CDC: Guidelines for Ebola personal protection gear
The CDC has streamlined its August 1st, 2014 guidance on personal protective equipment (PPE) for healthcare workers who treat suspected and confirmed cases of the Ebola virus in United States hospitals. The agency has added coveralls and disposable hoods to the list of required PPE, and has eschewed goggles. The reason for this omission is that goggles do not provide as much skin coverage as full face shields. Moreover, they may fog after long periods of use, tempting staff to adjust them while wearing contaminated gloves. The new recommendations also include:
· Double gloves.
· Waterproof boot covers that reach at least up to the mid-calf, or leg covers.
· Disposable fluid resistant or impermeable gown that goes to at least mid-calf or coverall without intergraded hood.
· Either N95 respirators or powered air purifying respirators.
· Disposable full-face shield.
· Surgical hood that completely covers the head and neck.
· Waterproof apron that covers the torso to the mid-calf should be used if the patient has diarrhea or vomiting.
Additionally, the new guidelines recommend medical facilities to have two specific PPE alternatives to choose from – both of which offer an equal level of protection when put on, worn, and taken off properly –, designated areas for donning and doffing PPE, and step-by-step removal instructions including the disinfection of noticeably contaminated equipment with an EPA-registered disinfectant wipe before taking the gear off, as well as disinfecting gloved hands with an -registered disinfectant wipe or alcohol-based hand rub in between removal steps.
This updated guidance is more in line with that of Doctors Without Borders (MSF), which has set a standard in the protection of its workers. Twenty-one members of the humanitarian group’s staff have contracted Ebola, but only a few cases occurred in hospital settings – the majority of those infections took place after local workers went home to their respective communities. The similarities between the CDC and MSF models include such priorities as protecting skin and mucous membranes from exposure to blood and bodily fluids, a thorough and systematic strategy for donning and doffing PPE to avoid contamination and ensure its correct use, using trained observers to monitor PPE use and removal and address missteps in real-time, and disinfecting PPE before taking it off.
According to CDC director Tom Frieden, Atlanta's Emory University Hospital, Nebraska Medical Center in Omaha and the National Institutes of Health have all followed these guidelines and as a result none of their staff have been infected with Ebola – as opposed to Texas Health Presbyterian Hospital in Dallas where two nurses contracted the virus from a patient. Other nurses from the same facility complained that they were sent into the room of said patient with their neck skin exposed. It is worth noting that the Dallas hospital doesn’t have a specialized biocontainment unit, as do the aforementioned three as well as St. Patrick Hospital in Missoula, Montana – the only four in the United States equipped with such a unit.
“The guidelines are fine and welcomed, but the truth is the guidelines are not the problem,” dean of the National School of Tropical Medicine in Houston and a professor at the Baylor College of Medicine Peter Hotez said. “Unless a hospital is going to specialize in biocontainment and rehearse and practice frequently and regularly, the hospital should not be asked to manage advanced Ebola patients with high viral loads. Unless we have many Ebola patients, these should all be referred to specialized facilities.” The CDC preemptively agreed with that notion in the press release in which it described the guidance. Furthermore, the agency made a point of the fact that PPE is only one aspect of infection control, and one that may provide a false sense of safety.
Thus, the CDC stressed that leadership, rigorous and repeated training, immediate screening and triage of potential cases, clear and standardized procedures – including a backup plan –, designation of an on-site Ebola manager, limiting staff in the isolation room, effective environmental cleaning, and oversight of practices are all equally important to avoid the transmission of the virus among healthcare workers.