Placement Makes the Poison
Infection Control Lessons from the 2014 Ebola Outbreak
BY VAL GARNER, ROXY GROSSNICKLE, DEREK NEWCOMER, AND FRED BOLTON
Infection control protocols and procedures have been used for decades in the United States. Yet the effectiveness of standard infection control programs came into question during the 2014 Ebola outbreak when professional caregivers themselves became infected with the virus. Hospitals and healthcare facilities suddenly needed to improve their programs to prevent further virus transmission. They had trouble finding contractors who would accept liability for the disinfection of their facilities after patients known to be infected by Ebola received care at their locations. Government at the local, state, and federal levels was challenged to inform the public of risks, implement policies to limit the spread of infection, and care for volunteer responders in West Africa. Response teams struggled to identify effective cleanup procedures in the absence of published data and guidance. Patient care itself generated challenges with respect to biohazardous waste packaging, transport, and disposal. One year later, is the U.S. any better prepared to manage future outbreaks? This article reflects on the 2014 Ebola outbreak from the perspectives of several emergency response and infection control professionals. EBOLA VIRUS INFECTION CONTROL AND WORKER PROTECTION The industrial hygienist typically seeks to reduce exposures by applying published exposure limits, accepted controls, or consensus standards. By analogy, the IH might seek a log-reduction of biological contaminate to reduce exposure risk when the true goal is to reduce infection risk. The shortcoming in this approach is that many biological materials can cause infection with one or only a few (im)properly placed units or particles. Further, infection risk is greatly variable due to myriad factors: transmission mode, agent form, the dispersing medium, individual susceptibility, inoculation site, and others. When it comes to highly infectious agents, the IH might well replace “dose makes the poison” with “placement makes the poison.”
 
As with any workplace, individual acceptance of, and adherence to, Ebola Treatment Unit (ETU) procedures and processes can vary greatly among workers. Even when workers are generally in total acceptance, procedural failures by a single individual can allow the uncontrolled spread of contamination in the work environment. The blending of work practice cultures and customs, as witnessed in the West African response, poses an additional challenge to achieving consistently implemented protocols under conditions where attention to detail is of paramount importance. Further, resource-limited environments can cause the risks to be viewed and managed differently; for example, the working life of single-use facepieces and supplies may be overextended as an alternative to ceasing operations.
 
Technical information is rarely understood equally by all parties. At one point, CDC guidance that Ebola Virus Disease (EBV) was not communicable by the aerosol route caused many to question the need for respiratory protection. Although the virus alone has not been found to be aerosol transmissible, it may nonetheless be infectious when attached to a particle or droplet, or in a media that can keep it viable. The respirator helps protect the worker from a virus particle being transferred to either an open wound or the respiratory system. The personal protective equipment (PPE) system, including the suit, booties, gloves, and head cover, allows the worker to be decontaminated and protected from the decontamination materials as well. Improper decontamination and doffing can transfer the virus to unprotected areas, leading to potential exposure and infection.
 
With respect to contamination control, assistance is provided to ETU clinical staff to facilitate doffing and donning procedures. Bleach solution is stored in central reservoir containers and may be piped to the point of use to ensure decontamination solution is readily available. Clinical laboratory samples are manipulated in contained glove boxes that limit contamination spread from leaking containers.
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