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Stopping Ebola Requires Commitment and Compliance

10/13/2014 11:39 EDT | Updated 12/13/2014 05:59 EST
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The recent news of yet another American case of Ebola in Dallas is without a doubt concerning. Worse is the realization the patient isn't a member of the public, but a health care worker, a nurse. But what makes this occurrence even more worrisome is the timing; most public health authorities believed they had the situation under control and were well on their way to moving past the unfortunate case of Thomas Eric Duncan.

While the high impact of this particular incident has led to headlines worldwide, the actual occurrence of infection spread in healthcare facilities is common. These events in which either a patient or more rarely, a member of healthcare staff, acquires an illness are known as healthcare associated infections (HAI). Though contracting a disease such as Ebola may be the most prevalent in the headlines, there are a number of different types including the spread of more well-known pathogens such as norovirus, Clostridium difficile and MRSA.

The spread of pathogens in the healthcare environment has been a concern for well over a century. Back in 1863, one of the champions for health care, Florence Nightingale, discussed the inadvertent transmission of 'contagion' and how best to prevent it. Her notes focused on everything from architectural design to ventilation, sanitation and the nature of the furniture inside. All her efforts were designed to maximize chances for recovery and minimized the odds for spread. As she pointed out, there is no such thing as an inevitable infection.

Her pioneering belief drove several other researchers, physicians and public health officials to examine the best ways to prevent spread. Though hospitals were the main focus, the protocols for safety -- known as precautions -- became commonplace in other environments such as schools, ports, and even agricultural facilities.

The process took nearly a century after Nightingale's literary call but by 1970, the general concept of precaution was realized as a set of protocols. Back then, the term was isolation technique but over the coming few decades, the name changed to Isolation Precautions to Universal Precautions to what is now known as Standard Precautions.

The tenets of standard precautions would seem straightforward to Nightingale as they take directly from her notes with added information based on research. Most are based on common sense while others derive from the biological nature of certain infectious agents. As a result, today's practices are far more intensive. They include strict adherence to hand hygiene, access to and knowledge of personal protective equipment (PPE), proper environmental cleaning, and specific protocols for specialized techniques, such as drawing blood, or putting on those 'space suits' (officially known as a positive pressure supplied air protective suits).

In addition to standard precautions, there are other more specific types of isolation protocols for infectious diseases capable of spreading rapidly.

  • For pathogens that can spread environmentally from the body, such as C. difficile, norovirus, and rotavirus, a process called contact precautions are needed. In this way, no part of a healthcare worker's body will come into contact with any bodily fluids.
  • For those respiratory viruses, including SARS, MERS, and avian influenza, workers must prevent contact with any expelled saliva from coughs and sneezes. These are called droplet precautions.
  • For those pathogens capable of transmitting through the air, such as tuberculosis, measles and chickenpox (but not Ebola), there are airborne precautions in which the patient is literally kept in a bubble to ensure no spread is possible.

All these precautions put together make up the core of today's infection prevention and control mandates. They also act as the foundation for the countless hours of education, training and refreshers practiced by every healthcare worker. But some can also be painstaking and difficult to maintain over time. Moreover, when a pathogen requires more than one precaution, the workload can be overwhelming and at times prohibitive.

As such, the most common problems with stopping the spread of infection are due to lapses in compliance, in which the procedures are not followed to the letter. There are many reasons including busy schedules, overwork, lack of access to proper supplies, and a need for recurrent training. All of them are justified in nature and reflect a systematic issue rather than a singular anomaly. Unfortunately, the consequences can be dire both for patients and healthcare workers.

In the context of Ebola, which requires the trifecta of standard, droplet and contact precautions, the burden can be extremely difficult for any healthcare worker. Such seems to be the case in Dallas; a breach of protocol is the stated reason for the HAI. However, when all aspects of infection prevention and control are considered, it would be unfair to actually place the blame on the worker herself. This should have been a team effort and all indications suggest this was not the case.

To stop Ebola, whether in a Dallas hospital or the affected countries in West Africa, what is needed is not only compliance, but also commitment. All healthcare facilities, as well as their regulating authorities and other public health officials should commit to reconnecting to Nightingale's efforts and aim to work to stop the contagion together. While the myriad precautions offer the means to ensure Ebola can be stopped, without the vocation of all involved, the virus will find the breaches and continue to spread.

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  • Ebola is highly infectious and even being in the same room as someone with the disease can put you at risk
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    Not as far as we know. Ebola isn't contagious until symptoms begin, and it spreads through direct contact with the bodily fluids of patients. It is not, from what we know of the science so far, an airborne virus. So contact with the patient's sweat, blood, vomit, feces or semen could cause infection, and the body remains infectious after death. Much of the spread in west Africa has been attributed to the initial distrust of medical staff, leaving many to be treated at home by loved ones, poorly equipped medics catching the disease from patients, and the traditional burial rites involving manually washing of the dead body. From what we know already, you can't catch it from the air, you can't catch it from food, you can't catch it from water.
  • You need to be worried if someone is sneezing or coughing hard
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    Apart from the fact that sneezing and coughing aren't generally thought to be symptoms of Ebola, the disease is not airborne, so unless someone coughed their phlegm directly into your mouth, you wouldn't catch the disease. Though medical staff will take every precaution to avoid coming into contact with the body of an infected person at all costs, with stringent hygiene there should be a way to contain the virus if it reaches the UK.
  • Cancelling all flights from west Africa would stop the spread of Ebola
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    This actually has pretty serious implications. British Airways suspended its four-times-weekly flights to Liberia and Sierra Leone until the end of March, the only direct flight to the region from the UK. In practice, anyone can just change planes somewhere else and get to Britain from Europe, north Africa, or the Middle East. And aid agencies say that flight cancellations are hampering efforts to get the disease under control, they rely on commercial flights to get to the infected regions. Liberia's information minister, Lewis Brown, told the Telegraph this week that BA was putting more people in danger. "We need as many airlines coming in to this region as possible, because the cost of bringing in supplies and aid workers is becoming prohibitive," he told the Telegraph. "There just aren't enough seats on the planes. I can understand BA's initial reaction back in August, but they must remember this is a global fight now, not just a west African one, and we can't just be shut out." Christopher Stokes, director of MSF in Brussels, agreed: “Airlines have shut down many flights and the unintended consequence has been to slow and hamper the relief effort, paradoxically increasing the risk of this epidemic spreading across countries in west Africa first, then potentially elsewhere. We have to stop Ebola at source and this means we have to be able to go there.”
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    The screening process is pretty porous, especially when individuals want to subvert it. Wake up on the morning of your flight, feel a bit hot, and you definitely don't want to be sent to an isolation booth for days and have to miss your flight. Take an ibuprofen and you can lower your temperature enough to get past the scanners. And if you suspect you have Ebola, you might be desperate to leave, seeing how much better the treatment success has been in western nations. And experts have warned that you cannot expect people to be honest about who they have had contact with. Thomas Eric Duncan, the Ebola victim who died in Texas, told officials he had not been in contact with anyone with the disease, but had in fact visited someone in the late stages of the virus, though he said he believed it was malaria. The extra screening that the US implemented since his death probably wouldn't have singled out Duncan when he arrived from hard-hit Liberia last month, because he had no symptoms while travelling.
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    They're not doctors, and it's a monumental task to train 23,500 people who work for the UK Border Agency how to correctly diagnose a complex disease, and spot it in the millions of people who come through British transport hubs. Public Health England has provided UK Border Force with advice on the assessment of an unwell patient on entry to UK, but they can't be expected to check everyone.
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    Just, no.