URGENT: Are CDC Ebola Guidelines 'Good Enough'?

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Specializes in RN, CHPN.

We now have two nurses who were infected with Ebola while caring for a patient. Although they were blamed for "breaching protocol," we know that's not the case now that reports of the deplorable conditions and lack of appropriate PPE and protocols has come to light.

Nurses allege staff worked with ebola patient 'without proper protective gear' | BreakingNews.ie

But even if CDC protocols and recommendations are followed in the wake of this disaster, the question is this:

Are they enough to protect nurses (and their families, and other patients in the hospital, and the public health)?

It sure doesn't seem like it. In fact, I feel confident in saying no, they're not. I've been doing some research, and I want to share my findings with my fellow nurses.

According to the World Health Organization, 4,493 people have died from Ebola, and 427 healthcare workers have been infected during patient care. 236 of them have died. For every 10 patients with Ebola, one nurse has been infected. And nearly half of them has died. Some of them did not have the appropriate PPE (like the nurses in Dallas). Some did.

Ebola is a Biosafety Level 4 pathogen -- the most severe category. The CDC has this to say about BSL-4 pathogens:

"The microbes in a BSL-4 lab are dangerous and exotic, posing a high risk of aerosol-transmitted infections. Infections caused by these microbes are frequently fatal and without treatment or vaccines. Two examples of microbes worked with in a BSL-4 laboratory include Ebola and Marburg viruses."

http://www.cdc.gov/training/quicklearns/biosafety/ (slide 10)

There is a HUGE discrepancy between safety guidelines issued by the CDC for healthcare workers and workers in research laboratories. Why should this be? Labs handle Ebola under controlled conditions. Nurses handle Ebola when it's being spewed out in projectile vomit and explosive diarrhea. But the guidelines for nurses don't come close to those for lab workers, which is outlined here for handling BSL-4 pathogens, including Ebola:

Laboratory practices

  • Change clothing before entering.
  • Shower upon exiting.
  • Decontaminate all materials before exiting.

Safety equipment

Facility construction

  • The laboratory is in a separate building or in an isolated and restricted zone of the building.
  • The laboratory has dedicated supply and exhaust air, as well as vacuum lines and decontamination systems.

http://www.cdc.gov/training/quicklearns/biosafety/ (slide 11)

Yet for nurses (and others in contact with a patient), the CDC only recommends an isolation gown, gloves, a surgical mask or respirator, and goggles or a face shield.

http://nsnbc.me/wp-content/uploads/2014/10/CDC_Ebola_Ebola-Guidelines.png

Why is this? It's the very same virus, the very unforgiving virus that kills 70% of those it infects, and in a horrifying way. There is no vaccine, and there is no cure. These are the reasons it is classified as a BLS-4 pathogen.

Yet the CDC keeps reassuring us that it's 'hard to catch' Ebola, and it's only spread through contact with body fluids. So why are those lab workers dressed like astronauts? Because Ebola is a very unforgiving virus that kills 70% of those it infects, and in a horrifying way. There is no vaccine, and there is no cure. Even if it's hard to catch, you don't want to catch it. That means every precaution must be taken.

And why do they say it poses a 'high risk of aerosol-transmitted infections' (link above), but then tell us it's only spread through direct contact?

Any pathogen can be aerosolized. Droplets form and hang in the air for as long as 90 minutes when a toilet is flushed, a patient sneezes or coughs, or during procedures likely to produce aerosolized droplets, such as intubation.

In speaking about Ebola transmission, Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota said this:

"Some scientists are urging health officials to acknowledge what they don't know. At a meeting on Ebola Tuesday, one infectious disease researcher told an audience at Johns Hopkins University in Baltimore that scientists should get comfortable with uncertainty and be honest with the public about gaps in knowledge about Ebola.

"We're making this up as we go. We have to be mindful that we're making it up. One of the worst enemies we can have today is dogma."

http://www.usatoday.com/story/news/nation/2014/10/15/nurses-protest-ebola/17302987/

Even if it does spread only through direct contact, workers should use the maximum protection needed. Why? There is absolutely no room for second best or probably good enough.

"Ebola kills 50% to 90% of people who become infected, which is much higher than any other infection we are used to dealing with. The 2009 influenza pandemic killed less than 0.01% of those infected, and SARS killed 15%. The price of getting it wrong with flu guidelines might be a week in bed, but for Ebola it is far more likely to be death."

http://nsnbc.me/2014/10/15/nurses-becoming-infected-ebola/

Even if you use more and better PPE than the CDC recommends -- and you're an expert in using it -- you might not be safe:

"Dr Sheikh Hummar Khan was the leading viral haemorrhagic fever expert of Sierra Leone, who had already treated over 100 Ebola patients using full personal protective equipment when he died from Ebola.

"Personal protective equipment guidelines should not be based on presumed mode of transmission alone, but also on uncertainty around transmission, on the severity of the disease, on health worker factors, and on available treatments or preventions."

"Health authorities such as the US CDC are conveying certainty that Ebola cannot be transmitted by any means other than direct contact. But it's a very poorly studied infection compared with other diseases and the sum of the evidence shows significant uncertainty around transmission.

There is no scientific evidence to explain why health workers using personal protective equipment are becoming infected, and nor has there been a reasoned approach to trying to explain it.

Instead, the blame has been placed on the health workers for lapsing in personal protective equipment protocols."

"If MSF (Doctors Without Borders) has more comprehensive protocols on protective wear, it is hard to understand why Western countries are not heeding them."

http://nsnbc.me/2014/10/15/nurses-becoming-infected-ebola/

I strongly urge nurses to campaign for PPE and protocols at least on the level of that utilized by MSF. Don't accept anything less. You deserve it, your families deserve it, the public deserves it, and the other patients in the facility deserve it.

The people 'in charge' of this crisis have made enough mistakes. Please don't become one more of them.

Please watch this excellent video of how nurses at Emory protect themselves:

Nurses show how they prepare to treat Ebola patients

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Excellent points and the links are great! It is far past time to "wake up". We are already behind. I Fear where we are headed.

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Specializes in Trauma | Surgical ICU.

One of the things I felt was truly amiss in the CDC guidelines was their emphasis on just the "CONTACT" precaution where a regular ISOLATION gown is enough. That is not true.

We need specific PPE that had been tested to resist blood and body fluids.

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Specializes in RN CRRN.

I can't believe the CDC has a poster to doff PPE by removing gloves, then reach up to your face wearing a dirty gown to remove face shield and mask, then remove dirty gown -after you have reached up to your head/face with soiled isolation gown sleeves right near your face in order to remove face mask/shield. Any microscopic wet gunk could flip off into an eye etc if on your sleeve. That isn't too far to travel for a droplet (sleeve to an eye).

The first page of the attachment (which I tried to delete-I just wanted to show the one example) is how to don PPE, the next two pages are two separate examples on how to doff PPE. The first example on doffing is ridiculous. The second one is what I see most RNs/staff do. And this is the CDC.

ppe-poster.pdf

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Specializes in Oncology.

Excellent points. This is extremely well written. I highly recommend you submit it to a newspaper to reach a broader audience, and thus bring more attention to this issue.

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Specializes in RN, CHPN.

The CDC has finally admitted they got it all wrong. Obviously. And this agency is supposed to be protecting our health? What were they thinking?

Lax U.S. Guidelines on Ebola Led to Poor Hospital Training, Experts Say

Many American hospitals have improperly trained their staffs to deal with Ebola patients because they were following federal guidelines that were too lax, infection control experts said on Wednesday.

Federal health officials effectively acknowledged the problems with their procedures for protecting health care workers by abruptly changing them. At 8 p.m. Tuesday, the CDC issued stricter guidelines for American hospitals with Ebola patients.

They are now closer to the procedures of Doctors Without Borders, which has decades of experience in fighting Ebola in Africa. In issuing the new guidelines, the C.D.C. acknowledged that its experts had learned by working alongside that medical charity.

The agency’s new voluntary guidelines include full-body suits covering the head and neck, supervision of the risky process of taking off protective gear, and the use of hand disinfectant as each item is removed.

Sean G. Kaufman, who oversaw infection control at Emory University Hospital while it treated Dr. Kent Brantly and Nancy Writebol, the first two American Ebola patients, called the earlier C.D.C. guidelines “absolutely irresponsible and dead wrong.” ...

The Doctors Without Borders guidelines are even stricter than the new C.D.C. directives in that they require full coverage of the torso, head and legs with fabrics that blood or vomit cannot soak through, along with rubber aprons, goggles or face shields, sealed wrists and rubber boots. Doctors and nurses wear two sets of gloves, including long outer ones that strap or are taped to the gown; janitors wear three sets.

As they undress in choreographed steps, Doctors Without Borders workers wash their hands with chlorine solution eight times and are sprayed with a chlorine mist. Most important, all personnel disrobe only under the eyes of a supervisor whose job is to prevent even a single misstep....

Read the entire article and see a photo of the newly recommended PPE here: http://www.nytimes.com/2014/10/16/us/lax-us-guidelines-on-ebola-led-to-poor-hospital-training-experts-say.html?_r=0

Are the new PPE and protocol recommendations from the CDC still falling short?

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Specializes in RN, CHPN.

Sorry about the huge image! If you scroll to the right, you will see a pic of the new PPE recommended by the CDC.

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Specializes in RN, CHPN.

Lax U.S. Guidelines on Ebola Led to Poor Hospital Training, Experts Say

Many American hospitals have improperly trained their staffs to deal with Ebola patients because they were following federal guidelines that were too lax, infection control experts said on Wednesday.

Federal health officials effectively acknowledged the problems with their procedures for protecting health care workers by abruptly changing them. At 8 p.m. Tuesday, the CDC issued stricter guidelines for American hospitals with Ebola patients.

They are now closer to the procedures of Doctors Without Borders, which has decades of experience in fighting Ebola in Africa. In issuing the new guidelines, the C.D.C. acknowledged that its experts had learned by working alongside that medical charity.

The agency’s new voluntary guidelines include full-body suits covering the head and neck, supervision of the risky process of taking off protective gear, and the use of hand disinfectant as each item is removed.

Sean G. Kaufman, who oversaw infection control at Emory University Hospital while it treated Dr. Kent Brantly and Nancy Writebol, the first two American Ebola patients, called the earlier C.D.C. guidelines “absolutely irresponsible and dead wrong.” ...

The Doctors Without Borders guidelines are even stricter than the new C.D.C. directives in that they require full coverage of the torso, head and legs with fabrics that blood or vomit cannot soak through, along with rubber aprons, goggles or face shields, sealed wrists and rubber boots. Doctors and nurses wear two sets of gloves, including long outer ones that strap or are taped to the gown; janitors wear three sets.

As they undress in choreographed steps, Doctors Without Borders workers wash their hands with chlorine solution eight times and are sprayed with a chlorine mist. Most important, all personnel disrobe only under the eyes of a supervisor whose job is to prevent even a single misstep....

Read the entire article and see a photo of the newly recommended PPE here:

http://www.nytimes.com/2014/10/16/us/lax-us-guidelines-on-ebola-led-to-poor-hospital-training-experts-say.html?_r=0

Are the new PPE and protocol recommendations from the CDC still falling short?

ppe-ai2html-460.jpg
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Specializes in RN CRRN.

NO - because in a different NY Times article they compare even current, as opposed to last week's, CDC guidelines used by some of the U.S.'s four biocontainment unit hospitals like Nebraska Medical Center and North Shore in New Jersey. CDC still recommends removing gloves, then face shield and mask then gown. This makes one bring your possibly wet gown with gunk on it to your face risking germs being flicked onto your skin or eyes etc. There is quite a bit of info in the article and photos. Here is the order the CDC recommends in removal of PPE, compared to what the biocontainment hospitals do. There are differences.

Quote from NY times piece 'Changes to Ebola Protection Worn by U.S. Hospital Workers:

1) Gloves

Original CDC Guidance: The gloves come off first. The rest of the disrobing process can be done with bare hands. A bare hand can safely pull off a glove by slipping it under the wristband (I assume they mean slipping a finger and peeling).

The Hospitals: Workers at some hospitals use two pairs of gloves so that the inner pair remains on during the disrobing process.

2) Face Shield

CDC: Goggles, Safety Glasses or Face Shields should be grasped from the band or ear pieces, which are considered 'clean' and safe to touch with bare hands"

The Hospitals: Nebraska's protocol calls for removing these only after the gown and second gloves are removed, and a third pair of sterile/clean gloves are put on.

3) Gown

The CDC: Bare hands untie knots in back which are not considered contaminated. A peeling motion is used to turn the gown inside out for disposal

The Hospitals: Protocol at North Shore, like that in Nebraska, specifies that the gown be removed before the second pair of gloves are taken off.

4) Mask

CDC: Masks are removed last by grasping behind the ears without touching the front which is considered contaminated

The Hospitals: Hospitals specify using the second or third pair of gloves to remove masks.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

NO they don't have it right....COMMENTARY: Health workers need optimal respiratory protection for Ebola | CIDRAP

We believe there is scientific and epidemiologic evidence that Ebola virus has the potential to be transmitted via infectious aerosol particles both near and at a distance from infected patients, which means that healthcare workers should be wearing respirators, not facemasks.1

The minimum level of protection in high-risk settings should be a respirator with an assigned protection factor greater than 10. A powered air-purifying respirator (PAPR) with a hood or helmet offers many advantages over an N95 filtering facepiece or similar respirator, being more protective, comfortable, and cost-effective in the long run.

We strongly urge the US Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) to seek funds for the purchase and transport of PAPRs to all healthcare workers currently fighting the battle against Ebola throughout Africa—and beyond.

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Specializes in RN CRRN.

Oops I meant NO they don't have it right. At All. CDC Director should step down.

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I wonder if the families of those two infected nurses (if not the nurses themselves) will be pursuing a negligence lawsuit against the CDC, and the Director who approved the woefully insufficient protocol in the first place? Hope so!

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