Ebola Fever: Reconciling Ebola Planning With Ebola Risk

[Marija Juraja]

Dear all,

I would like to know what peoples comments are regarding this article.
To me it places this disease outbreak in perspective and possibly offers some reassurance re the recommended precautions.
Again with healthcare workers and ensuring we are protecting them are we placing them more at risk with assuming higher levels of PPE?
With this higher level could they inadvertently cross contaminate themselves (as hazmat suits etc are not common ward PPE). Happy to hear what people think.

Annals of internal medicine
Ideas and Opinions | 21 August 2014
Ebola Fever: Reconciling Ebola Planning With Ebola Risk in U.S. Hospitals
Michael Klompas, MD, MPH; Daniel J. Diekema, MD; Neil O. Fishman, MD; and Deborah S. Yokoe, MD
[+-] Article and Author Information
Ann Intern Med. Published online 21 August 2014 doi:10.7326/M14-1918

West Africa is currently in the grip of a terrifying outbreak of Ebola virus disease (Ebola). As of this writing, the outbreak has infected 2127 persons, 1145 (54%) of whom have died. The outbreak currently involves Sierra Leone, Guinea, Liberia, and Nigeria; however, nations around the world are bracing for the possible arrival of travelers, expatriates, and aid workers from West Africa seeking care for documented Ebola or undifferentiated febrile illnesses that might prove to be Ebola.
Hospitals in the United States are scrambling to develop plans to manage patients with suspected or confirmed Ebola. A major emphasis of planning is specifying measures to protect health care personnel and prevent transmission within health care facilities. However, infection prevention and control teams are struggling to reconcile official guidance from the Centers for Disease Control and Prevention (CDC) with the temptation to maximize precautions that exceed CDC recommendations.
The CDC recommends placing patients with suspected or confirmed Ebola in a single-patient room and instituting contact and droplet precautions (1). These entail donning a fluid-impermeable gown, gloves, a surgical mask, and either goggles or a face shield. If the patient has “copious” secretions, the CDC also recommends shoe and leg coverings. If an aerosol-generating procedure is planned (such as intubation or bronchoscopy), the CDC recommends wearing an N95 mask and placing the patient in a negative-pressure room. Despite this guidance, many hospitals are planning to place all patients in negative-pressure rooms at all times, to compel all personnel to wear full-body hazardous material (HazMat) suits, and to require N95 masks or powered air-purifying respirators rather than surgical masks at all times.
Hospitals’ decisions to maximize precautions are understandable given the horrific mortality of this disease and reports of ongoing transmission in African hospitals. Fears among U.S. providers are undoubtedly further spurred by the dramatic footage of ambulance workers in Madrid, Spain, and Atlanta, Georgia, wearing full-body HazMat suits and personal respirators to transport infected patients. However, these excessive measures are unwarranted.
The CDC’s guidance is evidence-based. There have been more than 20 Ebola outbreaks in the past 40 years (2). Through these outbreaks, public health agencies and researchers have gained considerable experience in the control and prevention of this disease (3-4). Ebola is transmitted by direct contact with patients’ bodily fluids, especially blood. Other risk factors, such as contact with fruit bats or eating fruit that has been nibbled by fruit bats, are not germane to U.S. hospitals.
Sharing airspace with an infected patient is not a risk factor. Transmission requires direct physical contact and is inefficient. Studies of household contacts of patients with Ebola are informative in this regard. Among 173 household contacts of 27 patients with confirmed Ebola, the transmission rate was only 16% despite none of the standard infection control precautions routinely employed in U.S. hospitals being used (5). Of the 173 householders, 78 reported no physical contact with the infected patient. None became infected. Among those who did have physical contact, the risk for Ebola was highest after contact with patients’ blood. Other investigators have reported similar findings (6).
Another study evaluated contamination of the care environment (7). Investigators took 54 clinical specimens from 26 laboratory-confirmed Ebola cases. The researchers were able to isolate Ebola virus from 16 of the 54 specimens, including saliva, stool, semen, breast milk, tears, blood, and skin swabs. They then took 33 environmental samples, including swabs from a stethoscope used to examine an infected patient, a bed frame, a bedside chair, a patient’s food bowl, a patient’s spit bowl, the floor, intravenous fluid tubing, and the skin of 3 patient attendants. None were positive. The only extracorporeal specimens that tested positive for Ebola virus were a physician’s blood-stained glove and a bloody intravenous insertion site.
A case investigation from South Africa further affirms both the effectiveness of standard precautions and the very real risk for transmission through body fluid exposures (8). About 18 years ago, an anesthetics assistant in Johannesburg developed fever, headaches, and mental status changes associated with thrombocytopenia, hepatitis, and progressive renal failure. She was eventually diagnosed with Ebola 12 days after hospitalization. A case investigation was initiated, and her disease was ultimately attributed to care she had provided for a patient 3 days before the onset of her illness. She had helped to insert a central venous catheter in a patient with a febrile, multisystem disease of unknown etiology. The index patient had already recovered and been discharged, but investigators were able to locate him and retroactively confirm Ebola by isolating the virus from a semen specimen. The investigators estimated that more than 300 health care personnel provided care to these 2 patients, including invasive procedures, before Ebola was diagnosed, yet there were no additional transmissions despite the lack of Ebola-specific precautions.
These investigations affirm the appropriateness of the infection control practices recommended by the CDC. A fluid-impervious gown, gloves, a surgical mask, and a face shield are adequate to protect health care personnel from direct contact with blood or other body fluids during routine care. N95 masks or personal respirators are only necessary during aerosol-generating procedures.
Exceeding these recommendations may paradoxically increase risk. Introducing new and unfamiliar forms of personal protective equipment could lead to self-contamination during removal of such gear. Requiring HazMat suits and respirators will probably decrease the frequency of provider-patient contacts, inhibit providers’ ability to examine patients, and curtail the use of diagnostic tests. Patients without Ebola may also inadvertently be harmed because Ebola precautions will be required for all suspected cases even though malaria and other infections are more likely in patients from West Africa presenting with fever. Using extra gear inflates patients’ and caregivers’ anxiety levels, increases costs, and wastes valuable resources. More insidiously, requiring precautions that exceed the CDC’s recommendations fans a culture of mistrust and cynicism about our nation’s public health agency.
As health care professionals, we strive to provide evidence-based care driven by science rather than by the media or mass hysteria. We need to apply these principles to planning for Ebola as well.
References
1
Centers for Disease Control and Prevention. Infection Prevention and Control Recommendations for Hospitalized Patients With Known or Suspected Ebola Hemorrhagic Fever in U.S. Hospitals. Atlanta, GA: Centers for Disease Control and Prevention; 2014. Accessed at http://www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.html on 11 August 2014.

2
Centers for Disease Control and Prevention. Outbreaks Chronology: Ebola Hemorrhagic Fever. Atlanta, GA: Centers for Disease Control and Prevention; 2014. Accessed at http://www.cdc.gov/vhf/ebola/resources/outbreak-table.html on 11 August 2014.

3
Kerstins B, Matthys F. Interventions to control virus transmission during an outbreak of Ebola hemorrhagic fever: experience from Kikwit, Democratic Republic of the Congo, 1995. J Infect Dis. 1999;179 Suppl 1:S263-7. [PMID: 9988193]

4
Muyembe-Tamfum JJ, Kipasa M, Kiyungu C, Colebunders R. Ebola outbreak in Kikwit, Democratic Republic of the Congo: discovery and control measures. J Infect Dis. 1999;179 Suppl 1:S259-62. [PMID: 9988192]

5
Dowell SF, Mukunu R, Ksiazek TG, Khan AS, Rollin PE, Peters CJ. Transmission of Ebola hemorrhagic fever: a study of risk factors in family members, Kikwit, Democratic Republic of the Congo, 1995. Commission de Lutte contre les Epidmies Kikwit. J Infect Dis. 1999;179 Suppl 1:S87-91. [PMID: 9988169]

6
Francesconi P, Yoti Z, Declich S, Onek PA, Fabiani M, Olango J, et al. Ebola hemorrhagic fever transmission and risk factors of contacts, Uganda. Emerg Infect Dis. 2003;9:1430-7. [PMID: 14718087]

7
Bausch DG, Towner JS, Dowell SF, Kaducu F, Lukwiya M, Sanchez A, et al. Assessment of the risk of Ebola virus transmission from bodily fluids and fomites. J Infect Dis. 2007;196 Suppl 2:S142-7. [PMID: 17940942]

8
Richards GA, Murphy S, Jobson R, Mer M, Zinman C, Taylor R, et al. Unexpected Ebola virus in a tertiary setting: clinical and epidemiologic aspects. Crit Care Med. 2000;28:240-4. [PMID: 10667531]

Kind Regards

Marija Juraja |Clinical Service Coordinator (CICP) -Infection Prevention & Control Unit|
Division of Acute Medicine
The Queen Elizabeth Hospital | Central Adelaide Local Health Network
Level 8 Tower Building | 28 Woodville Road, WOODVILLE SOUTH 5011
t: +61 8 8222 7588| p: 47757| f: +61 8 8222 6461 | DX: 465432 |e:marija.juraja@health.sa.gov.au

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[Matthew Mason]

Hi Marija and list members,

My experience is that the more complicated you make something the more risk there is of mistakes being made. I have some experience in working in full HAZMAT suits. It takes lots of training and continual practice to get right and be comfortable/safe working in. This is not something that can be rolled out quickly. Using PPE to allay fears is not the right way to protect healthcare workers and is likely to do the opposite. It is quite clear that the risk of Ebola is not so much related to how easily it spreads, it is not airborne primarily, but more to the poor health infrastructure (resources, training, workloads and environment) in the areas where we are seeing the outbreak grow. In a health system such as Australia’s, good infection prevention practices at the contact/droplet level in conjunction with appropriate environmental cleaning is what is required.

Cheers Matt

Matt Mason RN, CICP, BNSci, M Rural Health, M Advanced Practice (IC)

Lecturer
School of Nursing & Midwifery
Faculty of Science, Health, Education and Engineering
University of the Sunshine Coast
University of the Sunshine Coast, Locked Bag 4, Maroochydore DC, Queensland, 4558 Australia.
CRICOS Provider No: 01595D
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[Glenys Harrington]

Hi Marija,

I agree with the authors perspectives and evidence presented in the article.

As with SARS the risk of inadvertent contamination increases with the
introduction of overly complicated or new and unfamiliar forms of personal
protective equipment particularly when this PPE is being removed. Hence
the reason during the SARS outbreak it was recommended in may affected
countries that a second person assist and observe PPE being removed.

Regards

Glenys

Glenys Harrington

Consultant

Infection Control Consultancy (ICC)

PO Box 5202

Middle Park

Victoria, 3206

Australia

M: +61 404 816 434

infexion@ozemail.com.au

ABN 47533508426

Of Juraja, Marija (Health)
With Ebola Risk

Dear all,

I would like to know what peoples comments are regarding this article.

To me it places this disease outbreak in perspective and possibly offers
some reassurance re the recommended precautions.

Again with healthcare workers and ensuring we are protecting them are we
placing them more at risk with assuming higher levels of PPE?

With this higher level could they inadvertently cross contaminate themselves
(as hazmat suits etc are not common ward PPE). Happy to hear what people
think.

Annals of internal medicine

Ideas and Opinions | 21 August 2014

Ebola Fever: Reconciling Ebola Planning With Ebola Risk in U.S. Hospitals

Michael Klompas, MD, MPH; Daniel J. Diekema, MD; Neil O. Fishman, MD; and
Deborah S. Yokoe, MD

[ +-]
Article and Author Information

Ann Intern Med. Published online 21 August 2014 doi:10.7326/M14-1918

West Africa is currently in the grip of a terrifying outbreak of Ebola virus
disease (Ebola). As of this writing, the outbreak has infected 2127 persons,
1145 (54%) of whom have died. The outbreak currently involves Sierra Leone,
Guinea, Liberia, and Nigeria; however, nations around the world are bracing
for the possible arrival of travelers, expatriates, and aid workers from
West Africa seeking care for documented Ebola or undifferentiated febrile
illnesses that might prove to be Ebola.

Hospitals in the United States are scrambling to develop plans to manage
patients with suspected or confirmed Ebola. A major emphasis of planning is
specifying measures to protect health care personnel and prevent
transmission within health care facilities. However, infection prevention
and control teams are struggling to reconcile official guidance from the
Centers for Disease Control and Prevention (CDC) with the temptation to
maximize precautions that exceed CDC recommendations.

The CDC recommends placing patients with suspected or confirmed Ebola in a
single-patient room and instituting contact and droplet precautions (
1).
These entail donning a fluid-impermeable gown, gloves, a surgical mask, and
either goggles or a face shield. If the patient has copious secretions,
the CDC also recommends shoe and leg coverings. If an aerosol-generating
procedure is planned (such as intubation or bronchoscopy), the CDC
recommends wearing an N95 mask and placing the patient in a
negative-pressure room. Despite this guidance, many hospitals are planning
to place all patients in negative-pressure rooms at all times, to compel all
personnel to wear full-body hazardous material (HazMat) suits, and to
require N95 masks or powered air-purifying respirators rather than surgical
masks at all times.

Hospitals’ decisions to maximize precautions are understandable given the
horrific mortality of this disease and reports of ongoing transmission in
African hospitals. Fears among U.S. providers are undoubtedly further
spurred by the dramatic footage of ambulance workers in Madrid, Spain, and
Atlanta, Georgia, wearing full-body HazMat suits and personal respirators to
transport infected patients. However, these excessive measures are
unwarranted.

The CDC’s guidance is evidence-based. There have been more than 20 Ebola
outbreaks in the past 40 years (
2).
Through these outbreaks, public health agencies and researchers have gained
considerable experience in the control and prevention of this disease (
3
4).
Ebola is transmitted by direct contact with patients’ bodily fluids,
especially blood. Other risk factors, such as contact with fruit bats or
eating fruit that has been nibbled by fruit bats, are not germane to U.S.
hospitals.

Sharing airspace with an infected patient is not a risk factor. Transmission
requires direct physical contact and is inefficient. Studies of household
contacts of patients with Ebola are informative in this regard. Among 173
household contacts of 27 patients with confirmed Ebola, the transmission
rate was only 16% despite none of the standard infection control precautions
routinely employed in U.S. hospitals being used (
5).
Of the 173 householders, 78 reported no physical contact with the infected
patient. None became infected. Among those who did have physical contact,
the risk for Ebola was highest after contact with patients’ blood. Other
investigators have reported similar findings (
6).

Another study evaluated contamination of the care environment (
7).
Investigators took 54 clinical specimens from 26 laboratory-confirmed Ebola
cases. The researchers were able to isolate Ebola virus from 16 of the 54
specimens, including saliva, stool, semen, breast milk, tears, blood, and
skin swabs. They then took 33 environmental samples, including swabs from a
stethoscope used to examine an infected patient, a bed frame, a bedside
chair, a patient’s food bowl, a patient’s spit bowl, the floor, intravenous
fluid tubing, and the skin of 3 patient attendants. None were positive. The
only extracorporeal specimens that tested positive for Ebola virus were a
physician’s blood-stained glove and a bloody intravenous insertion site.

A case investigation from South Africa further affirms both the
effectiveness of standard precautions and the very real risk for
transmission through body fluid exposures (
8).
About 18 years ago, an anesthetics assistant in Johannesburg developed
fever, headaches, and mental status changes associated with
thrombocytopenia, hepatitis, and progressive renal failure. She was
eventually diagnosed with Ebola 12 days after hospitalization. A case
investigation was initiated, and her disease was ultimately attributed to
care she had provided for a patient 3 days before the onset of her illness.
She had helped to insert a central venous catheter in a patient with a
febrile, multisystem disease of unknown etiology. The index patient had
already recovered and been discharged, but investigators were able to locate
him and retroactively confirm Ebola by isolating the virus from a semen
specimen. The investigators estimated that more than 300 health care
personnel provided care to these 2 patients, including invasive procedures,
before Ebola was diagnosed, yet there were no additional transmissions
despite the lack of Ebola-specific precautions.

These investigations affirm the appropriateness of the infection control
practices recommended by the CDC. A fluid-impervious gown, gloves, a
surgical mask, and a face shield are adequate to protect health care
personnel from direct contact with blood or other body fluids during routine
care. N95 masks or personal respirators are only necessary during
aerosol-generating procedures.

Exceeding these recommendations may paradoxically increase risk. Introducing
new and unfamiliar forms of personal protective equipment could lead to
self-contamination during removal of such gear. Requiring HazMat suits and
respirators will probably decrease the frequency of providerpatient
contacts, inhibit providers’ ability to examine patients, and curtail the
use of diagnostic tests. Patients without Ebola may also inadvertently be
harmed because Ebola precautions will be required for all suspected cases
even though malaria and other infections are more likely in patients from
West Africa presenting with fever. Using extra gear inflates patients’ and
caregivers’ anxiety levels, increases costs, and wastes valuable resources.
More insidiously, requiring precautions that exceed the CDC’s
recommendations fans a culture of mistrust and cynicism about our nation’s
public health agency.

As health care professionals, we strive to provide evidence-based care
driven by science rather than by the media or mass hysteria. We need to
apply these principles to planning for Ebola as well.

References

1

Centers for Disease Control and Prevention. Infection Prevention and
Control Recommendations for Hospitalized Patients With Known or Suspected
Ebola Hemorrhagic Fever in U.S. Hospitals. Atlanta, GA: Centers for Disease
Control and Prevention; 2014. Accessed at

http://www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.h
tml on 11 August 2014.

2

Centers for Disease Control and Prevention. Outbreaks Chronology: Ebola
Hemorrhagic Fever. Atlanta, GA: Centers for Disease Control and Prevention;
2014. Accessed at

http://www.cdc.gov/vhf/ebola/resources/outbreak-table.html on 11 August 2014.

3

Kerstins B, Matthys F. Interventions to control virus transmission during
an outbreak of Ebola hemorrhagic fever: experience from Kikwit, Democratic
Republic of the Congo, 1995. J Infect Dis. 1999;179 Suppl 1:S263-7. [PMID:
9988193]

4

Muyembe-Tamfum JJ, Kipasa M, Kiyungu C, Colebunders R. Ebola outbreak in
Kikwit, Democratic Republic of the Congo: discovery and control measures. J
Infect Dis. 1999;179 Suppl 1:S259-62. [PMID: 9988192]

5

Dowell SF, Mukunu R, Ksiazek TG, Khan AS, Rollin PE, Peters CJ.
Transmission of Ebola hemorrhagic fever: a study of risk factors in family
members, Kikwit, Democratic Republic of the Congo, 1995. Commission de Lutte
contre les Epidmies Kikwit. J Infect Dis. 1999;179 Suppl 1:S87-91. [PMID:
9988169]

6

Francesconi P, Yoti Z, Declich S, Onek PA, Fabiani M, Olango J, et al.
Ebola hemorrhagic fever transmission and risk factors of contacts, Uganda.
Emerg Infect Dis. 2003;9:1430-7. [PMID: 14718087]

7

Bausch DG, Towner JS, Dowell SF, Kaducu F, Lukwiya M, Sanchez A, et al.
Assessment of the risk of Ebola virus transmission from bodily fluids and
fomites. J Infect Dis. 2007;196 Suppl 2:S142-7. [PMID: 17940942]

8

Richards GA, Murphy S, Jobson R, Mer M, Zinman C, Taylor R, et al.
Unexpected Ebola virus in a tertiary setting: clinical and epidemiologic
aspects. Crit Care Med. 2000;28:240-4. [PMID: 10667531]

Kind Regards

Marija Juraja |Clinical Service Coordinator (CICP) -Infection Prevention &
Control Unit|

Division of Acute Medicine

The Queen Elizabeth Hospital | Central Adelaide Local Health Network

Level 8 Tower Building | 28 Woodville Road, WOODVILLE SOUTH 5011

t: +61 8 8222 7588| p: 47757| f: +61 8 8222 6461 | DX: 465432
|e:marija.juraja@health.sa.gov.au

This email may contain confidential information, which also may be legally
privileged. Only the intended recipient(s) may access , use, distribute or
copy this email. If this email is received in error, please inform the
sender by return email and delete the original. If there are doubts about
the validity of this message, please contact the sender by telephone. It is
the recipient’s responsibility to check the email and any attached files for
viruses.

60 years+SA health(Small)

MESSAGES POSTED TO THIS LIST ARE SOLELY THE OPINION OF THE AUTHOR, AND DO
NOT REPRESENT THE OPINION OF ACIPC.

The use of trade/product/commercial brand names through the list is
discouraged by ACIPC. If you wish to discuss specific reference to products
or services by brand or commercial names, please do this outside the list.

Archive of all messages are available at http://aicalist.org.au/archives –
registration and login required.

Replies to this message will be directed back to the list. To create a new
message send an email to aicalist@aicalist.org.au

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aicalist-request@aicalist.org.au.

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the quotes) to listserv@aicalist.org.au

MESSAGES POSTED TO THIS LIST ARE SOLELY THE OPINION OF THE AUTHOR, AND DO NOT REPRESENT THE OPINION OF ACIPC.

The use of trade/product/commercial brand names through the list is discouraged by ACIPC. If you wish to discuss specific reference to products or services by brand or commercial names, please do this outside the list.

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