Placement Makes the Poison​
Infection Control Lessons​ from the 2014 Ebola Outbreak
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.
A risk assessment might be nothing more than a discussion between a safety officer and a caregiver.
SAFETY OFFICER ENGAGEMENT A job hazard analysis (JHA) is vital to ensure workers’ overall success and safety, and it becomes even more important when the risk of the job increases. The relationship between hazard exposure and injury is complex and depends on several factors, including environmental conditions and human behaviors. The importance of a meticulous JHA was obvious when safety officers were preparing for West Africa ETU patient care operations following the U.S. outbreak. The JHA was meant to identify sensible measures to control the risks that volunteer caregivers presented to patient care providers. In the context of an ETU, however, the task at hand often provides no opportunity to create a written JHA, and a risk assessment might be nothing more than a discussion between a safety officer and a caregiver. In a dynamic ETU, “entry meetings” are held prior to crossing into the ETU “hot zone” (the area designated for patient isolation and care). These meetings are intended for clinicians and support staff to discuss the patient treatment plan. Unlike the institutional hospital, where patients are under close observation, several hours may elapse between hot zone entries. Therefore the patient care plan is developed with contingency for patient degeneration, which isn’t historically considered within the U.S. healthcare setting. Although personnel are well trained, they are quickly reminded that in a field setting, an ETU is not an ICU. Research into treatment options continues, but the ETU currently has limited capabilities for practicing advanced medicine. Clinicians struggle to limit their risk in the ETU while providing the best care possible, so the safety officer must be on guard for unanticipated procedures that diverge from the treatment plan. Despite what is encountered when entering the hot zone, personnel are reminded that there are no “emergencies.” Indeed, the mantra of caregiving is “slow is smooth and smooth is fast.” Ultimately, the objective is to provide treatment that presents the least risk to the medical team. A proven strategy for risk mitigation is to limit the number of personnel entering the hot zone; however, fewer hands available to perform work could mean longer time spent in PPE, which adds risk—not from Ebola, but from heat stress and fatigue. The treatment plan becomes a balance between providing supportive care and risk aversion, negotiated on the terms that the medical team’s safety is paramount to any required medical procedure. It is desirable that clinicians not fear their role of caring for Ebola-infected patients. However, complacency can be as detrimental as fear. To mitigate the potential risk of fear or complacency, a buddy system governs operations during critical activities in the ETU. Some of these activities include donning and doffing of PPE. Proper donning and doffing procedures are equally important in protecting the personnel, since both activities can result in a breach in the PPE barrier or incidental skin contact with contaminated PPE. The buddy is responsible for quality assurance, double checking the PPE for defects, and watching for missteps during the donning and doffing process. However, the buddy system is only as good as the evaluation methodology that backs up the procedures. The last step out of a hot zone is at least as important as the first step in. It is possible the most likely opportunity for exposure will be when personnel experience the relief of finishing the high-risk tasks in the hot zone and are r​emoving their PPE. Complacency, and possible lack of focus due to fatigue, can lead to possible exposures from contaminated PPE. Again, the buddy system becomes paramount. Mindful of these risks, the buddy coaches the team member through a script to carefully doff the contaminated PPE ensemble. Each item is removed in sequence under watch of the buddy, who provides instruction and support should exposure occur.
Field evaluations serve as a credible source of lessons learned for decontamination system guidance. Recently, EPA used fluorescent materials as a B. anthracis simulant to study and improve the effectiveness of biological decontamination procedures. The evaluation team found, in part, that cross-contamination can be reduced by light misting rather than standard spray-brush-rinse; minimizing decontamination solution volume; wearing an additional Tyvek suit beneath the ensemble; frequently changing attendant gloves after contacting contaminated items (tape, gloves, and so on); and using a multi-step process to handle contaminated samples. Similarly, information from other sources (also making use of fluorescent simulant materials) generated the following tips and practices that can greatly improve the effectiveness of decontamination and doffing practices.
Decontamination Decon team members should change or wash their gloves each time a different person is treated. Cross-contamination can be minimized by keeping team members in their assigned stations and scrupulously observing step-off lines when exiting the decon line. Suit openings should be cleaned, especially when items will be discarded. Decon time should be brief (approximately 5–10 minutes per team member), and team members should know that flooding techniques can wash “decon water” into suit openings. Damp or dry techniques can be used to avoid washing contaminants into and through suit openings, particularly the neck and wrists, and excess decon water should be removed before final doffing. Garments and Equipment Protective garments should be well-fitted to the user in order to minimize “breathing” or “bellowing” at openings (throat and wrists) as the decontamination technician moves within the suit. Shingle-like layering of garments ensures that decontamination solution runs to the outside. Tape can hold things together, but it doesn’t seal reliably. PPE openings should be wiped dry before final doffing, and brushes and sponges should be washed frequently. Respirators and other equipment can harbor contaminants. Clean SCBA high-pressure hoses and avoid further contact, if used. Keep the SCBA mask/regulator intact when doffing the mask. New or unfamiliar equipment should be de-bugged before it’s used in a crisis situation. Other Considerations Additional considerations apply when working with contaminated victims. Decontamination team members should provide for the victim’s modesty when possible, and use lots of water (since victims are already contaminated). Water temperature and pressure should be adjusted before application, and gloves should be changed or washed often. Carwash mitts work well when cleaning victims. A gentle touch is necessary when cleaning around the eyes, nose, and ears. Shampoo is effective for cleaning hair and skin. Head and body hair, navel, and armpits should be thoroughly cleaned. Finally, decontamination team members need to watch for hypothermia, even in hot climates.
Other common elements emerge from available studies, both published and unpublished:
  • It is technically difficult to eliminate prospective cross-contamination. Scrupulous personal hygiene (showering) is imperative.
  • Decontamination and doffing begin when the protective ensemble is donned. Its removal shouldn’t cause issues or difficulties.
  • Plan for, and drill on, contingencies, such as loss of water or power.
  • Anticipate and drill on in-suit (“man-down”) emergencies.
  • Work out the details of the “last one out” of the line.
  • Triage for heat stress, fatigue, and related hazards.
  • Be familiar with appropriate hot zone work practices (for example, no kneeling, stay out of product, minimize contact, and so on) and their impact on overall contamination.
Decontamination system performance can vary wildly for many reasons, including poor or unremembered technique, untested procedures or “shortcuts,” environmental conditions, and natural variability between people. PERFORMANCE ISSUES AND CHALLENGES Today’s PPE marketplace is a smorgasbord of nations, companies, and distributors. There is a greater variety of components than ever before, and very few combinations are tested systematically to determine performance vulnerabilities in a given decontamination system. The result is higher system uncertainty when taken with other considerations, such as the worker’s skill level, toxicity, exposure duration, and environmental factors. The primary challenge for the decontamination system is to minimize, if not eliminate, contamination transfer from PPE surfaces to unprotected skin or duty uniform. The system consists of the people who perform the actions; the procedures governing the actions; and the equipment used. Conceptually, there are three primary approaches to avoiding contamination transfer while doffing: “kill” it; remove it; or fix it in place. In practice, all three are present in virtually every decontamination system. Absent faulty or damaged PPE, system failures always point to an approach deficiency, particularly when the outcome is an ill worker. The 2014 U.S. Ebola outbreak yielded insight into just how vulnerable these systems can be.
VAL GARNER, CHMM, CIH, is the vice president of HSE/Risk Management for SWS Environmental Services, a leading national environmental emergency response cleanup organization. Garner has served as a project manager and safety officer for multiple projects involving infectious substances and biological hazards over the past 15 years. ROXY GROSSNICKLE is the manager of Occupational Safety and Health for The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. HJF staff augmented the U.S. military response to the recent Ebola outbreak in West Africa. FRED BOLTON has worked for 10 years as a Los Alamos National Laboratory hazmat​ responder and training instructor, which included providing technical support to several DOE national response teams. He was also responsible for testing and evaluating procedures for doffing contaminated protective ensembles in both military and civilian applications. CDR DEREK NEWCOMER, CIH, CSP, is a commissioned officer in the U.S. Public Health Service and chief of the Technical Assistance Branch, Division of Occupational Health and Safety, National Institutes of Health (NIH). NIH is the primary agency of the U.S. government responsible for biomedical and health-related research. He served as a safety officer during the federal response in West Africa. 
RESOURCES AIHA: Guideline for the Decontamination of Chemical Protective Clothing and Equipment (2005). ASTM F 903, Standard Test Method for Resistance of Protective Clothing Materials to Penetration by Liquids. ASTM F 739, Standard Test Method for Permeation of Liquids and Gases through Protective Clothing Materials under Conditions of Continuous Contact. Dupont: “Preparing for the Worst with HAZMAT Equipment Protection.” EPA: “Decontamination Line Protocol Evaluation for Biological Contamination Events” (PDF, March 2015). NFPA 1991, Standard on Vapor-Protective Ensembles for Hazardous Materials Emergencies. NFPA 1992, Standard on Liquid Splash-Protective Ensembles and Clothing for Hazardous Materials Emergencies. NFPA 1994, Standard on Protective Ensembles for First Responders to CBRN Terrorism Incidents. NFPA 1999, Protective Clothing and Ensembles for Emergency Medical Operations.