CDC rethinking Ebola guidelines after criticism they left nurses unprotected

Some hospitals considered group’s safety recommendations flimsy

Now that at least two Dallas nurses who cared for Ebola patient Thomas Eric Duncan have themselves been diagnosed with the virus, the Centers for Disease Control and Prevention is facing criticism that its initial recommendations to health care workers to protect themselves was inadequate.

The day after Duncan was diagnosed with Ebola, CDC Director Thomas Frieden told the public that it’s “easy” to prevent the spread of the disease if a person uses “gloves and barrier precautions,” because the only way to contract the virus is if an infected person’s body fluids enter the mucous membranes or an open wound of another person. He said health care workers at Texas Health Presbyterian Hospital in Dallas were taking “all of the precautions they need” to prevent infection.

Since then, Duncan has died and two of the nurses at Texas Health Presbyterian who cared for him have tested positive for the disease. On Wednesday, Texas officials admitted that more of the 76 hospital workers who had contact with Duncan could be next.

The disease’s spread suggests that the CDC underestimated how hard it is for doctors and nurses to care for Ebola sufferers without infecting themselves. It also raises questions about the guidance the agency gave to hospitals to protect their workers. The CDC made the gear recommendations more stringent this week, and also announced that from now on it would fly a team of infectious disease specialists to train staff at any hospital that receives an Ebola patient.

Frieden faced pointed questioning on Thursday afternoon from Congress at a hearing on the response. Rep. Michael Burgess, R-Texas, flashed a photo of Frieden visiting patients in West Africa, where he is shown completely covered in a yellow hazmat suit, and asked him why he would recommend less equipment for healthcare workers at home.

“The special type of personal protective equipment to be used is not simple and there’s no single right answer,” Frieden said. “The use of different types of protective equipment is obviously something we’re looking at very intensely now in Dallas.”

The CDC is also investigating the “breach of protocol” that Frieden says must have taken place for the infection to spread through the nurses’ protective gear. Both nurses are being moved from Texas Health Presbyterian—one to Emory University Hospital in Atlanta, Georgia and the other to an NIH isolation unit in Bethesda, Maryland. The two hospitals are among four in the country that have special biocontainment units for infectious diseases.

The CDC’s guidance for putting on and taking off gear, as well as the amount of gear, was seen by some epidemiologists as inadequate to prepare for the fatal virus. The agency had stressed that workers needed only an impermeable gown, a single pair of gloves, a face mask and goggles to safely treat patients. Earlier this week, Frieden announced the agency was immediately changing some of its recommendations, ordering health care workers treating Ebola patients to wear hoods that cover their necks and two pairs of gloves instead of just one.

Staff who originally treated Duncan did not have hoods covering their necks or leg coverings, because the CDC did not recommend them, Texas Health Presbyterian said on Thursday. They later wore full hazmat suits. A national nurses’ union said the nurses were not properly trained in how to take off their equipment without infecting themselves. On Thursday, the hospital’s chief clinical officer said the staff had not run an Ebola training exercise before Duncan arrived, and he apologized for the lapses in care.

Hospitals with biocontainment units that have safely treated Ebola patients in the U.S., as well as Doctors Without Borders staff fighting the virus in West Africa, have long recommended staff be fully covered. Emory University Hospital in Atlanta and Nebraska Medical Center in Omaha have treated Ebola patients without any healthcare workers contracting the illness so far. Their staffers are fully covered when they treat patients, with a hood and multiple pairs of gloves.

Some infectious disease leaders at other hospitals decided weeks ago to model their Ebola response on Nebraska and Emory, instead of on the CDC’s recommendations.

“We realized as we went forward that CDC recommendations were not adequate,” said Glen Mayhall, director of Infection Control and Hospital Epidemiology at the University of Texas Medical Branch in Galveston, Texas.

UTMB directs employees to wear three pairs of gloves, a hood and gowns that cover the legs and feet, in the event that the hospital were to care for an Ebola patient. Mayhall designed its protocol after Nebraska’s—doctors there wear three pairs of gloves and have their necks completely covered. UTMB also uses Nebraska’s procedures for taking on and pulling off the gear, which are repeatedly drilled into employees. Frieden has criticized the use of more than two pairs of gloves as potentially cumbersome, saying it could increase the risk of infection.

Dr. Abdul Memon, Jackson Health System’s chief medical officer for disaster and emergency preparedness in Miami, Florida, said his Ebola protocol involves full-body suits and a hood that covers the neck, in response to concerns from his doctors that a gown and mask were not enough protection.

Globally, more than 400 healthcare workers have contracted the virus while treating patients—and 200 of them have died. In the Annals of Internal Medicine, three physicians and infectious disease specialists wrote that the complications around correctly taking off personal protective equipment (PPE) like gloves, gowns and masks spread the infection to these workers. Studies have shown that nurses and physicians contaminate themselves around 10 percent of the time when taking off gloves that have fluid on them. If the nurse or doctor then touched his or her eye, Ebola could spread. The specialists recommend a single person supervise the taking off process every single time a physician or nurse treats an Ebola patient, so that they don’t infect themselves with their own protective equipment.

Another hole in the CDC’s guidance for putting on and removing the gear is that healthcare workers are told to take off their single pair of gloves, then take off their gown, mask and goggles. This raises the chance that a nurse’s bare hands could be contaminated, for example, by fluid on her gown, and she could inadvertently touch her face before washing her hands. Many hospitals, including the University of Texas Southwestern in Dallas, recommend that workers wear two pairs of gloves, and remove the inner pair after they’ve taken off all the other gear. Doctors Without Borders also uses a similar process, according to spokesman Tim Shenk, who stressed he was not comparing his group’s protocol to what happened at Dallas. The group's doctors also wash their gloves multiple times in a chlorine solution before removing them.

The CDC said it could not comment on what specific parts of its suggested protocol it's reconsidering, because it’s still reviewing them. The group says it will deploy a team of infectious disease specialists to assist hospitals with Ebola patients from now on to train staff in how to don and doff protective gear.

“We’re currently taking a hard look at our recommendations and may be making changes,” said CDC spokeswoman Melissa Brower.

Earlier this week, Frieden acknowledged the challenges in treating this disease. “We want to make sure that when patients are cared for, they're cared for safely,” Frieden said. “I think the events in Dallas this week really reiterate how hard it is to do that.  Care for a patient with Ebola requires meticulous attention to detail, and we're looking at every aspect to see how we can make it safer and easier.“

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