Infectious diseases: "Specialists say the greatest risk comes from taking the gear off."

[mia]

This individual was following full C.D.C. precautions,” Dr. Varga said, adding, “Gown, glove, mask and shield.” Asked how concerned he was that even after those precautions the worker tested positive, he replied, “We’re very concerned.”

Dr. Thomas R. Frieden, the director of the federal Centers for Disease Control and Prevention, said, however, that the latest report indicated a clear breach of safety protocol at the hospital....

The case also raises questions about whether the protective equipment recommended by the C.D.C. is adequate, and whether health care workers in American hospitals are receiving enough training and supervision in using it properly.

The protective gear is meant to keep the patient’s body fluids from coming into contact with health workers’ skin or mucous membranes in the eyes, nose or mouth. But even if the gear seals out the virus, it can become contaminated, and health workers can infect themselves if they remove it improperly and touch the outside of it. Specialists say the greatest risk comes from taking the gear off. It is supposed to be peeled off layer by layer according to a strict protocol, with a helper supervising and disinfecting parts of it at certain steps....

http://www.nytimes.com/2014/10/13/us/texas-health-worker-tests-positive-for-ebola.html?_r=0

[etherealtruth]

2. Always has been a "dangerous" part of the process n/t

[SheilaT]

3. That got talked about on one of the

NPR talk shows several months ago, I believe the Diane Rehm show. It's incredibly important to understand this. Ebola is still not easy to get, it is not airborne, but anyone who works directly with anyone who is symptomatic for Ebola is at great risk.

Here's another paragraph from that article, for those who don't read the whole thing:

In addition to being present in body fluids, the virus is also present on a patient’s skin after symptoms develop, said Dr. Bruce Ribner, the infectious disease specialist who heads the team that has cared for three Ebola patients at Emory University Medical Center in Atlanta. Speaking at a medical conference last week, Dr. Ribner said that his team had tested the patients, and that finding the virus on the skin underlined how contagious the disease is once symptoms set in.

[B2G]

4. So why are they taking decontamination showers

before removal?

And why weren't these HCWs on the high-risk list for monitoring?

The CDC is a complete fuckup.

[etherealtruth]

5. The CDC has very sound protocols ....?

The problems appear to be at the care level.

The procedures need to be reviewed and practiced on a very regular basis ... staff needs to be closely monitored/ supervised (not in a punitive way/ in a way that insures protocols are NOT broken). This sounds simple but is actually quite costly.

I am in no way way blaming the direct care staff .... My personal belief is that the hospitals have not dedicated enough resources into making sure protocols set forth by the CDC are followed.

[B2G]

7. If it's so easy to mess up one of their protocols,

to the point the 'messee' doesn't even realize they did, then their protocols suck.

End of story.

[etherealtruth]

8. It is "easy" ... but, not if one does not practice and receive routine training

this falls on the health care facility ... not the CDC.

Not being snarky, have you ever suited up for either biological or chemical hazards? It is a skill that must be practiced ... in the event that someone is not very well practiced there needs to be a coach or a monitor to help the worker maintain protocol.

It is not "rocket science" ... it is a skill that develops with practice and repetition (at the health care facility level)

[B2G]

10. Not to be snarky either, but

why are you so quick to assume that the CDC protocols are perfect and need no adjustment...that it MUST be something the HCWs are doing wrong?

The number of HCWs being infected is ridiculous...yet the CDC continues to blame the workers rather than taking a good long look at the direction they're giving them. Do they need additional protection? Are they missing a critical decomtamination step that needs to be added/modified? Should certain non-essential procedures be eliminated/reduced in their care?

Is it just possible that this virus transmits in a way that is getting around the protective suits?

You don't know...and neither do they it seems. They are so quick to scream 'breach of protocol' but have no idea how that happened.

[LisaL]

14. Exactly.

CDC guidelines are far from perfect.
Ebola is biosafety level 4 virus. Yet CDC is not insisting on level 4 protective measures.
I do not think these guidelines are anywhere near adequate.

[etherealtruth]

21. There is no 'perfection' ... however the protocols have been very effective ...

... in protecting healthcare workers with the handful of ebola patients treated in the US. I am not inclined to blame the direct care staff ... however, I am very willing to blame the hospital in Dallas (not knowing where they have failed ...., supplies, training, "practice" oversight).

The WHO and CDC protocols have proven to be very effective (I never claim perfection, as perfection does not exist), when utilized. I am not aware of any spread of the disease at any other institutions that have treated the (few) ebola patients .... if I am wrong please provide the information so that I may revise my thinking. These protocols are very effective, when implemented, even in the areas of West Africa where the disease in an epidemic.

As with the healthcare worker in Spain ... she likely contracted the disease by rubbing her face ... this is why monitoring the actions of caregivers is so important. I do not blame her .... it is obvious to me, the Spanish hospital suffered the same failures as did the hospital in Dallas.

[B2G]

23. That's because those facilities are equipped for BSL-4

Big difference.

And if a regular hospital can't contain it without serious overhauls, we are in for a world of hurt.

[etherealtruth]

26. "And if a regular hospital can't contain it without serious overhauls...

...we are in for a world of hurt."

On this we agree ... this is highlighting the inefficiencies and deficiencies in the US health care system when it comes to infectious disease

[LisaL]

24. Have been very effective?

How?
The nurse just got infected in Dallas following this very same protocol.
You can't count Emory and Nebraska because they are specifically designed for viruses such as Ebola.
So they have biosafety level 4 procedures, unlike regular hospitals.

[etherealtruth]

27. How do you suppose the areas in West Africa that have gotten a handle on this ...

... have achieved this.

I do believe that the Dallas ebola cases have highlighted how poorly prepared our hospitals are .... but (in the conversation above) I do not blame it on the CDC protocols ... I blame it on "cost saving measures " instituted at health care facilities .... which endanger staff and patients (noting again, I have been very careful not to blame the direct care workers)

[B2G]

30. Answer: They HAVEN'T.

Nigeria is the only exception, and if memory serves, they shut down air travel from infected countries.

If they hadn't done that, you can bet the cases would have continued to be imported in.

[etherealtruth]

37. Nigeria did ....they used a multi pronged approach

The largest problems have been lack of supplies, lack of trained personnel, lack of facilities , mistrust/ superstitious populations .... NOT the WHO protocols (and by extension CDC protocols).

Perhaps you have worked in healthcare "isolation" units .... I obtained my first degree in 1984 (nursing) ... my education for my nursing degree was generally very good ... however, the training in this area was fairly minimal (this is shortly after universal precautions were instituted). Though I had no problem enumerating the actions and rationales employed with lack of practice (it requires a certain level of coordination and thought) I did not work on an infectious disease unit and was not proficient (due to lack of ongoing training and practice).

I worked as a Hospice nurse at the tail end of the AIDS hysteria (though I do not dispute ebola is far more easily transmitted) .... and heard these very same things .... in order for the protocols to work the staff must be trained (with frequent updates) and well practiced.

I was a stay at home mother for years and earned another degree ... one in Environmental Science and hazardous material management .... again .... I have been trained in safety protocols and have "suited' numerous times .... once again, because this is not the area in which I work I am not proficient. It requires frequent training,practice and oversight.

The protocols have proved very effective in well trained, well equipped well practiced staff ... I am not sure where you are identifying the failures in the protocol ... If i were to identify a failure in the protocols I would say that training and practice of direct care staff should be more clearly defined

[kestrel91316]

41. You seem to be insinuating that we don't understand how Ebola is transmitted.

Please explain your novel theory, complete with its biological mechanism.

Research virologists, who know all about the genetics and biochemistry of these things, are quite clear that Ebola is NOT spread by aerosol exposure.

Human error is extremely common (remember, the average person only has a 100 IQ) and in a for-profit healthcare system, corners WILL be cut. People WILL be inadequately trained and supervised. Mistakes WILL be made.

No magical processes are necessary.

[B2G]

48. It's not spread by aerosol exposure?

Are you sure about that? Because I think you're wrong.

[kestrel91316]

53. The epidemiology alone is proof that it doesn't happen.

Do you have the slightest idea how many millions would be dead by now if it did????? Seriously. Everyone in that apartment would be dead. Everyone in the ER the first time he went in would be dead. It takes as little as 1-10 virus particles for Ebola to infect a human.

Flu and colds are spread by aerosol and not just droplets and fomites. And look at how they spread like wildfire.

You really need to get a grip. If you have factual information (preferably peer-reviewed literature) that says otherwise, kindly provide a link. Ebola is not spread by aerosol. The virus itself is too large and heavy to do that.

This Week in Virology with Dr. Racaniello (a leading virologist) is a great source for information about the science of Ebola. World Nut Daily, FauxNooz, and Alex Jones are NOT.

http://www.twiv.tv/tag/ebola/

And I don't want to hear that these people aren't "real" experts.

[B2G]

56. I think you're confusing aerosol with airborne nt

[B2G]

50. "Ebola is NOT spread by aerosol exposure"

I've followed your posts here kestrel. You know better.

•Avoid AGPs for patients with EVD.
•If performing AGPs, use a combination of measures to reduce exposures from aerosol-generating procedures when performed on Ebola HF patients.
•Visitors should not be present during aerosol-generating procedures.
•Limiting the number of HCP present during the procedure to only those essential for patient-care and support.
•Conduct the procedures in a private room and ideally in an Airborne Infection Isolation Room (AIIR) when feasible. Room doors should be kept closed during the procedure except when entering or leaving the room, and entry and exit should be minimized during and shortly after the procedure.
•HCP should wear gloves, a gown, disposable shoe covers, and either a face shield that fully covers the front and sides of the face or goggles, and respiratory protection that is at least as protective as a NIOSH certified fit-tested N95 filtering facepiece respirator or higher (e.g., powered air purifying respiratory or elastomeric respirator) during aerosol generating procedures.
•Conduct environmental surface cleaning following procedures (see section below on environmental infection control).
•If re-usable equipment or PPE (e.g. Powered air purifying respirator, elastomeric respirator, etc.) are used, they should be cleaned and disinfected according to manufacturer instructions and hospital policies.
•Collection and handling of soiled re-usable respirators must be done by trained individuals using PPE as described above for routine patient care


http://www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.html

[kestrel91316]

54. Aerosol spread has a very strict epidemiologic definition.

It is an epidemiologic and scientific fact that Ebola is NOT spread by aerosol.

It IS spread by droplets, including droplets of blood, urine, diarrhea, spittle, and snot. Respiratory protections are in place to prevent DROPLET spread, not aerosol spread.

You need to show me where any responsible scientist or public health authority says Ebola Zaire is spread by aerosol or STFU. You have NO idea what you are talking about.

Aerosols are particles of <5-30 microns that can float through the air across a room without settling out due to gravity. Do your homework.

[kestrel91316]

55. From your link in the FIRST SENTENCE:

"Standard, contact, and droplet precautions are recommended for management of hospitalized patients....."

http://www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.html

"Aerosol" precautions are not necessary. These words have very specific meanings.

[B2G]

58. I think you are splitting hairs here

CDC guidance very clearly states that aersol generating procedures are to be avoided. But if they are essential, stingent guidelines are in place.

The CDC has further stated that sustained contact within 3 feet of an ebola patient is considered to be direct contact.

That clearly indicates possible aerosol transmission.

[elias7]

62. Not splitting hairs

Aerosol precautions and droplet precautions are separate things. As a health care worker, I can tell you that these definitions and differentiations are vital.

[MADem]

29. It's also claustrophobic. I agree with you, it's not as easy as it looks. nt

[etherealtruth]

38. Oh god yes .... and as hot as hell

If one is not well practiced ... it is a recipe for disaster.

[LisaL]

13. I don't think they are taking showers.

For one, CDC guidelines don't ask for space suit.
Just for gowns, masks, and gloves.
You can't take a shower in one of those gowns without getting all wet.

[B2G]

15. So what???

If a chlorinated shower kills the virus, who would care about getting wet??

I mean, really. I'd be submersing myself in the stuff.

[LisaL]

17. I don't know about " so what."

I don't think they are taking showers. CDC guidelines don't require full body showers. You can't have a shower in the gear CDC guidelines call for, because it's not water proved.
You asked and I answered.

[B2G]

18. Which is in itself concerning

If water can soak through it, so can blood, urine, feces, vomit and saliva.

So what the hell are they thinking? Are they really using 'protective' gowns that aren't even waterproof?

Shaking my head...

[LisaL]

19. Not in CDC labs when their scientists work is Ebola virus.

There they use biosafety level 4 protocols.
But they don't think these protocols are necessary for doctors and nurses working with Ebola patients.
Biosafety level 4 is not required then.

[B2G]

20. Yes, I realize that

What I didn't realize is their protocols call for suiting that is not waterproof.

Do you have a link to the guidelines? I find that to be astounding news if true.

[LisaL]

22. Here is the guidelines.

They do require that gowns be fluid resistant. But the whole set up is not waterproof because it's not a one piece space suit. So water will obviously get in if you take a shower in that set up.

"•All persons entering the patient room should wear at least: ◦Gloves
◦Gown (fluid resistant or impermeable)
◦Eye protection (goggles or face shield)
◦Facemask

•Additional PPE might be required in certain situations (e.g., copious amounts of blood, other body fluids, vomit, or feces present in the environment), including but not limited to: ◦Double gloving
◦Disposable shoe covers
◦Leg coverings"



http://www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.html

[TorchTheWitch]

63. they don't need to take showers

What they do need to do however, is get spritzed all over with chlorine before removing their protective gear, and that's not been happening. If you watch the Frontline episode of Doctors Without Borders they wear space suits, goggles, waterproof boots and long rubber gloves. The head covering covers the entire head and neck except for the eyes. They suit up in pairs and check each other for any gaps or slits or cuts in any of the clothing. Every single bit of skin is protectively covered. After coming out from being in an isolation ward where there are people that are sick whether any of those people are touched or not another equally suited person right outside the door spritzes them all over with chlorine as well as the floor, walls, etc. of the space they stepped out from.

The Dallas hospital has not been doing this, and the protections they were using according to the CDC guidelines didn't call for foot coverings or whole head coverings much less the chlorine to disinfect their clothing before they take it off. It's much too easy to make a mistake in taking off contaminated clothing and coming into contact with virus on it that you can't see is there without the chlorine disinfection of the clothing first even if they were covered completely head to toe with protective clothing. Further, they use gowns rather than the one piece suits so it's also too easy to get infectious droplets on the part of the gown that is against the body. Shields without total face covering allow for infectious droplets to get underneath the shield and onto the face or neck of the person treating the patient especially when in most positions they'd be displaying that gap under the shield to the patient in a position of leaning over them.

Worse, these people in Dallas treating the patient weren't familiar with the protocols and didn't have time to practice and practice getting in and out of their gear, without someone knowledgeable and experienced always there to make sure they do everything correctly, weren't having anyone disinfecting their clothing, and the CDC guidelines weren't even calling for head to toe covering. No wonder one of these people got infected and that the CDC revised the protocol. And they wouldn't have revised the protocol if they didn't recognize that it wasn't good enough to begin with, and as a result one of the caregivers became infected yet the CDC is putting all the blame on her.

The US military is using protocols and clothing that the WHO and Doctors Without Borders has been using even including breathing apparatus with three days of training with someone knowledgeable and practiced in using and disinfecting the clothing, and they aren't even going to be coming into direct contact with any patients. Whoever they're listening to must not be the CDC and it's who we should be listening to.

[LisaL]

64. CDC revised protocol to severely limit contact between patient and caregivers.

And only essential procedures for the patient.
So no more ventilators and dialyses.
Instead of suggesting more stringent PPE requirements, decontamination and such.

[kestrel91316]

40. Please explain how the CDC is at fault if the nurse failed to follow protocol.

I'll be waiting for your reasoned, fact-based answer............

[B2G]

42. I would love to have that discussion with you

just as soon as the CDC can tell us which protocol she failed to follow. They have no idea at the moment.

Until then, it's just speculation.

[LisaL]

47. They clearly don't know.

Nurse denies she failed to follow any protocols.
CDC seem to be putting blame on her because their protocols are "perfect."

[SidDithers]

43. Don't hold your breath...nt

Sid

[LisaL]

46. What proof is there that she failed?

From what has been reported, she denies any breach in protocol.
So I am waiting for your well reasoned answer as to what evidence is there that she failed.

[Warpy]

59. Very few hospitals provide decontamination facilities

and it's appalling to me that the CDC still isn't recommending shoe coverings. They learned NOTHING from having MRSA tracked into the community on the bottom of healthcare staff shoes.

Ebola won't survive outdoors the way MRSA did, but it will survive in hospital halls where non infected patients are walking in stocking feet.

[TwilightGardener]

6. Spreads far easier than claimed--at least with some strains--and nobody will admit it.

Because then it's panic time. Edit to add: if I was a nurse again, caring for these people, I'd be dousing myself with Betadine after every shift.

[valerief]

9. This is where robots could be employed. Of course, they'd have to be designed and

built first and that would take $$$ away from the wealth hoarders.

[B2G]

11. Robots are going to provide patient care?

Uh...no.

[valerief]

12. Yes, in these extremely infectious instances. People are thrown away via war

and now you want to throw them away via healthcare? If there's a better way to protect everyone and help the patient, please tell me how.

[B2G]

16. What are you even talking about?

A robot cannot perform the procedures necessary for patient care.

The best a robot can do is decomtaminate the rooms. That does nothing to help the HCW who are attending to the patient.

[LisaL]

31. Robots nowdays can even do intricate surgeries.

I think it's quite possible to design the robot that could do basic patient care (remotely controlled).

[B2G]

32. I was talking about feasiblity

not possibility.

No robot is going to be a solution to this. That's my point.

[LisaL]

33. I fail to see why it's not feasible.

If robot can do surgery, it surely can bring someone some meds, take temperature, etc.

[B2G]

36. Can it intubate?

Can it prep for dialysis? Can it start an IV drip?

I know you know what's involved here. We don't that that technology, nor will we have in the foreseeable future.

[LisaL]

44. If robots can do surgery, then why couldn't they do other procedures?

And by the way, intubation, dialysis and ventilation that Dallas hospital did on Mr. Duncan could all be high risk procedures for exposure to the virus.
I don't know that this hospital (which is not at biosafety level 4) should even have been doing any of the above.

[kestrel91316]

45. (isn't this magical thinking among some people amazing???)

Yeah, just let the robots (that don't exist) do the job. Nothing could possibly go wrong.

[LisaL]

49. Just as amazing as magical thinking that nurse didn't follow protocol.

Even though she denies it, and there is no evidence of what she supposedly failed to follow.

[kestrel91316]

51. The infection is strong evidence.

How is think a human might commit an error in following complex instructions "magical thinking"?

I think you don't know what that phrase means.

I used to work in a medical mycology lab. I was given very strict instructions on how to work safely with Cryptococcus neoformans.

If I had become infected, nobody would have to rethink the established science of how Cryptococcus infection occurs. Everyone would know that I had breached safety protocol, including me.

[LisaL]

52. Well, CDC is adjusting their recommended protocols, or haven't you heard?

[kestrel91316]

57. They are constantly adjusting them.

That still doesn't mean that the human error theory is "magical thinking" as you claimed.

[LisaL]

61. I love the new protocols.

Limit the number of people taking care of Ebola patients to a minimum.
Only carry out essential procedures.
I presume that means new patients won't be getting dialysis and ventilation?

[seabeyond]

25. it seems to be where the issue is, on the few cases we have seen. thanks. and...

it certainly makes sense

[MADem]

28. Maybe they need to figure out some protocol where the worker is bathed in that UV light

that kills the virus before they even start to take off the gear...?

Then they take a shower in a bleach solution, maybe...?

I can see where that would be a big problem, trying to keep the crud on the outside of the gear from coming in contact with the worker...it's not easy to take off a raincoat coming in from the rain without getting a little moisture on yourself.

[Retrograde]

34. Sounds like all that gear may lead to a false sense of security

"Hey, I'm protected 'cause I'm wearing gloves and a mask and a gown etc. Now I'll just take of this glove, and use my bare hand to remove the other one..." It's bad enough to do that when you've just been wearing the gloves to prepare chiles, but when you're around an invisible, undetectable, potentially lethal pathogen it may be hard to remember that it's potentially there on all the exposed surfaces.

[Boomer]

35. The definition of "difficult" being used is not appropriate

If healthcare workers are at risk from just one slip in protocol, then to the common lay person Ebola is "easy" to catch, not "difficult" to catch.

The intent may be to reassure the public, but the opposite is happening: the CDC loses credibility. There are many other diseases that are far more contagious and much easier to catch, but trying to underplay the obvious risks associated with Ebola just makes the situation worse.

[distantearlywarning]

60. Exactly. +1000

[LiberalArkie]

39. I am sorry, but there is still a major problem at the hospitals.

I went to a large hospital for respiratory tests. I had contact with 3 MD's, about 5 nurses and 3 techs. Not a single one of them washed their hands before seeing me. The stuff was in the rooms. A little squirt from the bottle sitting by the door would have been nice. But not a single one did it.

I thought that the hand washing protocol had been out for a long time and was required. I did not say anything, I was just wanted to see if anyone ended up doing it. The nurse taking my blood did have gloves on though. I don't think she changed them from when she took the blood from the previous person though.

This was last week. Flu season just getting ramped up and getting checked for asthma.