The Ebola virus, discovered in Africa in 1976, first appeared in the U.S. on Aug. 2, when Dr. Kent Brantly returned to the U.S. from West Africa, for treatment at Emory University Hospital in Atlanta.1
Ebola virus disease (EVD; also Ebola hemorrhagic fever, or EHF), or simply Ebola, is a disease of humans and other primates cause by Ebola viruses (EBOV). Ebola is spread just as human immunodeficiency virus (HIV), hepatitis B or C is spread, through contact with blood and bodily fluids.
Over the past 20 years we have successfully managed a number of outbreaks, such as anthrax, AIDS, H5N1 (Avian Flu), and influenza A viruses; all transmitted either through contact with bodily fluids, airborne, droplet or contaminated surfaces.
The outbreak of Ebola in Dallas involving two nurses caring for an Ebola patient is comparable in so many ways, to the 2003 outbreak of Severe Acute Respiratory Syndrome (SARS) in Canada.
SARS is a severe form of pneumonia caused by a coronavirus dubbed SARS-CoV. This highly contagious disease originated in Guangdong Province in southern China in the fall of 2002, and began to spread to a number of countries by people traveling on international flights during February 2003.2
The main symptoms of SARS are high fever and respiratory problems. The virus appears to be transmitted through droplets in the air and contaminated surfaces. In total, 44 people in Canada died from SARS, approximately 400 became ill, and 25,000 Toronto residents were placed in quarantine.3
Three medical workers died during the SARS outbreak. One was a family doctor and the other two were nurses.4 The healthcare community became outraged, demanding better transparency, better information flow and better protection for healthcare providers taking care of SARS patients.5,6
What is common to these contagious disease situations, is that they force medical and public health authorities, as well as federal, state and local governments, to review and revise policy, making some very difficult, and at times, unpopular decisions.
These contagious diseases raise ethical questions on quarantine versus individual rights of freedom, the right to privacy and confidentiality versus public disclosure and protection, and the healthcare workers’ duty to care versus their own welfare and the welfare of their family.
Although healthcare workers generally are a humanitarian group, healthcare workers may refuse to work during a pandemic due to fear for their own safety and that of their families. During the early years (1980’s) of the Human Immunodeficiency Virus (HIV) epidemic doctors, nurses and healthcare administrators debated whether it was acceptable to refuse to treat those with HIV; and amidst the SARS outbreak in Canada some HCW’s were not willing to treat SARS patients.7,8
Historically, healthcare personnel have often been the first victims of epidemics.9 Healthcare providers are on the front line of care and they are generally well-versed in the proper methods of protection needed for standard precautions. They practice these protocols on a daily basis and understand their importance in preventing the spread of disease.
Standard precautions are a set of infection control practices used to prevent transmission of diseases that can be acquired by direct contact with blood, body fluids, non-intact skin (including rashes), and mucous membranes. These measures are to be used when providing care to all individuals, whether or not they appear infectious or symptomatic.
The CDC Standard Precaution basic steps include:
1. Practicing appropriate hand hygiene before and after contact with a patient, after contact with the surfaces or objects around the patient, and after removing gloves (if used).
2. Wearing Personal Protective Equipment (PPE); e.g., disposable gloves when the care provider may have contact with blood, feces, urine, or any other body fluids; a gown to prevent contamination of the provider’s clothing with blood or body fluids; and a face mask, face shield, and/or goggles if splashing of blood or body fluids might occur.
3. Cleaning of care equipment between patients.10
Additional components that should be considered under standard precautions include: care of the environment, handling of linens and waste, sharps injury prevention, use of protective equipment during resuscitation, patient placement, safe injection practices, respiratory hygiene/cough etiquette, and use of a mask during special lumbar puncture procedures.
In addition to standard precautions, healthcare providers also need to follow transmission-based precautions for patients with known or suspected pathogens that can be transmitted by airborne or droplet transmission or by contact with dry skin or contaminated surfaces.
Airborne Precautions is used for infections spread in small particles in the air. A fit-tested N-95 or higher level disposable respirator should be donned prior to room entry and removed after exiting room.
Droplet Precautions is followed for infections spread in large droplets by coughing, talking or during the performance of certain procedures such as suctioning or bronchoscopy. Droplets may contain microorganisms and generally travel no more than three feet from the patient. A facemask, such as a surgical mask, for close contact with the patient; should be donned upon entering the room.
Contact Precautions is adhered to for infections spread by skin to skin. Hand hygiene and wearing of gloves or gowns when touching the patient or the patient’s immediate environment is recommended.
The OSHA PPE Standards 1910.132 and 1910.133 require employers to provide PPE for employees with hazard exposure in the workplace, train employees on the proper use of PPE, and properly maintain, store, and dispose of PPE.11
Further CDC Guidance
When two Dallas nurses caring for an Ebola patient became infected with the Ebola virus attention was directed to the effectiveness of the standard precautions guideline, the adequacy of the PPE, as well as the knowledge of the user to implement best practice principles pertaining to donning and doffing protective equipment.
After thorough review of the situation in Dallas and consulting with various professional medical organizations, the CDC made a decision to revise their PPE guidance for healthcare workers treating Ebola patients. It was apparent that the challenges in managing Ebola patients stemmed from insufficient personal protective equipment and healthcare provider competency in the use of PPE.
Doctors Without Borders staff fighting the virus in West Africa are well trained, fully covered, wear layers of protective clothing and multiple pairs of gloves, and are supervised as they don and doff PPE.12 The healthcare providers at Emory University Hospital in Atlanta and Nebraska Medical Center in Omaha follow a similar practice.13
The current guidelines did not instruct medical staff to cover every inch of skin when caring for patients with Ebola. Further the guidelines recommended a single pair of gloves and advised workers to remove their single pair of gloves following care, then take off their gown, goggles and mask, followed by hand disinfection. This raises the chance that a healthcare provider’s bare hands could be contaminated during the removal of PPE.
The CDC Guidance released Oct. 20 for healthcare workers caring for Ebola patients contains the following key principles:
Prior to working with Ebola patients, all healthcare workers involved in the care of Ebola patients must have received repeated training and have demonstrated competency in performing all Ebola-related infection control practices and procedures, and specifically in donning/doffing proper PPE.
While working in PPE, healthcare workers caring for Ebola patients should have no skin exposed.
The overall safe care of Ebola patients in a facility must be overseen by an onsite manager at all times, and each step of every PPE donning/doffing procedure must be supervised by a trained observer to ensure proper completion of established PPE protocols.14
CDC guidance has thus transitioned from a single layer protection to a multiple layer protection strategy with full body coverage. Users no longer have choice.
Specific PPE for treating patients of the Ebola virus now includes single use, fluid-resistant or impermeable gowns or coveralls, aprons, hoods, respirators with face shield, boot covers and double gloves. No longer is a surgical mask acceptable.
A Powered Air Respirator (PAPR), which uses a motorized air source to filter and clean ambient air before it is given to the user or an N95 Respirator which removes as much as 95% of all airborne pathogen particulates with aerodynamic diameter of 0.3 micrometers or greater is recommended.
Further, the CDC provides step by step instructions on hand hygiene disinfectant protocols. These steps are critical, because this is a time when healthcare providers can come into contact with contaminated fluids that have splashed onto their protective clothing. Exposure of any skin might increase the risk of being infected with Ebola.
Hand Hygiene practice changed from two single hand hygiene events (prior to care and after removal of PPE) to multiple hand hygiene applications including: hand hygiene prior to care, application of an alcohol based hand rub (ABHR) to gloved hands throughout care, application of ABHR to gloved hands as you remove each PPE item, and hand hygiene after care.
Although the CDC recommends the wearing of nitrile examination gloves with longer cuffs, many question whether synthetic surgical gloves would be a better choice. Surgical gloves fit better and provide increased comfort and dexterity for the wearer, especially when they double glove.
According to standards established by the American Society for Testing and Materials (ASTM), which the FDA adopts, surgical gloves are tested to higher standards than examination gloves for freedom from holes, physical
dimensions, tensile strength, ultimate elongation, and stress at elongation.
Emphasis has also been placed on the importance of training, practice, competence, and observation of healthcare workers in correct donning and doffing of PPE.
Healthcare workers must now undergo rigorous training, to be supervised by trained monitors and follow step by step instructions when putting on and taking off personal protective equipment. The guideline also calls for designated areas for putting on and taking off protective gear.
The Ebola outbreak has highlighted the need to continuously review and revise policy to ensure we have the most appropriate and best safety practices and programs in place in hospitals.
Although personal protective devices are effective at decreasing exposure to infectious diseases and preventing cross contamination; we know that simply wearing PPE is not enough. PPE itself can introduce risk. Proper training, practice, competency and routine observation is required in donning and doffing of PPE to protect healthcare providers.
Hopefully, in the near future, we will be able to provide our front line heroes with even better protection. As technology plays a greater role in healthcare to combat infectious disease, we are seeing the emergence of antimicrobial surface coatings on medical devices such as gloves and linens.
The science of this antimicrobial technology is both theoretically and practically sound; and when used in conjunction with other sound practices has the potential to introduce PPE that prevents microbial transmission. Increasing pressure to protect both patient and healthcare provider will play a crucial role in the growth and adoption of antimicrobial devices.
References for this article can be accessed here.
Patty Taylor is Vice President of Professional Education and Clinical Affairs for Ansell.