Ebola protection: How much is enough?

There's an excellent piece in today's New York Times that focuses on the key question hospital epidemiologists across the country are struggling with: what are the appropriate infection control measures to protect healthcare workers caring for patients infected with Ebola virus? We've blogged on this issue to some extent before (here and here). Are contact and droplet precautions enough (as recommended by CDC), or do we need Tychem suits, PAPRs, and fluid resistant booties, or maybe even something beyond that?

What do we know about Ebola viral disease to guide us in this decision?

• The virus is transmitted via multiple routes: direct or indirect (fomite) contact with blood and body fluids (including urine, stool, vomitus, sweat, tears, semen, breast milk, and saliva), droplet, and fecal-oral. Airborne transmission is also possible if aerosolization occurs.
• Healthcare workers are a major risk group for infection.
• The disease manifestations drive transmission (bleeding, vomiting, diarrhea), leading to environmental contamination and contamination of HCW clothing, unprotected skin and mucosal surfaces. Simulated vomiting studies have shown that droplets can travel over 10 feet. The virus can remain infectious 1-2 days outside the human body.
• Healthcare workers have become infected despite use of maximal barrier precautions.
• If transmission occurs, the disease has a high mortality. 
• There is no known effective antiviral therapy. Experience is too limited to understand the impact that state-of-the-art supportive care can have on improving mortality.
• We have no post-exposure prophylaxis.

Now put yourself in the shoes of a 26-year-old ICU nurse with a 1-year-old child at home who has just been assigned to care for an Ebola-infected patient with active vomiting and diarrhea for a 12-hour shift. What level of protection would you want? It's nurses who will likely face the highest risk since they care for patients for long periods of time and have the most contact with blood and body fluids.

It's interesting in the New York Times piece to contrast the perspective of Nancy Foster, a non-HCW executive of the American Hospital Association, who works in an office far removed from the patient care setting, to that of Dr. Michael Callahan, an infectious disease specialist who has direct experience in Africa with Ebola outbreaks. Ms. Foster tells us that gloves, gown, face mask and eye protection are “perfectly fine.” Dr. Callahan notes that the "perfectly fine" strategy “led to the infection of my nurses and physician co-workers who came in contact with body fluids.” The Ebola veteran notes, “I understand the desire to maintain absolute protection in U.S. hospitals.”

How we deal with perceptions of risk is fascinating. The risks we choose to accept and those we don't can't be explained rationally. But that's quintessentially human. As I see it, healthcare workers that accept the challenge of caring for Ebola patients are providing a great service and face a level of risk that is hard to define. These brave souls deserve to have input on the personal protective equipment they wear. And if they want Tychem suits, so be it. Our job is to then ensure that they can safely use them.

Photo: Newsweek.com. Boris Roessler/DPA.