Two likely sources for their infection:
1. Inadequate PPE and/or
2. No decontamination process of the PPE prior to its removal
The CDC and the WHO recommendations for personal protective equipment for Health Care Workers treating Patients with Hemorrhagic Fever are inadequate as mentioned by numerous others on this thread: BSL-2 gear for a BSL-4 pathogen. The MSF health care workers in Africa, while not using BSL-4 protective equipment, are certainly are using BSL-3 level equipment when treating Ebola patients: rubber boots, plastic head coverings, goggles, N-100 respirators, triple gloves, tyvek suits, plastic aprons, tape around glove edges: no inch of skin exposed!
Removal of potentially contaminated PPE is another potential occasion for exposure of the HCW, especially as the CDC guidelines do not mention decontamination of potentially exposed PPE is necessary prior to its removal. A decontamination process, using a minimum of 2 people, must be done prior to removal of PPE worn when treating patients infected with this virus.
Any Infectious Disease prevention protocols designed for HCW treating Ebola patients must consider that mistakes will be made. Procedures must be designed to prevent errors from occurring or minimize the impact of these errors on both the patient and the HCW. For example, the BSL-3 PPE worn by the MSF healthcare workers and the rigorous decontamination process in place prior to their removal minimizes the chance that should the HCW have a breach of protocol (i.e. touch their face with a glove), the HCW only touches the PPE, not their skin. Since their PPE is also thoroughly decontaminated prior to its removal, the HCW is not exposed to the virus.
The Dallas Hospital HCW should also be asking: Why were there no secondary infections of healthcare workers who treated Drs. Brantly and Sacra and Mrs. Writbol? Was it a result of the patients being treated in a facility specifically designed to handle patients infected with a BSL-4 pathogen? Was it a result of the HCW receiving extensive training in the use of BSL-4 PPE? Was it because the HCW in these specialized facilities used adequate PPE and employed exposure prevention procedures designed for treating a patient infected with a BSL-4 pathogen? - procedures that included decontamination before removal of their PPE? If future outbreaks of Ebola among U.S. HCW are to be prevented, hospitals must now begin to consider implementing different and more stringent infectious disease prevention protocols than those presently proposed by the CDC. At a minimum: 1. the HCW must be trained in and use BSL-3 gear such as that worn by the MSF and 2. a decontamination procedure must be implemented prior to removal of their potentially contaminated PPE. The cost of additional PPE and decontamination prior to its removal far outweigh the cost to the hospital of treating an Ebola infected employee, or worse, the death of an employee to Ebola. Hospital may also increasingly find themselves unable to locate HCWs willing to work in their infectious disease unit if it houses an Ebola patient.
Well said! Thank you!
Excellent questions and ideas.
Could the reason that the HCW’s that treated Duncan and the Spanish man got infected be specifically because their patients died? In other words, is this virus enormously more virulent and spreadable at the point of death?
Brantley and Whitebol, et. al, didn’t make it to that point.
Maybe the CDC is right. It’s not transmitted in the early stages, or maybe even the mid stages. And that’s why Duncan’s family, the ambulance drivers, the intake people on the first and second visits to the hospital, etc., etc., have not gotten it yet. Just this poor nurse who was around him at the very last.