be painful andirritating, Marta is fortunate she did not develop a herpes eye infection that can recur with a potential tocause blindness. Most people are infected with herpesvirus type 1 that resides in the nerve tissueassociated with the upper respiratory tract. About 10% of those infected experience recurrent oral/facialskin lesions that contain the live virus until the lesions are crusted over. A few percent of those infectedcan also shed the virus in their saliva even when they have no active lesions.Prevention:A pitfall of not wearing proper protective eyewear can be the development of acute infectiousconjunctivitis (also known aspinkeye). This can be caused by viruses (e.g., adenovirus, enterovirus,coxsackievirus) or bacteria (e.g.,Chlamydia trachomatis,Haemophilus influenzae,Staphylococcusaureus,Streptococcus pneumoniae,Moraxella lacunata). It is spread through contact with contaminatedrespiratory fluids and hands. Health care workers with conjunctivitis should be restricted from patientcontact and contact with patients’ environments. Conjunctivitis usually subsides in 2-5 days withouttreatment. Antibiotics are sometimes prescribed. While pinkeye can be painful and irritating, Marta isfortunate she did not develop a herpes eye infection that can recur with a potential to cause blindness.Most people are infected with herpesvirus type 1 that resides in the nerve tissue associated with theupper respiratory tract. About 10% of those infected experience recurrent oral/facial skin lesions thatcontain the live virus until the lesions are crusted over. A few percent of those infected can also shed thevirus in their saliva even when they have no active lesions.Some Related Regulations and Recommendations:•“Wear a surgical mask and eye protection with solid side shields or a face shield to protect mucousmembranes of the eyes, nose and mouth during procedures likely to generate splashing or spatteringof blood or other body fluids” (CDC).•“Masks in combination with eye protection devices, such as goggles or glasses with solid sideshields, or chin-length face shields shall be worn whenever splashes, sprays, spatter or droplets ofblood or other potentially infectious materials may be generated and eye, nose or mouthcontamination can be reasonably anticipated” (OSHA).Adapted from: Miller CH. Plotting a course around infection prevention pitfalls.Infect Contrl in Pract2013;12(4):1-2.Chapter Review Questions1.C2.A3.B4.D5.C6.A7.C8.A9.C10.A11.A12.C13.B14.D15.B16.D

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TEACHAnswer KeyMILLER:Infection Control and Management of Hazardous Materials for the Dental Team,6th Edition8Infection Control Rationale andRegulationsANSWER KEYCase ScenariosPostexposure ManagementPotential Consequences:Phil didn’t use the proper procedures for postexposure follow-up. Although hissharps injury healed without further problems, it could have led to an infection with bloodborne or otherinfectious agents. It is important for a dental practice to contract with a qualified health care provider(QHP) to provide medical evaluation, counseling, and follow-up care to dental employees exposed toblood or other potentially infectious materials. Timely follow-up after an exposure is critical, particularly ifthe administration of human immunodeficiency virus (HIV) prophylaxis is decided upon by the QHP. Alsothe QHP should have as much information as possible about the exposure incident, including sourcepatient information, so the appropriate risk assessment and medical follow-up can be administered. Sincethe QHP knew nothing about the source patient involved in Phil’s exposure, the physician likely assumedthe possibility of bloodborne pathogen exposure requiring subsequent blood testing.Prevention:The lack of staff coordination in this office could be addressed by designating an InfectionControl Coordinator (ICC) to make sure everyone is in compliance with patient and provider safetyprocedures. The CDC recommends the appointment of such a person to manage safety. Coordinationcan be greatly improved by establishing a daily team huddle to discuss the day’s schedule and to allowthe ICC to present relevant information about office safety.In Dr. G’s office, the ICC could (among otherduties):•organize a postexposure management program.•promote the importance of adding multiple scalers to instrument set-ups to eliminate the need forsharpening contaminated scalers at chairside.•develop (along with the office staff) an infection prevention and safety manual that includes currentCDC recommendations and OSHA regulations. (This should include the written exposure control planrequired by OSHA for all health care facilities.)•facilitate the appropriate on-site exposure response (e.g., first aid, identification of the source patientand acquiring informed consent for source patient testing, access to timely medical follow-up for theexposed dental health care provider).Some OSHA Regulations:OSHA states: “Following a report of an exposure incident, the employer shallmake immediately available to the exposed employee a confidential medical evaluation and follow-up,including at least the following elements:•documentation of the route(s) of exposure, and the circumstances under which the exposure incidentoccurred•identification and documentation of the source individual, unless the employer can establish thatidentification is infeasible or prohibited by state or local law•the source individual’s blood shall be tested as soon as feasible and after consent is obtained in orderto determine HBV and HIV infectivity; if consent is not obtained, the employer shall establish thatlegally required consent cannot be obtained; when the source individual’s consent is not required bylaw, the source individual’s blood, if available, shall be tested and the results documented•when the source individual is already known to be infected with HBV or HIV, testing for the sourceindividual’s known HBV or HIV status need not be repeated•results of the source individual’s testing shall be made available to the exposed employee, and theemployee shall be informed of applicable laws and regulations concerning disclosure of the identityand infectious status of the source individual”Additional OSHA regulations are given in Appendix G of the textbook.

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Chapter8:Infection Control Rationale and Regulations2TEACHAnswer KeyMILLER:Infection Control and Management of Hazardous Materials for the Dental Team,6th EditionAdapted from: Miller CH. Defining the role of the dental safety coordinator–part 1.Infect Contrl in Pract2015; 14(2):1-2.Compliance with RegulationsPotential Consequences:It was obvious that there was no substantial culture of safety in Dr. Corner’spractice, and there was poor coordination of safety efforts with little monitoring of compliance withregulations. Complacency had set in. Some of the staff knew about some safety items, and others didnot. Certain safety procedures, products, or equipment had changed over the years but were not noted inthe 8-year-old ECP. For example, since the Needlestick Safety and Prevention Act (as part of OSHA’sbloodborne pathogens standard) was established, there was likely no ongoing consideration andevaluation of safety devices, which should be reflected in the ECP. A specific postexposure evaluationprogram was only partially organized and not given the important priority needed. Delays in the evaluationresult in jeopardizing the success of the time-critical postexposure testing and prophylaxis whenindicated. Also, not providing the evaluating physician with necessary information about the exposure canjeopardize the evaluation and treatment. The absence or unavailability of OSHA-required SDSs mayprolong necessary actions needed to control or lessen potential damage from exposure to hazardouschemicals.It is clear that this office was not aware of many of the safety regulations and recommendations fordentistry, so compliance was indeed at risk.Prevention:Designation of an ICC who manages the safety program for this office will challengecomplacency about infection prevention procedures and provide support for monitoring compliance withregulations and recommendations and maintaining a culture of safety for the practice. OSHA requires thatthe ECP be updated at least annually. The procedures described in this plan must coincide with what isactually done in the office, so it can be used for training new employees and serve as a checklist formonitoring compliance. The office’s ECP will be used as a guide by an OSHA inspector should one everbe in the office monitoring compliance with the bloodborne pathogens standard. So its contents certainlymust match current office activity.Having personal physicians evaluate employees’ exposure incidents is fine, if everything isprearranged and if the physicians are qualified for such counseling and evaluations; are readily available;and are provided with critical information about the exposed person, the source patient, andcircumstances surrounding the incident. A better choice would be an occupational injury medical facilitylocated close to the practice. The practice’s workman’s compensation insurance provider can provide alist of occupational injury medical facilities that provide testing for employees and source patient, ifneeded. OSHA and the CDC indicate that a postexposure evaluation needs to be prompt.OSHA also requires that each dental facility have a written hazard communication program.Some Related Regulations and Recommendations:•“Assign at least one individual trained in infection prevention responsibility for coordinating theprogram” (CDC).•“The ECP must be updated at least annually and made available to all employees with a potential forexposure to blood or saliva” (OSHA).•“The employer shall maintain in the workplace copies of the required safety data sheets for eachhazardous chemical, and shall ensure that they are readily accessible during each work shift toemployees when they are in their work area(s)” (OSHA).•“Employers shall develop, implement, and maintain at each workplace, a written hazardcommunication program which at least describes how the criteria for labels and other forms ofwarning, safety data sheets, and employee information and training will be met, and which alsoincludes a list of the hazardous chemicals known to be present and the methods the employer willuse to inform employees of the hazards of non-routine (periodic) tasks and the hazards associatedwith chemicals contained in unlabeled pipes in their work areas” (OSHA).

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Chapter8:Infection Control Rationale and Regulations3TEACHAnswer KeyMILLER:Infection Control and Management of Hazardous Materials for the Dental Team,6th Edition•OSHA states:“Ifyou are stuck by a needle or other sharp or get blood or other potentiallyinfectious materials in your eyes, nose, mouth, or on broken skin, immediately flood theexposed area with water and clean any wound with soap and water or a skin disinfectant ifavailable. Report this immediately to your employer and seek immediate medical attention.”•CDC states: “If you experienced a needlestick or sharps injury or were exposed to the blood or otherbody fluid of a patient during the course of your work, immediately follow these steps: washneedlesticks and cuts with soap and water; flush splashes to the nose, mouth, or skin with water;irrigate eyes with clean water, saline, or sterile irrigants; report the incident to your supervisor;immediately seek medical treatment.”Reprinted with permission from: Miller CH. Defining the role of the infection control coordinator–part 2.Infect Contrl in Pract2015; 14(3):1-2.Chapter Review Questions1.A2.C3.B4.C5.A6.D7.B8.D9.C10.A

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TEACHAnswer KeyMILLER:Infection Control and Management of Hazardous Materials for the Dental Team,6th Edition9Preparing for Patient Safety andOccupational HealthANSWER KEYCase ScenariosCulture of SafetyPotential Consequences:The potential consequences of exposure to patient materials in the officerelate to possible transmission of bloodborne diseases such as hepatitis B in nonimmune persons and ofhepatitis C, for which there is no vaccine. HIV disease may be a small risk. Other nonspecific infections(usually localized rather than systemic in nature) also may occur at the injury site as a result of exposureto bacteria or other viruses in the blood or saliva involved. Another often overlooked consequence tosharps injuries is the anxiety one goes through waiting for the results of the tests for bloodborne virusexposure–which, by the way, were all negative for Roberta on both occasions. This anxiety was themain reason for Roberta’s New Year’s resolution.Prevention:If Dr. Walgang and his staff had empowered themselves by developing a sharps injuryprevention program and a “Culture of Safety” for the office, it’s likely that Roberta’s injuries would nothave occurred. The chairside assistants put Roberta at risk by not following proper procedures. Sharpsneed to be disposed of in a sharps container placed near chairside and not put into instrument cassettesor on instrument trays. This puts someone else (e.g., sterilization assistant) at risk because now he or shemust handle the sharp. Instruments need to be returned to cassettes or trays in a stable fashion. Basedon Olivia’s and Marty’s comments, there was not a culture of safety in Dr. Walgang’s office.Aculture of safetyrefers to factors that influence overall attitudes and behavior about safety in theoffice. It’s one general strategy recommended by the Centers for Disease Control and Prevention (CDC)–National Institute for Occupational Safety and Health (NIOSH). A culture of safety reflects the sharedcommitment of the employer and employees toward ensuring the safety of the work environment. Theemployer should openly support a safety culture by:•providing an adequate supply of resources;•engaging worker participation in safety planning;•making available appropriate safety devices and protective equipment;•introducing workers to a safety culture when they are first hired.Other components of a safety culture include:•identifying and removing sharps injury hazards;•developing feedback systems to communicate safety (e.g., newsletters, bulletin boards, brochures,meeting agendas, rewards for identifying dangerous situations, celebrations for success andimprovements);•promoting individual accountability (e.g., assess safety compliance, have staff sign a pledge topromote safety);•measuring improvements in safety (e.g., before-and-after survey of staff perception of safety in theoffice, sharps injury reports).Some Related Regulations and Recommendations:•“Place used disposable syringes and needles, scalpel blades, and other sharp items in appropriatepuncture-resistant containerslocated as close as feasible to the area in which the items are used”(CDC).•“Immediately or as soon as possible after use, contaminated reusable sharps shall be placed inappropriate containers until properlyreprocessed” (CDC).•“Contaminated sharps shall be discarded immediately or as soon as feasible in containers that areclosable, puncture resistant, leakproof on sides and bottom, and labeled or color-coded” (OSHA).

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Chapter9:Preparing for Patient Safety and Occupational Health2TEACHAnswer KeyMILLER:Infection Control and Management of Hazardous Materials for the Dental Team,6th Edition•“During use, containers for contaminated sharps shall be:oEasily accessible to personnel and located as close as is feasible to the immediate area wheresharps are used (e.g., near chairside) or can be reasonably anticipated to be found (e.g.,laundries);oMaintained upright throughout use; andoReplaced routinely and not be allowed to overflow” (OSHA).Reprinted with permission from: Miller CH. Empower by connecting with compliance.Infect Contrl in Pract2012; 11(1):1-2.Needlestick and Culture of SafetyPotential Consequences:Contaminated needlesticks can transmit bloodborne infectious agents ofhepatitis B, hepatitis C, and human immunodeficiency virus disease (HIV disease).Hepatitis B is a well-recognized risk fordental health care personnel(DHCP), but vaccination and useof standard precautions have greatly reduced this risk. Hepatitis C is not easily transmitted throughoccupational exposure, and the low risk for DHCP is similar to that among people in other occupations.As of December 2002, the CDC has confirmed occupational HIV seroconversion in 57 Americanhealth care workers, none of which have been DHCP. Thus the risk of acquiring HIV-disease afterpercutaneous exposure of DHCP to HIV-infected blood is surely quite low. In fact to date, no DHCP areknown to have become HIV-positive following documented occupational exposure to an infected patient’sblood or body fluid (though 6 dental personnel/138 HCWs are possible occupationally acquired HIVpatients).Since saliva is teeming with microbes, needlesticks involving saliva can result in bacterial infections atthe injury site.Prevention:Dr. M should have taken care of the used needle himself after injecting Ms. Handlemeyer bysafely recapping the needle, followed by its removal and disposal in a sharps container. It’s best to takecare of a disposable sharp yourself rather than put someone else at risk. This is why sharps containersshould be near the site where sharps are used and found. Unfortunately disposable dental syringes arenot in common use, so the needle has to be removed from the syringe for disposal. This is a dangerousactivity, and the fact that there are sharp points on both ends of a dental needle make it worse. WhenPantella decidedto handle the needle, she should have safely recapped the needle before she tried toremove it from the syringe.Considering this scenario, it’s important to develop a solid “culture of safety” in the atmosphere for allof the staff to avoid contact with patients’ blood and saliva. For exampleeach staff person can choose asafety topic (see below for a few examples) and prepare a related, step-by-step compliance checklist fordiscussion at a staff meeting. Also a contest can be held for the best hand-made safety poster, phrase, orjingle. Maybe the doctor would provide a free lunch for the winner.SomeSafetyTopics forChecklists:•Sharps safety•Postexposure procedures•Operatory prep•Operatory clean-up•Donning and removing personal protective equipment (PPE)•Location of safety data sheets, chemical lists, OSHA standards, exposure control plan, emergencyexit plan, eyewash stations, PPE, fire extinguishersSome Regulations and Recommendations:•“Develop a written personnel health program for DHCP that includes policies, procedures, andguidelines for education and training; immunizations; exposure prevention and post-exposuremanagement; medical conditions, work-related illness, and associated work restrictions; contactdermatitis and latex hypersensitivity; and maintenance of records, data management, andconfidentiality” (CDC).

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Chapter9:Preparing for Patient Safety and Occupational Health3TEACHAnswer KeyMILLER:Infection Control and Management of Hazardous Materials for the Dental Team,6th Edition•“Ensure that DHCP who handle and dispose of potentially infective wastes are trained in appropriatehandling and disposal methods and that they are informed of the possible health and safety hazards”(CDC).•“Disposable contaminated sharps shall be discarded immediately or as soon as feasible after use …in proper containers easily accessible to personnel and located as close as is feasible to theimmediate area where sharps are used or can be reasonably anticipated to be found” (OSHA).Reprinted with permission from: Miller CH. Special series on empowerment: Avoid contact with blood andother body fluids.Infect Contrl in Pract2011; 10(3):4.Chapter Review Questions1.C2.D3.A4.B5.C6.D7.A

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TEACHAnswer KeyMILLER:Infection Control and Management of Hazardous Materials for the Dental Team,6th Edition10ImmunizationANSWER KEYCase ScenarioVaccinationPotential Consequences:Determining where one “caught” a specific disease is usually difficult, anddifferent respiratory illnesses are difficult to distinguish based on signs and symptoms alone. However,one plausible explanation of this scenario is that Ember became infected with the influenza virus from herdaughter and spread the agent to at least two of her patients when she returned to work. Ember hadnever been immunized against the flu, and she was apparently already infected when she did get theshot. Other considerations are that influenza can be spread to others up to about 6 feet away. Influenzahas a short incubation time of 1 to 4 days, with an average 2 days. So Ember could have been infectedby Mona over the weekend. Also influenza is characterized by an abrupt onset of symptoms, and one isusually contagious 1 day before the symptoms appear to 5 to 10 days after the onset of illness. Ember feltfine on Tuesday at work but was symptomatic on Wednesday. The two patients scheduled to return onFriday likely became infected by Ember on Tuesday, and by Friday they had developed respiratorysymptoms. All of these events are within the common contagious and incubation periods for influenza.While the two “Friday patients” may indeed have developed colds, the early symptoms of influenza areoften confused with those of the common cold or other respiratory diseases.Prevention: Influenza is mainly spread by the larger droplets of respiratory fluids generated when aninfected person coughs, sneezes, or maybe even talks. Less often a person also may get influenza bytouching a surface contaminated with the influenza virus and then touching his or her own mouth or nose.It’s not known how Ember interacted with her patients. For example, did she talk to them while notwearing her mask? Did she perform proper gloving and surface asepsis? Did she sneeze or clear herthroat near patients? Prevention includes staying home when sick and recognizing that one can becontagious without having symptoms of a disease. It is likely that asymptomatic carriers are moreimportant in spreading diseases than those who are obviously ill–the latter are recognizable and can beavoided. Proper hand hygiene and surface asepsis of touch surfaces in health care facilities are importantin preventing the spread of a variety of disease agents. If Ember had been immunized against influenza,there would have been less concern for her spreading influenza directly to her patients.Some Related CDC Recommendations:•The CDC recommends annual immunization against influenza for all persons (with few exceptions)ages 6 months and older, which includes all health care workers.•“Develop a written personnel health program for dental health-care personnel (DHCP) that includespolicies, procedures, and guidelines for education and training; immunizations; exposure preventionand post-exposure management; medical conditions, work-related illness, and associated workrestrictions; contact dermatitis and latex hypersensitivity; and maintenance of records, datamanagement, and confidentiality.•Develop a written comprehensive policy on immunizing DHCP, including a list of all required andrecommended immunizations.•Refer DHCP to a prearranged qualified health-care professional or to their own health-careprofessional to receive all appropriate immunizations based on the latest recommendations as wellas their medical history and risk for occupational exposure.•Develop and have readily available to all DHCP comprehensive written policies regarding workrestriction and exclusion that include a statement of authority defining who may implement suchpolicies.•Develop policies for work restriction and exclusion that encourage personnel to seek appropriatepreventive and curative care and report their illnesses, medical conditions, or treatments that mayrender them more susceptible to opportunistic infection or exposures; do not penalize DHCP withloss of wages, benefits, or job status.”Adapted from: Miller CH. Steering towards patient safety.Infect Contrl in Pract2013; 12(6):1-2.

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