guidance for U.S. healthcare workers on personal protective
equipment for Ebola
The Centers for Disease Control and Prevention is tightening previous
infection control guidance for healthcare workers caring for patients with
Ebola, to ensure there is no ambiguity. The guidance focuses on specific
personal protective equipment (PPE) healthcare workers should use and offers
detailed step by step instructions for how to put the equipment on and take
it off safely.
Recent experience from safely treating patients with Ebola at Emory
University Hospital, Nebraska Medical Center and National Institutes of
Health Clinical Center are reflected in the guidance.
The enhanced guidance is centered on three principles:
All healthcare workers undergo rigorous training and are practiced and
competent with PPE, including taking it on and off in a systemic manner
No skin exposure when PPE is worn
All workers are supervised by a trained monitor who watches each worker
taking PPE on and off
All patients treated at Emory University Hospital, Nebraska Medical Center
and the NIH Clinical Center have followed the three principles. None of the
workers at these facilities have contracted the illness.
Principle #1: Rigorous and repeated training: Focusing only on PPE gives a
false sense of security of safe care and worker safety. Training is a
critical aspect of ensuring infection control. Facilities need to ensure all
healthcare providers practice numerous times to make sure they understand
how to appropriately use the equipment, especially in the step by step
donning and doffing of PPE. CDC and partners will ramp up training offerings
for healthcare personnel across the country to reiterate all the aspects of
safe care recommendations.
Principle #2: No skin exposure when PPE is worn: Given the intensive and
invasive care that US hospitals provide for Ebola patients, the tightened
guidelines are more directive in recommending no skin exposure when PPE is
CDC is recommending all of the same PPE included in the August 1, 2014
guidance, with the addition of coveralls and single-use, disposable
hoods. Goggles are no longer recommended as they may not provide complete
skin coverage in comparison to a single use disposable full face
shield. Additionally, goggles are not disposable, may fog after extended
use, and healthcare workers may be tempted to manipulate them with
contaminated gloved hands. PPE recommended for U.S. healthcare workers
caring for patients with Ebola includes:
Boot covers that are waterproof and go to at least mid-calf or leg covers
Single use fluid resistant or imperable gown that extends to at least
mid-calf or coverall without intergraded hood.
Respirators, including either N95 respirators or powered air purifying
Single-use, full-face shield that is disposable
Surgical hoods to ensure complete coverage of the head and neck
Apron that is waterproof and covers the torso to the level of the mid-calf
should be used if Ebola patients have vomiting or diarrhea
The guidance describes different options for combining PPE to allow a
facility to select PPE for their protocols based on availability, healthcare
personnel familiarity, comfort and preference while continuing to provide a
standardized, high level of protection for healthcare personnel.
The guidance includes having:
Two specific, recommended PPE options for facilities to choose from. Both
options provide equivalent protection if worn, donned and doffed correctly.
Designated areas for putting on and taking off PPE. Facilities should ensure
that space and lay-out allows for clear separation between clean and
potentially contaminated areas
Trained observer to monitor PPE use and safe removal
Step-by-step PPE removal instructions that include:
Disinfecting visibly contaminated PPE using an EPA-registered disinfectant
wipe prior to taking off equipment
Disinfection of gloved hands using either an EPA-registered disinfectant
wipe or alcohol-based hand rub between steps of taking off PPE.
Principle #3: Trained monitor: CDC is recommending a trained monitor
actively observe and supervise each worker taking PPE on and off. This is to
ensure each worker follows the step by step processes, especially to
disinfect visibly contaminated PPE. The trained monitor can spot any
missteps in real-time and immediately address.
The CDC reminds health workers to "Think Ebola" and to "Care Carefully."
Healthcare workers should take a detailed travel and exposure history with
patients who exhibit fever, severe headache, muscle pain, weakness,
diarrhea, vomiting, stomach pain, unexplained hemorrhage. If the patient is
under investigation for Ebola, healthcare workers should activate the
hospital preparedness plan for Ebola, isolate the patient in a separate room
with a private bathroom, and to ensure standardized protocols are in place
for PPE use and disposal. Healthcare workers should not have physical
contact with the patient without putting on appropriate PPE.
CDC's guidance for U.S. healthcare settings is similar to MSF's (Doctors
Without Borders) guidance
Both CDC's and MSF's guidance focuses on: Protecting skin and mucous
membranes from all exposures to blood and body fluids during patient care;
Meticulous, systematic strategy for putting on and taking off PPE to avoid
contamination and to ensure correct usage of PPE; Use of oversight and
observers to ensure processes are followed.
Disinfection of PPE prior to taking off: CDC recommends disinfecting visibly
contaminated PPE using an EPA-registered disinfectant wipe prior to taking
off equipment. Additionally, CDC recommends disinfection of gloved hands
using either an EPA-registered disinfectant wipe or alcohol-based hand rub
between steps of taking off PPE. Due to differences in the U.S. healthcare
system and West African healthcare settings, MSF's guidance recommends
spraying as a method for PPE disinfection rather than disinfectant wipes.
CDC reminds all employers and healthcare workers that PPE is only one aspect
of infection control and providing safe care to patients with Ebola. Other
aspects include five pillars of safety:
Facility leadership has responsibility to provide resources and support for
implementation of effective prevention precautions. Management should
maintain a culture of worker safety in which appropriate PPE is available
and correctly maintained, and workers are provided with appropriate
Designated on-site Ebola site manager responsible for oversight of
implementing precautions for healthcare personnel and patient safety in the
Clear, standardized procedures where facilities choose one of two options
and have a back-up plan in case supplies are not available.
Trained healthcare personnel: facilities need to ensure all healthcare
providers practice numerous times to make sure they understand how to
appropriately use the equipment.
Oversight of practices are critical to ensuring that implementation
protocols are done accurately, and any error in putting on or taking off PPE
is identified in real-time, corrected and addressed, in case potential
Visit CDC for the guidance.
Study shows exit
screening vital to halting global Ebola spread
Three Ebola-infected travelers a month would be expected to get on
international flights from the West African countries suffering epidemics of
the deadly virus if there were no effective exit screening, scientists said
The three countries, Guinea, Liberia and Sierra Leone, do all check
departing air passengers for fever, although the test cannot spot sufferers
in the period before they show symptoms, which can be up to 21 days.
The researchers, whose work was published in The Lancet medical
journal on Tuesday, said exit screening was nevertheless one of the most
effective ways of limiting Ebola's spread.
Using modeling based on 2014 global flight schedules and 2013 passenger
itineraries, as well as current epidemic conditions and flight restrictions,
the analysis showed that, on average, just under three (2.8) Ebola-infected
travelers are projected to travel on an international flight every month.
Dr. Kamran Khan of St Michael's Hospital in Toronto, Canada, who led the
research, said the study showed it was far more effective and less
disruptive to screen travelers from the affected countries in West Africa as
they leave, rather than when they land, as the United States, Britain,
France and some other countries have begun to do.
"While screening travelers arriving at airports outside of West Africa may
offer a sense of security, this would have at best marginal benefits, and
could draw valuable resources away from more effective public health
interventions," Khan said.
Ebola is known to have killed more than 4,500 people in Liberia, Sierra
Leone and Guinea. But with at least half the cases going unreported and a 70
percent fatality rate, by World Health Organization (WHO) estimates, the
true toll in what is by far the worst outbreak on record is probably more
Cases of the hemorrhagic fever have already been imported into Nigeria,
Senegal, Spain and the United States, and WHO officials have said it is
"unavoidable" that Ebola cases will be seen in more countries.
Many medical experts have argued that the best place to prevent the spread
of Ebola is at its source.
Khan said excessive constraints on air travel could have "severe economic
consequences that could destabilize the region and possibly disrupt critical
supplies of essential health and humanitarian services".
The study found that, of the almost 500,000 travelers who flew on commercial
flights out of Conakry, Monrovia and Freetown international airports in
2013, more than half were destined for one of five countries: Ghana (17.5
percent), Senegal (14.4 percent), Britain (8.7 percent), France (7.1
percent) or Gambia (6.8 percent).
It also found that more than 60 percent of travelers in 2014 were likely to
be heading for poor or middle-income countries, where the medical and public
health resources to prevent a wider outbreak are likely to be more limited.
Visit Reuters for the story.
Ebola and the
epidemics of the past
In the winter of 1947, an American tourist arrived in New York City on a bus
from Mexico, feeling feverish and stiff. He checked into a hotel and did
some sightseeing before his condition worsened. A red rash now covered his
body. He went to a local hospital, which monitored his vital signs and
transferred him to a contagious disease facility, where he was incorrectly
diagnosed with a mild drug reaction. He died a few days later of smallpox.
By this point, the man had infected at least a dozen New Yorkers, one of
whom died. Taking no chances, city officials began a massive but voluntary
vaccination campaign against a disease that had killed more people than any
other in history.
Sound familiar? Parts of the 1947 smallpox scare - the sick traveler
harboring a deadly disease, the missed hospital diagnosis, the quickly
spreading infection - strike a disturbing chord. A key difference between
that crisis and our current one with Ebola is, of course, the absence of an
effective vaccine - and the fact that Ebola is usually transmitted through
close, direct physical contact with the bodily fluids of someone infected.
But Americans in the 1940s had a different mind-set as well. Today many
Americans doubt that health authorities can handle the crisis. Back then, by
contrast, there was a growing confidence in the power of medical research to
solve any problem, tame any epidemic, conquer any disease. It was a
confidence grounded in the miracle drugs and vaccines beginning to emerge
from university and pharmaceutical laboratories, and in the public health
apparatus that had served the nation and its troops so well during World War
The great medical breakthroughs in the mid-19th century came mainly from
Europe. Among these was the concept of germ theory proposed by Louis
Pasteur, Robert Koch and Joseph Lister. Germ theory linked specific germs to
specific diseases, like rabies, cholera and tuberculosis. It taught people
to accept the peculiar idea that humans shared their communities, their
homes, even their bodies with invisible, often dangerous microorganisms. Put
simply, what you didn't see could make you very ill.
Germ theory spurred the development of modern laboratory research. Its
impact on pathology and bacteriology can hardly be overstated. In 1900, the
life expectancy for an American man was 46, and for an American woman 48. By
1950, the figures had jumped to 65 and 72 respectively.
Some of this increase can be explained by factors such as better nutrition,
cleaner water and the passage of pure food and drug laws. But much of it was
due to the vaccines, sulfa drugs and antibiotics aimed at the deadly
infections that put children at special risk.
In terms of public confidence, America's golden age of medicine reached its
peak in the 1950s. It was here that the miracle of the laboratory routed the
terror of infectious disease in the most dramatic imaginable way. The
disease was polioâ€”also known as infantile paralysisâ€”which descended like a
plague upon Americans each summer, killing thousands of children and leaving
thousands more in leg braces, wheelchairs and iron lungs. Polio in the
1950s, like Ebola today, put everyone at risk.
But Americans channeled these fears into a common purpose, much like the
smallpox episode of 1947. Uniting behind Franklin D. Roosevelt's March of
Dimes, they raised hundreds of millions of dollars to find an effective
polio vaccine. In a move probably incomprehensible to most parents today,
they volunteered their children - almost two million of them - for the
massive public trials in 1954 that tested Dr. Jonas Salk's killed-virus
injected polio vaccine.
Salk's triumph was followed, in short order, by Albert Sabin's equally
effective live-virus oral polio vaccine (given on a sugar cube or in a
medicine dropper) as well as vaccines for measles, mumps, chickenpox and
whooping cough. Meanwhile, the remarkable success of penicillin and other
antibiotics in destroying harmful bacteria led some researchers to declare
victory in the war against infectious disease.
Medical students in the 1960s were warned away from the field and encouraged
to study chronic disorders like cancer and heart disease, where the real
actionâ€”and the research moneyâ€”would be found. Rarely has a scientific
prediction been so thoroughly shredded. The hubris of that era collapsed
under the combined weight of HIV/AIDS, SARS, Ebola, Avian flu and deadly
drug-resistant bacterial infections. And let's not forget Enterovirus D68, a
pathogen that has sickened more than 1,000 American children this year and
likely killed at least six. In the so-called war between â€śman and microbes,â€ť
there is never a truce.
The first outbreaks of Ebola occurred in rural African villages, but rarely
traveled far. Unlike bacteria, viruses cannot live long on their own. They
depend on the cells of the host they invade to reproduce. When the host
dies, the virus does, too. Having killed off so many villagers, Ebola simply
burned itself out.
The difference in 2014 is that Ebola no longer haunts just the rural
countryside. Its reach now extends into densely populated cities, where
there is no shortage of human hosts. There already have been 10 times more
deaths from Ebola than in any previous outbreak, and that number is climbing
fast. Now it has reached the U.S. - disease, in our interconnected world,
being an easy plane ride away.
History assures us that Ebola will be
conquered. It also tells us that the next "fatal strain" is likely bubbling
up somewhere right now - in a bat cave, a pig farm or an open-air poultry
market. That's the nature of these microbial beasts, and we may not be
spending enough now to understand these threats. But public trust in dealing
with future crises is perhaps the dearest resource of all.
Visit the Wall Street Journal for the full story.
scientists prove link between viral infection and autoimmune disease
Common viral infections can pave the way to autoimmune disease, Australian
scientists have revealed in breakthrough research published internationally.
Professor Mariapia Degli-Esposti, from The University of Western Australia
and the Lions Eye Institute, said the research proved a link between chronic
viral infection and autoimmune disease.
Published in the leading journal Immunity, the Australian research
found that chronic cytomegalovirus (CMV) infection could lead to the
development of Sjogren's (SHOW-grins) syndrome. CMV - a member of the herpes
family - is a common viral infection that causes mild flu-like symptoms in
healthy people but can lead to more serious illness in those with
compromised immune systems. Between 50 and 80 percent of people in developed
countries are infected with CMV. Although normally innocuous, given the
right genetic background, chronic viral infection with CMV can trigger
"Sjogren's syndrome (SS) is the second most common autoimmune disease in
humans, affecting up to three percent of the population or more than four
million people in the United States alone," Professor Degli-Esposti said.
"It affects the function of salivary and lacrimal glands and leads to a
debilitating disease characterized by the loss of saliva and tear
Overwhelmingly, it is a disease suffered by women, with most symptoms of the
disorder emerging in the 40 to 60 year age group. There are two forms -
primary Sjogren's syndrome, defined as a dry eye and mouth that occurs by
itself - and secondary Sjogren's syndrome, with the same symptoms occurring
in those with a major underlying disease such as rheumatoid arthritis or
Professor Degli-Esposti said this new research was highly significant
because it had identified a cause of SS, and in doing so, demonstrated a
novel, unknown function of an immune cell population.
Visit University of Western Australia for the study.
apologizes for Ebola mistakes
DALLAS â€” The head of the group that runs the Texas hospital under scrutiny
for mishandling an Ebola scare apologized Sunday in full-page ads in local
Dallas newspapers, saying the hospital "made mistakes in handling this very
Barclay E. Berdan, chief executive of the Texas Health Resources, which
operates a network of 25 hospitals here, said in an open letter that
hospital officials were deeply sorry for having misdiagnosed symptoms shown
by Thomas Eric Duncan, the Liberian man who was sent home after his first
visit to the emergency room of Texas Health Presbyterian Hospital but was
later readmitted and then died of Ebola two weeks later.
"The fact that Mr. Duncan had traveled to Africa was not communicated
effectively among the care team, though it was in his medical chart," Berdan
wrote. "On that visit to the Emergency Department, we did not correctly
diagnose his symptoms as those of Ebola. For this we are deeply sorry."
The letter was the latest in an attempt to turn around a crippling public
relations disaster for the hospital, which was criticized for making serious
errors and then announcing incorrect information about those mistakes.
Last Thursday, Dr. Daniel Varga, the chief clinical officer for Texas Health
Resources, apologized for the missteps in prepared remarks before members of
the House Energy and Commerce Committee.
"Unfortunately, in our initial treatment of Mr. Duncan, despite our best
intentions and a highly skilled medical team, we made mistakes," Varga said.
"We did not correctly diagnose his symptoms as those of Ebola. We are deeply
"Based on what we already know, I can tell you many of the theories and
allegations being presented in the media do not align with facts stated in
the medical record and accounts of caregivers who were present at the
scene," he said in the letter published in The Dallas Morning News
and The Fort Worth Star-Telegram newspapers.
The nurses have been transferred to hospitals with specialized isolation
units, including one at the National Institutes of Health.
Dr. Anthony S. Fauci, director of the NIH's National Institute of Allergy
and Infectious Diseases, said the hospital had been following guidelines on
protection gear from the Centers for Disease Control and Prevention, which
were prepared by the World Health Organization for treating people in rustic
conditions in Africa.
There have been reports that business had slowed considerably at the Dallas
hospital, with a number of patients canceling appointments. The hospital has
declined to say whether admissions were down or cancellations up.
County Judge Clay Jenkins, the county's chief executive and director of
homeland security, said the hospital was safe and open for business.
"You cannot get Ebola from going into a building where someone is being
treated on a different floor for Ebola, and currently there's no one being
treated for Ebola here, and all of the medical waste has been thoroughly
cleaned up," Jenkins told reporters Saturday as he stood outside
Presbyterian. "There's no reason to not come here."
Jenkins said that about 25 Presbyterian employees had taken the hospital up
on its offer to sleep at the hospital to avoid spreading any possible
contamination to their homes. The hospital made rooms available for
employees who treated Duncan to allow them to stay at the hospital
throughout their monitoring periods. The agreements that the state and the
county have asked the workers to sign voluntarily â€” which prohibit them from
traveling on public transportation and from going to public places â€” state
that the workers would be given the opportunity to stay at Presbyterian "on
a non-admission status," in order to make the monitoring process easier.
In addition to the rooms available for workers
being monitored, the hospital was also allowing any other employees to stay
at the hospital rather than go home, "to avoid even the remote possibility
of any potential exposure to family, friends and the broader public." (The
New York Times)
Visit the Boston Globe for the story.
hygiene reporting discrepancies continue
DebMed announced the results of its third annual survey exploring methods
used by hospitals to gather hand hygiene data, the reliability of that data
and the commitment of healthcare facilities to improving hand hygiene. With
responses from more than 400 infection preventionists, nurses and other
healthcare leaders from U.S. hospitals, the survey reveals that despite the
prevalence of available electronic technologies, manual methods are still
predominately used for tracking hand hygiene, leading to a vast
inconsistency in hand hygiene compliance reporting, and ultimately leaving
patients and clinical staff at risk for infection.
Key findings include:
66 percent of respondents said their facility reports hand hygiene
compliance to be 81 percent or greater, however,
59 percent believe that their true hand hygiene compliance is actually less
than 70 percent
13 percent of those surveyed said they are "extremely satisfied" by the
reliability of their facility's hand hygiene compliance data
In addition to the reporting discrepancies, the survey also found that there
are significant inconsistencies between healthcare workers' beliefs, and the
actual practices of hand hygiene compliance in their facilities.
78 percent believe electronic hand hygiene compliance monitoring is a more
accurate option than direct observation yet
62 percent use manual direct observation by staff as the primary method used
to measure and report hand hygiene compliance, with another 34 percent using
manual direct observation by "secret shoppers"
With that said, 88 percent believe the Hawthorne effect, which states that
people will change their behavior if they know they are being watched,
impacts the accuracy of reported hand hygiene compliance rates
"The survey results are promising, yet accurately represent the challenges
the industry faces in regard to clean hands and safer care for patients,"
said Heather McLarney, vice president of marketing, DebMed. "The numbers
confirm what we hear firsthand from infection preventionists. They and other
hospital staff want to implement the best hand hygiene practices for
improved patient safety and health, but they face the reality of a host of
other IT priorities competing for funding and focus like Meaningful Use,
ICD-10 and EHR implementations."
Further, the survey findings cite the oft-used "in and out" method of only
cleaning hands before and after patient interaction still reigns at most
facilities, despite the fact that data shows additional hand cleaning â€“ such
as after touching a bed rail or medical chart â€“ lowers infection rates.
94 percent believe the WHO Five Moments and Centers for Disease Control and
Prevention Guidelines (CDC) are a higher clinical standard that help reduce
the spread of infections better than cleaning hands before and after patient
care, a four percent increase from 2013, and
63 percent teach staff to follow the WHO and CDC hand hygiene guidelines,
but only 44 percent actually follow those standards, as the majority (54
percent) only clean hands when entering and exiting patient rooms
In looking back at the survey data collected the previous two years, there
is a positive trend in not only the adoption of better technologies, but
also the more imminent plans for purchase among those not yet using
There is a two percent increase in facilities using electronic monitoring
43 percent surveyed said they are currently considering implementing an
electronic monitoring system, and 33 percent said their facility intends to
purchase an electronic monitoring system within the next year
Visit PR Newswire for the study.
Canada leads the
way on Ebola experimental drugs: ZMapp, TKM-Ebola and VSV-EBOV
As health workers and government officials scramble to make advancements in
Ebola drug research, one country has emerged as a major player in the
development of the world's top treatment options: Canada.
With the Ebola death toll topping 4,400 in West Africa and two Dallas health
workers infected this week, all eyes are on TKM-Ebola and ZMapp, two
front-runner drugs developed in Canada, that doctors are using to treat
Although the United States helped to fund and produce the treatments, both
medications were researched in Canada. And industry insiders say it's all
thanks to a handful of innovative scientists at a small laboratory in
"The lab in Winnipeg certainly raised awareness in Canada," said Tom
Geisbert, a virologist and Ebola expert currently researching vaccines and
treatments at the University of Texas Medical Branch.
Why has Canada emerged as an important player in the race for Ebola drugs?
Geisbert said, "I can tell you in two words: Heinz Feldmann."
Feldmann, a virologist who began his career researching influenza but later
focused on Ebola and Marburg viruses in Germany, became the first special
pathogens chief at Canada's National Microbiology Laboratory, NML, in
Winnipeg. The lab first opened in 1999 and has since become part of the
Infectious Disease Prevention and Control branch of the Public Health Agency
of Canada. Though Feldmann later moved on to U.S. institutions, the lab
continues to pursue cutting-edge research.
The idea began in the early 1990s, when infectious diseases were a hot topic
among politicians. According to the Canadian Press, officials and high-level
doctors were concerned at the time that Canada didn't have a lab equipped to
handle highly dangerous, Level 4 diseases such as Ebola. If Canadian
officials wanted to test these specimens, they had to be sent to the U.S.
Centers for Disease Control and Prevention in Atlanta, GA. Today, the
Winnipeg lab does have what it needs but also continues to work with its
Another promising drug candidate, TKM-Ebola,
which has been used to treat American physician Rick Sacra and other
patients, was developed by Tekmira Pharmaceuticals based in Vancouver,
British Columbia. The company has been working on Ebola research for many
years, thanks largely to funding from the U.S. Department of Defense, and
has seen its stock jump during the recent outbreak.
Visit IB Times for the story.
launches new dedicated eye sink
Pure Processing LLC, developer of ergonomic medical device pre-cleaning
systems and accessories, is introducing a new pre-cleaning system
specifically for eye instruments. The lightweight, movable Pure Station
Dedicated Eye Sink can be installed on a countertop, inserted into a sink,
or recessed into a mobile cart to create a dedicated pre-cleaning area for
intraocular instruments. This reduces the potential for cross-contamination
by material or residue from general surgical instruments, as recommended in
ANSI/AAMI ST 79:2006:A1:2008/Annex N.
"Compliance to standards, especially to best practices that help prevent
infection, is even more critical in today's emerging microbial landscape,
and in light of the dangers and costs infections pose for patients and their
healthcare providers," said Dan Gusanders, president of Pure Processing.
"Our innovation focuses on enhancing ergonomics and pre-cleaning compliance.
We identified the need for a safe, effective, efficient dedicated
pre-cleaning capability for intraocular instruments and developed a new
system, based on our proven technology, that meets that need. The Pure
Station Dedicated Eye Sink has the potential to become an essential support
tool for eye surgery."
The first compliance feature of the Pure
Station Dedicated Eye Sink is its visual labeling. The upper edge of the
system includes a permanent label that states: "EYE INSTRUMENTS ONLY." The
same label also instructs users to "Discard water used to clean or rinse
after each use," and to "Follow device manufacturer's instructions for use."
In addition, there are two configurations available; one with the proven
Pure Processing pump system for lumens and channels, and one without. For
more information, please visit