This post is inspired by the two nurses, Nina Pham and Amber Vinson, who contracted Ebola virus after treating Thomas Eric Duncan at Texas Health Presbyterian Hospital. See the timeline of events surrounding Duncan’s diagnosis and treatment here.
I was somewhat surprised – and moderately alarmed – when Nina Pham was diagnosed last weekend. That Amber Vinson also contracted Ebola is also alarming but as we learn more about how the hospital treated Duncan it’s not a huge surprise. When Pham’s diagnosis was announce, while the possibility of Ebola having mutated and “gone mobile” was scary it also seemed remote. More likely it seemed to me was that the nurses either didn’t have good personal protective equipment (PPE) or that the hospital didn’t have a good decontamination protocol for workers coming out of the hot zone. It now appears that not only was the PPE used insufficient but that there was no decontamination protocol in place. Given that, it doesn’t surprise me that several health care workers became ill. When working with highly toxic materials or contagions good PPE is essential but if you don’t have a good decontamination protocol in place then you can easily expose yourself to the hazard when removing your PPE. Good practice is to decontaminate your PPE before removing it. My understanding is that bleach kills Ebola virus so, with the caveat that a little knowledge can be a dangerous thing, my take is that proper decon of potentially-exposed health workers would involve spraying them down with bleach before they removed their PPE.
I am not a rookie when it comes to working with hazardous materials. For about 15 years I worked on chemical and biological warfare defense-related R&D projects; specifically, my co-workers and I developed equipment to detect trace amounts of chemical and biological warfare agents in the air [1]. (We also did R&D on detecting agents on surfaces, but most of our work was focused on airborne detection – so, as Ebola is not an airborne threat, nothing I did was directly applicable to detecting it in the environment.) Our goal was to detect trace amounts of hazardous material from a distance so that people could be warned of the threat and take measures to avoid exposure [2]. I can’t recall how many R&D proposals I wrote which started off, “The primary tenet of nuclear, chemical, and biological defense is contamination avoidance…” but it was more than a few. At the risk of stating the obvious, exposed chemical and biological agents can be lethal. I never had occasion to work with actual biological agents but I did on one occasion work with actual chemical agents [3]. (The possibility of a rapid and extremely unpleasant death if you screw up definitely keeps one focused on the job at hand.) When working with chemical agents, and hazardous materials in general, you never do anything before donning PPE, setting up the decontamination station, and making sure that the decon station is properly staffed. Everyone doing work in the hot zone gets a safety briefing and training on how to use their PPE. Everyone takes a test to establish that they know how to use their PPE. If you don’t pass then you don’t work. (Safety briefing and training probably amount to half a day.) Good protocol and good preparation are key to safety.
While I only had modest involvement with biological agent detection, I did have occasion to review safety protocols for working with bio-agents. Ebola is a Biosafety Level 4 (BSL-4) material. There are PPE standards and decon protocols for working in a BSL-4 lab – see, e.g., here. It doesn’t take a trained professional to notice that the practices in place at Texas Presbyterian were nowhere near meeting recommended practice. One of the things that concerns me is that if there were a large-scale outbreak then the (deficient) processes used at Texas Presbyterian would probably be typical of most hospitals – although perhaps less likely of that happening now after so much publicity. I trust people who’ve been trained to work with BSL-4 materials to implement good practices – but few people have been trained to work with BSL-4 materials. It would be prudent to get more people – health workers, in particular – trained up.
Think good thoughts for Nina Pham and Amber Vinson.
Notes:
- In addition, I was also a member of the Emergency Response Team at work. We received HazMat training and drilled multiple times a year to prepare us for dealing with spills of hazardous industrial chemicals. (Fortunately, we never had to do so.)
- When people asked me what I did I’d often say “environmental quality monitoring.”
- We typically worked with surrogates for the actual agents. The surrogate materials were reasonably good mimics for the real thing in terms of developing detection equipment and were far less hazardous.
UPDATE #1 10/18/2014: New info via the NY Times, “Controls Poor in Dallas, Nurse Says“:
A nurse who observed and participated in the care of Ebola patients at Texas Health Presbyterian Hospital spoke out publicly on Thursday about what she characterized as inadequate training and infection control there.
The nurse, Briana Aguirre, 30, who has worked at the hospital for three years, said in an interview that when Thomas Eric Duncan arrived at the emergency room on Sept. 28, it took at least three hours to place him in isolation, despite suspicions that he had contracted the deadly virus. Mr. Duncan had visited the emergency room three days earlier with a fever and other symptoms, as well as a history of recent travel from West Africa, but was sent home with antibiotics after being misdiagnosed.
Ms. Aguirre described a confused and chaotic scene when he returned. “A lot of questions unanswered, staff not knowing exactly what to do, mishandling things,” she said.
The doctor handling the case, whom Ms. Aguirre would not name, waited hours to call the Centers for Disease Control and Prevention for guidance, she said….
Ms. Aguirre said she and other nurses were “horrified” at the protocols used to care for Ms. Pham. She said they received instruction only once about the proper use of personal protective equipment — gloves, masks, gowns, hoods and shields — before entering Ms. Pham’s room, and then were shown how to remove the potentially contaminated gear while in the room. The garb left a triangle of skin exposed on the front of her neck….
“The very first time I was being instructed to put the stuff on I immediately voiced my concerns,” Ms. Aguirre said. “Why would I be wearing two pairs of gloves, three pairs of bootees, have my entire body covered in plastic, have two hoods on and have an area so close to my mouth and my nose exposed? And they said, ‘We know, we’ve addressed it and basically our verdict on that at this time is we’re taping that area closed.’ ”
She said the hospital had offered a single, voluntary session on treating Ebola patients a month or two before Mr. Duncan’s arrival. “There were some fliers stuck up in our break room saying they were having a seminar to discuss some facts about Ebola,” Ms. Aguirre said. “I didn’t go. I had a friend who said it was good information, very interesting, but it was not hands-on. It was just a lecture.”
Pretty much confirms that training, PPE, and decon were inadequate.
UPDATE #2 10/18/2014:
When I heard yesterday that Pres. Obama would be appointing an Ebola Czar I thought, “Ebola preparedness and response seems like something the CDC Director should be responsible for but, okay, maybe he’s already got a full plate and he hasn’t exactly done a bang up job to this point. Perhaps appointing an Ebola Czar makes sense? Say someone with a background in public health or infectious disease? It could be constructive to bring in an experienced professional whose sole focus is to coordinate government efforts and, more significantly, ensure that what the govt does makes sense.” Yeah. That would make/would have made sense. Unfortunately, instead of an experienced public health administrator or infectious disease specialist we get a political operative. [Facepalm] Which sign of the Apocalypse is it when Sen. Ted Cruz says something that, for the most part, makes sense?