Physicians, nurses, and other clinicians caring for patients with the deadly Ebola virus should wear personal protective equipment (PPE) that does not expose any skin, the Centers for Disease Control and Prevention (CDC) announced Monday night. That means donning a surgical hood that completely covers the head and neck, and a single-use, full-face shield instead of goggles.
The advice, which appears in a revised set of guidelines for PPE in Ebola care, supersedes an earlier recommendation that allowed for a small degree of skin exposure. The updated protocol also calls for replacing masks with either a N95 respirator or a powered air purifying respirator to offer better protection against close-range aerosol contaminants such as blood or sputum generated by intubation, suctioning, and other high-risk procedures.
In addition, the CDC now is recommending that clinicians rigorously train and demonstrate competency at both putting on and taking off PPE. The latter step, if done improperly, puts healthcare workers at risk for contamination. Also, a trained monitor should oversee each time a clinician puts on and takes off this gear.
The updated guidelines “provide an increased margin of safety,” said CDC Director Dr. Tom Frieden, MD, MPH, at a news conference Monday evening.
Infection of nurses prompts review of CDC protocol
The new Ebola guidance comes in the wake of two registered nurses at Texas Health Presbyterian Hospital Dallas contracting the virus from Liberian national Thomas Eric Duncan. Duncan died in Dallas on Oct. 8, exactly two weeks after he started showing symptoms of the virus. After an initial visit to the emergency room at Texas Health Presbyterian Hospital on Sept. 25, he was sent home, despite having a fever of 103 degrees and a recent travel history from Liberia. He returned to the hospital two days later, at which point he was admitted to the hospital and placed under isolation.
The CDC has not yet determined how the nurses, Nina Pham and Amber Vinson, became infected, but insufficient PPE is on the list of suspects, as is the way the nurses might have taken off contaminated gear. Hospital officials indicated that the two nurses, and other clinicians treating Duncan during the first two days of his hospitalization, wore CDC-prescribed gowns, gloves, masks, and eye protection that would have exposed parts of their faces and necks. On September 30, the day Duncan’s Ebola diagnosis was confirmed, healthcare workers switched to hooded hazmat-style PPE, hospital officials
However, medical records from the Dallas hospital suggest that Pham, and possibly other health care workers, may not have been wearing protective equipment while providing initial care to Duncan after he was moved to intensive care. In Pham’s first entry in the records, she makes no mention of protective gear — although doctors and nurses may not always note their own safeguards in medical records, since they are focused on logging the patient’s care. When she logged again the following morning, she mentioned wearing a double gown, face shield and protective footwear — equipment she mentioned again in later entries.
In the first apparent mention of Vinson, she is said to have worn personal protection, including a hazardous-materials suit and face shield. Hospital officials have said masks that cover the nose and mouth were optional, consistent with CDC guidelines at the time. The CDC later advised leg covers and isolation suits, and the hospital complied, Texas Health Presbyterian officials said. CDC guidelines for PPE (old and new) are pictured below:
First U.S. Ebola cases reveal weaknesses in protocol
The CDC has been criticized for promulgating PPE guidelines for Ebola care that put clinicians in jeopardy. The nurses’ union National Nurses United has called on US hospitals to equip nurses with hazmat suits whenever they deal with suspected or known Ebola cases.
In Monday’s news conference, Dr. Frieden said his agency’s previous set of PPE recommendations, based on those of the World Health Organization, “didn’t work” for Texas Health Presbyterian. The WHO’s guidelines were developed for health workers fighting Ebola “in the field” — in more remote places, often outdoors, and without intensive training for health workers, Dr. Anthony Fauci, head of the National Institute of Allergy and Infectious Diseases at NIH, said on Sunday.
But in U.S. hospitals, where patients are treated by highly trained specialists with access to advanced life-saving technology, the risks to healthcare workers are different. While the overall risk of contracting Ebola remains far, far lower among U.S. healthcare workers compared to those in West Africa, the intensive level of care provided in American hospitals may elevate the risk of transmission. Specifically, the use of invasive medical procedures like intubation and dialysis–both of which were performed by the Dallas hospital staff in an effort to save Duncan’s life–increases healthcare workers’ exposure to the infected patient’s bodily fluids. In those settings, said Dr. Fauci, extra protective gear is needed.
“Very clearly, when you go into a hospital, have to intubate somebody, have all of the body fluids, you’ve got to be completely covered. So that’s going to be one of the things … to be complete covering with no skin showing whatsoever,” said Dr. Fauci.
The new guidelines, Dr. Frieden said, generally reflect not only the protocols of Doctors Without Borders in its Ebola campaigns in Africa, but also the protocols of Emory University Hospital, Nebraska Medical Center, and the National Institutes of Health (NIH) Clinical Center. They are three of four hospitals with state-of-the-art biocontainment units designed for the likes of Ebola. None of their healthcare workers have yet to contract the virus in the course of caring for infected patients.
Pham was transferred from Texas Health Presbyterian to the NIH Clinical Center, while Vinson was sent to Emory University Hospital. Vinson is the fourth patient with Ebola to be treated at Emory University Hospital. On Monday it discharged the third of its first three patients with Ebola. The patient, declared disease-free, has requested anonymity. The other two patients were American missionaries who became exposed to the virus in Liberia. They were discharged in August.