An abundance of "abundances of caution"

Googling “abundance of caution Ebola” yields 213,000 hits and a treasure trove of misguided responses to Ebola fears. You can even refer to this excellent Washington Post article about how to make “an abundance of caution” work for you! It’s to the point now that if I hear “abundance of caution” being used in a sentence about Ebola, I translate it to “what I am suggesting makes no actual sense but demonstrates my extreme seriousness about fighting the very idea of Ebola”. 

Some “abundance of caution” (AOC) actions are completely off-the-rails, like preventing students or teachers from attending schools when they had no risk for Ebola exposure, while others may appear reasonable but have no scientific basis (like the excessive movement restrictions some states have applied to asymptomatic returnees from outbreak areas). Another example of the latter category of AOC actions recently took effect in California, as CalOSHA issued updated Ebola guidance for hospitals. The CalOSHA guidance for personal protective equipment meets CDC recommendations, but allows only one option for respiratory protection (PAPR) and only one option for skin covering (full body coverall). I’ll outsource the rest of this post to a SHEA press release from last week. Suffice it to say that I sincerely hope they dial this back, and that it doesn't become a standard for federal OSHA guidance.

SHEA Supports Scientifically Sound Approaches to Ensure Protection for Healthcare Personnel Fighting Ebola

November 24, 2014 (Arlington, VA) – The Society for Healthcare Epidemiology of America (SHEA) is dedicated to the prevention of infection in healthcare settings, including the protection of healthcare personnel (HCP) who provide care to patients with known or suspected Ebola virus disease (EVD). 

SHEA supports the current Centers for Disease Control and Prevention (CDC) guidance on Personal Protective Equipment (PPE) to be used by HCP caring for patients with EVD. This guidance is consistent with the established science regarding how EVD is transmitted.

Recently updated guidance from California's Division of Occupational Safety and Health (Cal/OSHA) meets the CDC recommendations, but specifies only one form of respiratory protection (powered air purifying respirator (PAPR)) and only one form of barrier protection (impermeable coverall) for all inpatient and emergency department (ED) care of those with suspected or confirmed EVD. However, there are no data to suggest that these specific forms of PPE provide better protection for HCP than alternatives that are also included in CDC guidance (e.g., N95 respirators, fluid impermeable hoods, AAMI-4 gowns and leg coverings). 

There are several types of PPE that provide full protection against Ebola transmission, and the local preference of nurses, physicians and other HCP is paramount to select the best PPE for their facility (from among CDC-adherent options). Considerations of familiarity, tolerability (e.g. discomfort, overheating), risk for self-contamination during doffing, and amenability to training all require local input. Thus wide adoption of the narrow requirements established by Cal-OSHA could have unintended adverse consequences. For example, hospitals that have already trained their HCP in safe use of AAMI-4 gowns may inadvertently increase exposure risk by switching to unfamiliar coveralls that are widely considered to be more difficult to doff without self-contamination. Furthermore, mandating PPE that is excessive for the fluid risk of a suspected or confirmed EVD patient results in unnecessary impediments to timely and effective clinical care (e.g., requiring PAPR and coverall for evaluation of an ED patient with low grade fever and no other symptoms). Since most suspected EVD patients cared for in US hospitals test negative for EVD but may have other life threatening conditions that require timely therapy (e.g., malaria), such impediments can lead to harm. Finally, unnecessarily narrow limitations on PPE types will exacerbate already critical PPE shortages and limit the ability of US hospitals to be prepared to care for those with known or suspected EVD. 

HCP have a right to a safe work environment during the care of patients with any communicable disease, including Ebola. SHEA believes that the current CDC guidance, when practiced correctly and reinforced by adequate training of HCP, protects HCP from Ebola transmission. 

Photo by John Spink