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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