CDC Statement: Investigating Additional Potential Ebola Exposures To American Citizens In West Africa

 

 

# 9828

 

Yesterday, in NIH Statement On Arrival Of American HCW With Ebola Virus For Treatment, we looked at the evacuation of an American HCW  - infected with Ebola – from Sierra Leone to the NIH hospital in Bethesda, Md.

Late yesterday the CDC announced they are investigating this HCWs exposure, with an eye cast towards others who may have been exposed at the same time.

 

A second HCW, who was exposed (but has not tested positive for the virus) is being flown to Emory University Medical Center in Georgia.   First the CDC’s statement, after which I’ll return with a bit more:

 

 

CDC investigating potential exposures of American citizens to Ebola in West Africa

 

For Immediate Release: Friday, March 13, 2015
Contact: CDC Media Relations
404-639-3286

On March 13, an American volunteer healthcare worker in Sierra Leone who tested positive for Ebola virus returned to the U.S. by medevac and was admitted to the NIH Clinical Center for care and treatment.  As a result of this case, CDC is conducting an investigation of individuals in Sierra Leone, including several other American citizens, who may have had potential exposure to this index patient or exposures similar to those that resulted in the infection of the index patient.  At this time, none of these individuals have tested positive for Ebola. These individuals are volunteers in the Ebola response and are currently being monitored in Sierra Leone.  Out of an abundance of caution, CDC and the State Department are developing contingency plans for returning those Americans with potential exposure to the U.S. by non-commercial air transport. Those individuals will voluntarily self-isolate and be under direct active monitoring for the 21-day incubation period.

One of these American citizens had potential exposure to the individual being treated at NIH and is currently being transported via charter to the Atlanta area to be close to Emory University Hospital. The individual has not shown symptoms of Ebola and has not been diagnosed with Ebola. Upon arrival in Atlanta, the individual will voluntarily self-isolate and be under direct active monitoring for the 21-day incubation period

 

 

Although the Ebola outbreak in Liberia in West Africa has significantly improved, Sierra Leone and Guinea continue to report dozens of cases each week.   Liberia, amazingly has gone two weeks with reporting a new case, and overall, the number of new cases in the latest reporting week is down about 80% over the peak we were seeing last fall.

Some excerpts from The World Health Organization’s latest Ebola Situation Report (11 March 2015) follow:

SUMMARY

• A total of 116 new confirmed cases of Ebola virus disease (EVD) were reported in the week to 8 March, compared with 132 the previous week. Liberia reported no new confirmed cases for the second consecutive week. New cases in Guinea and Sierra Leone occurred in a geographically contiguous arc around the coastal capital cities of Conakry and Freetown, with a total of 11 districts reporting cases. Although there has been no significant decline in overall case incidence since late January, the recent contraction in the geographical distribution of cases is a positive development, enabling response efforts to be focused on a smaller area.
• Guinea reported 58 new confirmed cases in the week to 8 March, compared with 51 cases the previous week. Cases were clustered in an area around and including the capital Conakry (13 cases), with the nearby prefectures of Boffa (2 cases), Coyah (8 cases), Dubreka (5 cases), Forecariah (28 cases), and Kindia (2 cases) the only other prefectures to report cases.
• Sierra Leone reported 58 new confirmed cases in the week to 8 March; the first time since June 2014 that weekly incidence has not exceeded that of Guinea. Cases were reported from 5 north and western districts clustered around the capital Freetown, which reported 27 new confirmed cases. The neighbouring districts of Bombali (6 cases), Kambia (7 cases), Port Loko (12 cases) and Western Rural (6 cases) also reported cases.
• In the 4 days to 5 March there were 90 reported suspected cases in Liberia, none of whom tested positive for EVD, indicating that vigilance is being maintained. A total of 102 contacts were being followed up.
• The number of confirmed EVD deaths occurring in the community has risen for the past 3 weeks in Guinea, suggesting that there are still significant challenges in terms of contact tracing and community engagement. Of a total of 40 EVD-positive deaths reported in the week to 8 March, 24 occurred in the community. By contrast, a far smaller proportion of EVD-positive deaths occurred in the community in Sierra Leone: 11 of 83. A total of 13 unsafe burials were reported from Guinea and 2 from Sierra Leone over the same period.
• In the week to 1 March, 7 of 51 (14%) confirmed cases of EVD reported from Guinea arose among known contacts of previous cases, indicating that there are a large number of untraced contacts associated with known chains of transmission, and that unknown chains of transmission persist. In Sierra Leone, by contrast, 52 of 81 (64%) of confirmed EVD cases arose among known contacts over the same period. The average daily number of contacts traced in the week to 8 March was 1433 in Guinea, compared with 7934 in Sierra Leone.
• The relatively low proportion of cases arising among known contacts, the relatively high proportion of EVD-positive deaths that occur in the community, and the continued occurrence of unsafe burials in Guinea are all indicative of continued difficulties engaging effectively with affected communities. A total of 7 Guinean prefectures reported at least one security incident in the week to 8 March.
• During the week to 1 March, five cross-border meetings took place, including a coordination meeting in Kambia and Forecariah to facilitate communication, share best practices, and align strategies.
• In the week to 8 March, 1 new health worker infection was reported in Guinea, bringing the total number of health worker infections reported across the three most-affected countries since the start of the outbreak to 840, with 491 deaths.

Referral: VDU On MERS In HCWs

Credit Dr. Ian Mackay VDU Blog 

 

# 9584

 

 

Dr. Ian Mackay has a new post up today that looks at the unusually high number of Health Care Workers infected with the MERS coronavirus over the past three years. 

 

As he points out, HCWs are considered `canaries’ in the coalmine, and when those who are supposed to be taking special care not to get infected continue to fall prey to the virus, it is considered a potential red flag.

Along with his patented graphics, Ian provides some excellent commentary the shedding for 42 days of the virus by an infected, but asymptomatic nurse, and how that might help explain some of the community infections for which there is no obvious exposure.

 

Follow the link to read:

 

 

MERS-CoV snapdate on canaries...

MERS-CoV detections among healthcare workers (HCWs)

HCWs are akin to the canary in the coal mine - when HCWs get sick with a particular bug, this can signal that the bug may well be more active in the the wider community.

(Continue . . . )

Webcast Of HCW Ebola Training Session Today – 10 am EDT

 

 

# 9227

 

The first tenet of the CDC’s updated Interim Guidance for HCWS on working with Ebola patients stresses the importance of taking training prior to encountering an Ebola patient:

1. Prior to working with Ebola patients, all healthcare workers involved in the care of Ebola patients must have received repeated training and have demonstrated competency in performing all Ebola-related infection control practices and procedures, and specifically in donning/doffing proper PPE.

With 5,000 hospitals around the nation, and thousands more clinics and healthcare settings, getting this training out to millions of healthcare workers in short order is a major task.  Fortunately, with the internet, training sessions can be shared with thousands of people at a time. 

Today one of those trainings sessions will be webcast live.

 

GNYHA/1199SEIU HEP and PQC to Host Ebola Educational Session October 21

On October 21, 2014, the GNYHA/1199SEIU Healthcare Education Project (HEP) and the Partnership for Quality Care (PQC) will host an Ebola educational session for health care workers-both clinical and non-clinical-at the Javits Center in New York City. The PQC is a national organization of health care providers and health care workers modeled in part after HEP.

The entire GNYHA family is invited to attend this extremely important event, including non-union institutions, institutions with non-1199SEIU unions (Civil Service Employees Association, DC-37, New York State Nurses Association, United Federation of Teachers, etc.), and our New Jersey, Connecticut, and Rhode Island members.

Speakers will include New York City Department of Health and Mental Hygiene Commissioner Mary Bassett, MD, MPH; New York State Department of Health Acting Commissioner Howard Zucker, MD, JD; and infection control experts from CDC and GNYHA member hospitals. There will also be a hands-on demonstration of wearing and removing personal protective equipment.

Visit the GNYHA calendar to register for the October 21 Ebola Educational Session.

UPDATE: The October 21 Ebola Educational Session, hosted by the GNYHA/1199SEIU Healthcare Education Project, and the Partnership for Quality Care is available to live stream on the GNYHA website. The event will begin at 10am EST.

Click here to watch the live stream. 

CDC Guidance: Initial Steps In Caring For A Suspected Ebola Patient

Credit FEMA

 

# 9220

 

Given the current concerns over the possibility of having another Ebola patient walk into a hospital Emergency room, Clinic, or Doctor’s office the CDC has been working on various types of guidance, and we expect updated advice on PPEs to be released in the next few days (see NIH: `More Stringent’ PPE Standards For Ebola On The Way).

 

While clinicians have been asked to be alert for the signs of Ebola in anyone with recent travel history to West Africa, there hasn’t been a set of coordinated guidelines telling healthcare workers what to do next.

 

Yesterday, in an attempt to provide some `first steps’  for front line workers confronted with a possible Ebola patient, the CDC released the following infographic and advice, outlining what steps `should’ and `should not’ be done for a patient under investigation (PUI) for Ebola.

 

 

Could it be Ebola?[PDF - 1 page]

 

When Caring for Suspect or Confirmed Patients with Ebola

 What SHOULD be done for a patient under investigation (PUI) for Ebola virus disease?

1. Activate the hospital preparedness plan for Ebola, which should include
   1. Initiate the notification plan for suspect or confirmed Ebola patient immediately.
   2. Ensure hospital infection control is notified.
   3. Create a clinical care team led by a senior level experienced clinician that includes at a minimum a hospital infection control specialist, a senior nurse, an infectious disease specialist, and critical care consultants.
   4. Assign a senior staff member from the clinical care team to coordinate testing and reporting of results from the hospital laboratory, state health department laboratory, CDC, and local and state public health. For a list of state and local health department phone numbers, see http://www.cdc.gov/vhf/ebola/outbreaks/state-local-health-department-contacts.html.
2. Isolate the patient in a separate room with a private bathroom.
3. Ensure a standardized protocol is in place for how and where to remove and dispose of personal protective equipment (PPE) properly and that this information is posted in the patient care area.
4. When interviewing the patient, collect data on:
   1. Earliest date of symptom onset and the sequence of sign/symptom development preceding presentation to an emergency department.
   2. Detailed and precise travel history (e.g., dates, times, locations).
   3. Names of any persons with whom the patient may have had contact during and any time after the earliest date of symptom onset.
5. Consider and evaluate for all potential alternative diagnoses (e.g. malaria, typhoid fever).
6. Reassure patient and family that appropriate care will be provided.
7. Ensure patient has the ability to communicate with family.

What SHOULD NOT be done for a patient under investigation for Ebola virus disease?

1. Don’t have any physical contact with the patient (e.g., perform examination, collect clinical samples, position for x-rays) without first putting on appropriate PPE and using recommended infection control practices necessary to prevent Ebola virus transmission.
2. Don’t neglect the patient’s medical needs; assess and treat patient’s other medical conditions as indicated (e.g., diabetes, hypertension).
3. Don’t forget to evaluate for all potential alternative diagnoses (e.g. malaria, typhoid fever).
4. Don’t perform elective tests or procedures; minimize sample collection, laboratory testing, and diagnostic imaging (e.g., blood draws, X-rays) to those procedures necessary to provide acute care.
5. Don’t allow family members to visit without putting on appropriate PPE; provide a telephone for family to communicate with patient.

Don’t judge or snub the patient; maintain a professional and compassionate atmosphere.

General Information

• Ebola virus disease Information for Clinicians in U.S. Healthcare Settings
• Safe Management of Patients with Ebola Virus Disease (EVD) in U.S. Hospitals

Statement: WHO-Deployed Health Worker Tests Positive For Ebola

Credit CDC PHIL

 

 

# 8994

 

Although proper PPEs and stringent infection control protocols have been shown to protect Health care workers during this – and previous – Ebola outbreaks there is no denying that there still remains some risk of infection – particularly on the ground in Africa where facilities are not always optimal.

Today the World Health Organization has announced the first instance of one of their deployed personnel being infected with the Ebola virus. 

 

The following comes from an emailed press statement.  It will likely be posted on this webpage on the WHO site later today.

 

WHO-DEPLOYED HEALTH WORKER RECEIVING CARE AFTER TESTING POSITIVE FOR EBOLA

24 August 2014

WHO is working to ensure an international health worker who is deployed for the Organization in Sierra Leone and has contracted Ebola receives the best care possible including the option of medical evacuation to another care facility if necessary.

International health workers are an important part of this Ebola response.  Even before the Ebola outbreak began, after years of conflict, the area of West Africa most affected by this disease suffered from a weakened and fragile health system with a shortage of health workers. Surge capacity of international health experts is essential to supplement the work of the local frontline workers in this response.

Since the beginning of the international response to the outbreak in March, WHO has deployed nearly 400 people from across the Organization and from partners in the Global Outbreak Alert and Response Network (GOARN) to help respond to the disease in Guinea, Liberia, Nigeria and Sierra Leone.  This is the first time someone working under the aegis of WHO has fallen ill with the disease. 

The Ebola virus is spread through contact with bodily fluids and people giving care or working around infected patients are known to be a high risk group. In the past six months of the outbreak, more than 225 health workers have fallen ill and nearly 130 have lost their lives to the disease they were working to contain.

WHO recognizes there is a risk for health workers who work around Ebola and takes many precautions before they deploy to help them protect themselves in the field. Once there, the Organization ensures those workers have access to appropriate medical advice and support.

NPPTL N95 Day Webinar: Respirator Preparedness in Healthcare

 

# 8973

 

 

A follow up to yesterday’s post (CDC Guidance: Donning & Removing PPEs), two weeks from this coming Friday (Sept 5th), NIOSH and NPPTL (The National Personal Protective Technology Laboratory) will hold a webinar designed for Health care workers on Respirator Preparedness as part of their annual  N95 day promotion.

 

For details on how to register (attendance is limited), and for more on other N95 day activities, here are some excerpts from the N95 day webpage:

 

Coming Soon! The NIOSH-Approved Holiday, N95 Day!

N95 Day is a time to recognize the importance of respiratory protection in the workplace and familiarize yourself with the resources available to help you make educated decisions when selecting and wearing a respirator.

NIOSH Twitter Chat

NIOSH respiratory protection experts are practicing their words per minute typing speed! This forum is an opportunity to ask all your N95 respirator questions. @NIOSH and @NPPTL will focus on best practices when using N95 respirators. This is a non-industry specific chat, so we hope to hear from representatives across all types of N95-using workplaces.

Join us at 2:00 p.m. EST. We will be using the hashtag: #N95Chat for this Twitter chat. The best way to tune into this chat is by typing #N95Chat into your Twitter search box. Leading the discussion will be the Director of the NIOSH National Personal Protective Technology Laboratory, Dr. Maryann D’Alessandro.

Webinar

This year, the NIOSH National Personal Protective Technology Laboratory, the Total Worker Health group, and the Health Effects Laboratory Division are teaming up to focus on an important message that every N95 user and respiratory protection program administrator should always keep in mind– respirator preparedness is about proper practices every day. This N95 Day webinar will focus specifically on the healthcare industry. A panel of three NIOSH experts will talk about their individual research involving N95 respirators and how that research is important to respiratory protection programs and, ultimately, the N95 users in healthcare.

For more detailed information and to register, go to our N95 Day 2014 Webinar page: Respirator Preparedness in Healthcare: Where Technology Meets Good Practices

As a refresher, check out the N95 Day articles on the NIOSH Blog from the last two years. These blog posts highlight the spirit of the day, encouraging users everywhere to familiarize themselves with the N95 literature and guidelines available from NIOSH:

N95 Day 2012: http://blogs.cdc.gov/niosh-science-blog/2012/09/05/n95day/

N95 Day 2013: http://blogs.cdc.gov/niosh-science-blog/2013/09/05/n95-day-2013/

We hope respirator users will look forward to the festivities as we tout our N95 resources through the channels of Facebook, Twitter, and the NIOSH blog once again. To take part in the day, mark N95 Day on your calendar for September 5th and keep an eye on your social media.

Follow us @NPPTL and @NIOSH on twitter (#N95Day) and as well as on the NIOSH facebook page.

 

 

As September is also National Preparedness Month, it is worth mentioning that having a box of N95 respirators tucked away in you disaster kit isn’t such a bad idea.

 

Of course, having a stash of N95s isn’t enough. You need to be fit tested, and learn how to don them, and take them off (see Survival Of The Fit-tested).

 

For more on the differences between N95 and surgical masks, particularly when dealing with infectious diseases, you may wish to look a a blog I wrote last summer,  called The Great Mask Debate Revisited.

Nigeria: 10th Ebola Case Confirmed

 

 

# 8937

 

The tragedy of healthcare workers exposed to Ebola continues to evolve in Nigeria as that country reports their 10th positive case – all apparently as a result of  contact with the index case, a Liberian named Patrick Sawyer who fell ill while flying to Lagos 22 days ago. 

 

Media reports suggest he told HCWs he had malaria, and became both erratic and combative when he was told he might have Ebola, thereby exposing more to the virus. 

 

Whatever the circumstances (and Caveat Lector should be the rule when dealing with media reports) – the end result has been the infection of at least 9 additional people – with more either suspected or under observation. First a brief update from Reuters, then I’ll have a bit more.

 

Nigeria's Lagos now has 10 Ebola cases: health minister

ABUJA Mon Aug 11, 2014 3:18pm IST

(Reuters) - Nigeria's Lagos has 10 confirmed cases of Ebola, up from seven at the last count, although only two so far have died, including the Liberian who brought the virus in, the health minister said on Monday.

All were people who had had primary contact with Patrick Sawyer, who collapsed on arrival at Lagos airport on July 25th and later died, Health Minister Onyebuchi Chukwu told a news conference.

 

For those wondering why the number is now 10, when the World Health Organization and the media were reporting 13 cases on Friday – the answer is simple;  Friday’s number was a combination of suspected, probable, and confirmed cases.

From WHO GAR update August 8th

 

While there are many who were alarmed last week by the deliberate importation to a high containment facility at Emory University Hospital of two Ebola positive patients, the events in Nigeria show the bigger risk to health care workers comes from having direct contact with someone they don’t know is infected.

 

Previously, the R0 or Basic Reproductive Number for Ebola has been calculated as being under 2.0. Essentially, the number of new cases in a susceptible population likely to arise from a single infection.

 

The basic reproductive number of Ebola and the effects of public health measures: the cases of Congo and Uganda.

Chowell G¹, Hengartner NW, Castillo-Chavez C, Fenimore PW, Hyman JM.

Abstract

Despite improved control measures, Ebola remains a serious public health risk in African regions where recurrent outbreaks have been observed since the initial epidemic in 1976. Using epidemic modeling and data from two well-documented Ebola outbreaks (Congo 1995 and Uganda 2000), we estimate the number of secondary cases generated by an index case in the absence of control interventions R0. Our estimate of R0 is 1.83 (SD 0.06) for Congo (1995) and 1.34 (SD 0.03) for Uganda (2000).

 

Making the number of secondary cases reported in Nigeria from a single case unusually high, although you cannot extrapolate the R0 off a single  transmission event.  

 

Each link in the chain of transmission is different, and the R0 is only an `average’ over time.

 

During the SARS outbreak of 2003 (a much more contagious respiratory virus), studies found most infected persons would only infect 1 or perhaps 2 additional people, and sometimes none.  But a small percentage of those infected were far more efficient in spreading the disease, with some responsible for 10 or more secondary infections.

 

This super spreader phenomenon gave rise to the 20/80 rule, that 20% of the cases were responsible for 80% of the transmission of the virus (see 2011 IJID study Super-spreaders in infectious diseases).

 

While it might be tempting to ascribe the aggressive spread to HCWs in Nigeria to Sawyer being a `super spreader’, that isn’t the only credible explanation.

 

As any healthcare worker will tell you, trying to restrain or `take down’ a combative – sometimes irrational  - patient is one of the most dreaded, and dangerous things they may be called upon to do.

 

The risk of physical injury to the HCW, and to the patient, is greatly increased, as are the risks of exposure to blood or other body fluids.  Protective gear – if worn – can be quickly damaged or compromised .

 

And since Healthcare workers are limited as to how much force they can ethically use to restrain a patient – a constraint not usually honored by the  patient – it often requires 3, 4, 5 or even more people to subdue someone without injuring them.

This may help explain, at least in part, how so many HCWs have become infected from exposure to a single Ebola case. 

 

I would note that there are media reports (see Nigerians beg Obama to give Lagos nurse vaccine) that at least one of the Nigerian nurses infected did not participate in restraining Sawyer, but did perform routine nursing duties (taking vitals, feeding the patient, etc.) and touched some of the same surfaces as the patient.

 

What PPEs she may have employed while performing these duties, and the veracity of these media reports, isn’t abundantly clear. 

A detailed epidemiological investigation into the chain of transmission in Nigeria ought to give us a better idea of exactly what happened there. Where infection control procedures broke down, whether Sawyer was a `super-spreader’, or if the staff was simply blindsided by combination of bad luck and timing.

 

Hopefully that investigation is underway, and the results will be forthcoming sooner rather than later.

CIDRAP Commentary: Protecting HCWs From MERS-CoV

Credit CDC

 

 

# 8642\

 

One of the harsh lessons of the SARS outbreak of 2003 is that doctors originally underestimated its ability to infect healthcare workers, while at the same time, overestimated the level of protection offered by standard PPEs (personal protective equipment). 

 

As a result, many HCWs were infected by the SARS virus, and a number of them died, including two nurses in Toronto: Nelia Laroza, age 52 - and Tecla Lin, age 58.

 

The Campbell Commission SARS report (2006), a damning account of the failures of hospitals to protect their workers during the 2003 outbreak in Ontario, offers one overriding piece of advice:

 

Most important, the problems include Ontario’s failure to recognize in hospital worker safety the precautionary principle that reasonable action to reduce risk, like the use of a fitted N95 respirator, need not await scientific certainty. – SARS Commission Executive Summary.

 

Today we are faced with a similar situation.

 

MERS, much like SARS, is an emerging coronavirus from a zoonotic source, one that can cause a wide spectrum of illness including severe respiratory distress (and possibly death), and one that has spread most efficiently in a hospital environment.

 

A little over a year ago, in WHO: Interim Infection Control Guidance On nCoV (MERS), we looked at the advice from the World Health Organization on PPEs to be used by HCWs in direct contact with suspected, probable and confirmed MERS-CoV infection:

In addition to Standard Precautions, all  individuals, including visitors and HCWs, when in close contact (within 1 m) or upon entering the room or cubicle of patients with probable or confirmed nCoV infection should always:

• wear a medical mask;
• wear eye protection (i.e. goggles or a face shield);
• wear a clean, non-sterile, long-sleeved gown; and gloves (some procedures may require sterile
  gloves);
• perform hand hygiene before and after contact with the patient and his or her surroundings and
  immediately after removal of PPE.

 

The CDC recommends the use of fit-tested N95 respirators as a minimum level of protection caregivers, but this upgrade in PPEs is only recommended by the WHO for use during `aerosol generating procedures’. 

 

Admittedly, in hospitals located in resource limited nations, even these standards might be very difficult to achieve or maintain.

 

Since then, we’ve seen an explosion of cases in hospitals in Saudi Arabia and the UAE, begging the questions:

 

Are hospitals and employees not fully and consistently implementing the WHO PPE guidelines?

Or are these guidelines simply inadequate to the task of protecting against this virus?

 

Last night CIDRAP published a long, and pointed commentary on this issue, which should be required reading by every hospital administrator, nurse, and doctor who may soon be called upon to deal with the arrival of a MERS case.

 

Not only do the author’s call for an immediate upgrade to the WHO infection control standards for dealing with MERS, they call for upgrades to the CDC’s interim guidance for MERS-CoV infection control as well.

 

You’ll want to take your time reading this thoughtful analysis. After you return, I’ll have a bit more:

 

COMMENTARY: Protecting health workers from airborne MERS-CoV—learning from SARS

Lisa M Brosseau, ScD, and Rachael Jones, PhD|

May 19, 2014

Editor's Note: Today's commentary was submitted to CIDRAP by the authors. Dr Brosseau is a Professor and Dr Jones an Assistant Professor in the School of Public Health, Division of Environmental and Occupational Health Sciences, at the University of Illinois at Chicago.

_____________________________________

Although US and European officials recommend airborne precautions for the routine care of MERS-CoV (Middle East respiratory syndrome coronavirus) patients, the World Health Organization (WHO) does not, and that needs to change.

 

Compelling evidence and prudence dictate higher levels of respiratory protection, and even guidance from the US Centers for Disease Control and Prevention (CDC) falls short. In addition, the example 2 days ago of likely MERS transmission in Indiana after contact in a business setting illustrates that recommendations need to lean toward conservative measures for this unpredictable virus.

(Continue . . .)

 

 

Long time readers of this blog are aware that we’ve discussed N95 respirator use and safety often in the past (see Survival Of The Fit-tested) and the uncertain protective qualities of surgical masks (see The Great Mask Debate Revisited). 

 

Another issue, often revisited, is our finite supply (and likely shortage of) PPEs during any serious pandemic and the likely reluctance of HCWs to work (or worse, their attrition from acquired infection) due to inadequate PPEs.

 

Our Strategic National Stockpile reportedly contains well over 100 million  N95 and surgical masks (see Caught With Our Masks Down), but the demand for PPEs during a serious pandemic would far exceed the available supply.  At one time the HHS estimated the nation would need 30 billion masks (27 billion surgical, 5 Billion N95) to deal with a major pandemic (see Time Magazine A New Pandemic Fear: A Shortage of Surgical Masks).

 

In May of 2008 - in OSHA's Proposed Guidance On Respirators And Facemasks, we looked at their preliminary estimates of mask use by hospital and EMS/First Responders in a single pandemic wave. 

Source DRAFT Workplace Stockpiling of Respirators and Facemask for Pandemic Influenza

 

In 2009 the Minnesota Center for Health Care Ethics and University of Minnesota Center for Bioethics  released draft ethical pandemic guidelines on the rationing of scarce resources, where they estimated their were only enough PPE’s in the state of Minnesota to last 3 weeks into a severe pandemic.

 

This is perceived as being a big enough problem that recently we saw a report from NIOSH: Options To Maximize The Supply of Respirators During A Pandemic.  

As long as MERS remains a rare infection, and no other pandemic virus rises to the forefront, we’ve ample PPEs (at least in developed countries) to deal with the situation.  But should a major pandemic ever erupt, the world would quickly find itself dealing with serious shortages of disposable protective equipment.

 

While we aren’t currently facing a pandemic threat, it is inevitable that we will again someday.

 

Which is why I recommend that everyone’s emergency kit contain at least a few N95 respirators and some surgical facemasks.  Not so much for wearing when outside the home, but for use when caring for a family member at home – whether they have seasonal flu, or something more exotic. 

 

Masks and respirators should not be regarded as perfect protection against infection, and with regards to the more expensive N95s, it takes more than just having a box in your closet (see Survival Of The Fit-tested) to protect you.

 

The bottom line, is that you hope to avail yourself of the (admittedly, limited) protection afforded by facemasks during an emergency, your best bet is to buy any supplies well before you need them.

Media Reporting 8th MERS Case In Jordan

 

 

# 8573

 

Five days ago, in Jordanian News Agency Reports 7th Coronavirus Case – HCW, we learned of a health care worker who was infected with the virus after exposure to a Saudi who sought medical care in Jordan.  Today, several media reports indicate another hospital employee has now tested positive.

 

So far, I’ve seen nothing official appear on the Jordanian MOH site. This report from Al Sharq.

 

Corona goes north and hits again in Jordan

05/05/2014 @ 14:52

 Amman - SPA

A source at the Jordanian Ministry of Health for the discovery of new cases infected with Corona at a hospital in the capital, Amman.

The source explained in a press statement today that the new situation that has been discovered infected with Corona, pointing out that the Jordanian Ministry of Health held an emergency meeting of the committee to discuss the repercussions of the epidemiology of the virus.

This is the eighth case is recorded in Jordan, where Jordanian Ministry of Health last week new cases of laboratory-virus installed Corona for a health cadres in Jordan

 

 

MERS, HCWs, And Infection Control

Credit CDC

 

# 8505

 

 

Although there is a good deal we don’t know about the current outbreaks of MERS-CoV in healthcare settings in both Jeddah, Saudi Arabia and in the UAE, one thing is glaringly obvious: 

 

Healthcare workers are being infected at a disturbing rate.   Somewhere between 20%-25% of all known cases have reportedly been HCWS.

 

A fact that has apparently unnerved some medical staff, as over the past week we’ve seen stories indicating that some doctors, nurses, paramedics and healthcare facilities have refused to treat suspected MERS cases (see  KSA: Red Crescent Orders Ambulances & ERs To Accept MERS Cases). 

 

The CDC’s interim guidance for MERS-CoV infection control is very stringent, and it is based on a number of considerations:

• Suspected high rate of morbidity and mortality among infected patients
• Evidence of limited human-to-human transmission
• Poorly characterized clinical signs and symptoms
• Unknown modes of transmission of MERS-CoV
• Lack of a vaccine and chemoprophylaxis

 

The World Health Organization’s recommended infection control guidelines are not quite as exacting (no doubt due to the wide disparity of resources available among nations), but nonetheless – if consistently observed – ought to provide reasonable protection to HCWs. 

 

For the past couple of months the WHO has included this reminder in every MERS update (bolding mine):

 

Infection prevention and control measures are critical to prevent the possible spread of MERS-CoV in health care facilities. Health-care facilities that provide for patients suspected or confirmed to be infected with MERS-CoV infection should take appropriate measures to decrease the risk of transmission of the virus from an infected patient to other patients, health-care workers and visitors. Health care workers should be educated, trained and refreshed with skills on infection prevention and control.

It is not always possible to identify patients with MERS-CoV early because some have mild or unusual symptoms. For this reason, it is important that health-care workers apply standard precautions consistently with all patients – regardless of their diagnosis – in all work practices all the time.

Droplet precautions should be added to the standard precautions when providing care to all patients with symptoms of acute respiratory infection. Contact precautions and eye protection should be added when caring for probable or confirmed cases of MERS-CoV infection. Airborne precautions should be applied when performing aerosol generating procedures.

 

Last year, when the first MERS HCW infections began to show up, we looked at the history of `sub-optimal’ compliance with infection control protocols, including during the 2009 H1N1 pandemic (see nCoV: PPE Adherence & Infection Control). 

 

Admittedly, PPEs can be hot, uncomfortable, and a considerable bother to put on and take off properly, so lapses in infection control are not uncommon, at least during normal times..

 

The $64 question is why we are seeing so many HCWs infected with the MERS virus when they’ve been repeatedly warned to observe stricter infection control protocols?

While we don’t know, a few possibilities include:

• Recommended infection control practices are not being applied fully and consistently.  (I’ve seen media reports complaining of lack of PPEs in hospitals and ambulances, including this one  h/t Sharon Sanders on FluTrackers)
• Asymptomatic patients or staff are able to transmit the virus (known to happen with influenza, but unproven with MERS and not seen with SARS).
• The virus has become more easily transmittable between humans in recent weeks (always a possibility, but unproven)
• As we’ve seen with some influenza viruses (see PPEs & Transocular Influenza Transmission), the virus can be contracted via the ocular route (possible, but again, unproven). (Note: I’ve seen a lot of pictures of Saudi medical staff wearing surgical masks, but less commonly any eye protection)
• Or, a combination of factors, not necessarily limited to this list.

 

Answers to these, and other pressing questions, can only come from detailed epidemiological investigations into these outbreaks.  Something that, presumably, is being done but whose details have not been publicly released. 

 

SARS – another novel coronavirus that thrived (albeit, briefly) in health care environments  – was brought under control only after hospitals figured out how to prevent its transmission in the workplace. 

 

Which makes figuring out how, and why, this virus seems to be transmitting so well in hospitals a major priority.

 

For those not intimately familiar with the different levels of infection control, the CDC defines `Standard Precautions’ as:

 

 “Standard precautions” are a set of basic steps care providers use to protect their patients and themselves
from infection.  These basic steps include: 

1. Practicing appropriate hand hygiene before and after contact with a patient, after contact with the
   surfaces or objects around the patient, and after removing gloves (if used). 
2. Wearing disposable gloves when the care provider may have contact with blood, feces, urine, or
   any other body fluids.
3. Wearing a gown to prevent contamination of the provider’s clothing with blood or body fluids.
4. Using a face mask, face shield, and/or goggles if splashing of blood or body fluids might occur. 
5. Cleaning of care equipment between patients.  

 

The next layer of infection control is `Droplet Precautions’, which add the requirement of wearing a face mask (surgical mask) anytime when in a room with a person who has a respiratory infection.

These precautions are used in addition to standard precautions listed above.

`Airborne Precautions’ are the most stringent, and add placing the patient in an airborne infection isolation room (AIIR) if available, and the following PPEs:

• Wear a fit-tested N-95 or higher level disposable respirator, if available, when caring for the patient; the respirator should be donned prior to room entry and removed after exiting room
• If substantial spraying of respiratory fluids is anticipated, gloves and gown as well as goggles or face shield should be worn

 

And lastly, the World Health Organization provides these guidance documents on dealing with MERS in the healthcare, and home environment.

 

Technical guidance - infection prevention and control

• Interim guidance for infection prevention and control during health care for probable or confirmed cases of novel coronavirus (nCoV) infection pdf, 164kb 06 May 2013
• Rapid advice note on home care for patients with Middle East respiratory syndrome coronavirus (MERS-CoV) infection presenting with mild symptoms and management of contacts pdf, 133kb  08 August 2013

Dr. Mackay On HCWs & MERS Infection Rates

Credit Dr. Ian Mackay VDU BLog

 

 

 

# 8470

 

One of the `red flags’ we’ve looked for over the years with disease outbreaks like SARS and Avian Flu is the number of Health Care Workers (HCWs) that contract the illness.  While HCWs are far more apt to come in contact with infectious patients during an outbreak, they are also (presumably) following infection control protocols that should help to protect them.

 

I say `Presumably’ because quality of and adherence to these protocols  varies considerably depending on where in the world we look.  In some developing countries, PPEs (Personal Protective Equipment) like disposable masks, gloves, and gowns are often in short supply.

 

But in the Middle East - where MERS has been infecting humans for at least two years - the the Health Care system should be well aware of the threat, and adequately equipped to minimize transmission to the staff. 

 

So it is a bit of a mystery why not only the number, but the rate of HCWs being infected with MERS-CoV, continues to rise.

 

Dr. Ian Mackay provides some illuminating graphics showing this trend, along with some commentary, on his blog this morning:.

 

 

MERS-CoV: Healthcare worker numbers are spiking...

One of several questions I have about MERS just now is whether there are in fact more healthcare worker MERS-CoV-positive cases occurring now compared to previously. It feels like there are.

Overall there are 50 HCWs listed in my database at writing. This is a database I maintain from official (WHO and the various Ministries of Health) data as well as FluTrackers' independent data collection; all of which are publicly available. For those who follow me, you will know that I often complain about the MERS data being incomplete. So take these charts as providing you with a good guide to the situation rather than an official document. You are reading a blog after all.

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SHEA Infection Control Recommendations On HCW Attire

MRSA - Photo Credit CDC PHIL

# 8227

While exotic infectious diseases like bird flu make for fascinating study, in reality you are far more likely to be adversely impacted by an HAI (Hospital Acquired Infection) than you are by  H5N1 or H7N9 right now.  MRSA, Pseudomonas, CRE, NDM-Producing CRKP are just a few of the invasive, and often deadly, bacteria that can spread easily in a healthcare setting.

This oft quoted assessment from the CDC on the burden of Hospital Acquired Infections in the United States is from 2010.

 

A new report from CDC updates previous estimates of healthcare-associated infections. In American hospitals alone, healthcare-associated infections account for an estimated 1.7 million infections and 99,000 associated deaths each year. Of these infections:

• 32 percent of all healthcare-associated infection are urinary tract infections
• 22 percent are surgical site infections
• 15 percent are pneumonia (lung infections)
• 14 percent are bloodstream infections

 

In recent years we’ve looked at a number of infection control programs and policies designed to reduce these infections, including:

Aye, There’s The Rub

Study: Exam Gloves, Dispensers & Bacterial Contamination

NEJM: Targeted vs Universal Decolonization For ICU Patients

 

While hand hygiene and environmental surface cleaning have been at the forefront of the battle against HAIs, a debate over the impact of HCW (health care worker) attire in the spread of infections has raged, largely unresolved for several years.

 

Contaminated lab coats, long sleeves, neckties, and jewelry have all come under scrutiny as potential vectors for bacteria, and we’ve seen attempts by both governmental regulation, and hospital policy, to address these concerns.

 

While `textile transfer’ of bacteria in the healthcare setting makes sense, the scientific evidence linking sleeve cuffs and neckties to actual HAIs is scant, mostly anecdotal, and sometimes even contradictory.

 

In 2011, a study (see The Long And The Short Of It) found no statistical difference between the amount of bacteria of freshly laundered short sleeve uniforms versus infrequently laundered white coats after only 8 hours wear.

 

The argument can still be made, however, that long sleeve cuffs (and neckties) are more likely to come in contact with a series of patients than the fabric of short sleeved shirts.

 

In 2007, Britain’s NHS decided to ban the wearing of long-sleeved white coats, wristwatches, and neckties by healthcare providers in hospital wards. In the United States, the AMA (American Medical Assoc.) considered a “bare below the elbows” dress code during their annual meeting in 2009, but decided the issue needed more study. 

 

Some healthcare facilities – like the Mayo Clinic – have pushed ahead with their own dress codes to address the issue.  

 

In 2011, in Lab Coat Legislation, I reported on attempts by the New York State legislature to enact a  `hygienic dress code for medical professionals’ – one that would  eventually prohibit the wearing of jewelry, wristwatches, neckties, long sleeves, and the iconic white lab coat.

 

Fast forward to 2014, and SHEA (the Society for Healthcare Epidemiology of America) – while acknowledging gaps in our understanding of the role that attire can play in the spread of HAIs -  has released updated recommendations for HCW attire in clinical settings.

 

For Immediate Release: January 20, 2014
Society for Healthcare Epidemiology of America
Contact: Tamara Moore / tmoore@gymr.com/ 202-745-5114
Study contact: Gonzalo Bearman MD, MPH/ gbearman@mcvh-vcu.edu

Infectious Diseases Experts Issue Guidance on Healthcare Personnel Attire

Recommendations to help prevent healthcare-associated infections transmitted through clothing

CHICAGO (January 20, 2014) – New guidance from the Society for Healthcare Epidemiology of America (SHEA) provides recommendations to prevent transmission of healthcare-associated infections through healthcare personnel (HCP) attire in non-operating room settings. The guidance was published online in the February issue of Infection Control and Hospital Epidemiology, the journal of the SHEA, along with a review of patient and healthcare provider perceptions of HCP attire and transmission risk, suggesting professionalism may not be contingent on the traditional white coat.

" studies have demonstrated the clothing of healthcare personnel may have a role in transmission of pathogens, the role of clothing in passing infectious pathogens to patients has not yet been well established," said Gonzalo Bearman, MD, MPH, a lead author of the study and member of SHEA's Guidelines Committee. "This document is an effort to analyze the available data, issue reasonable recommendations, define expert consensus, and describe the need for future studies to close the gaps in knowledge on infection prevention as it relates to HCP attire."

The authors outlined the following practices to be considered by individual facilities:

1. "Bare below the elbows" (BBE): Facilities may consider adopting a BBE approach to inpatient care as a supplemental infection prevention policy; however, an optimal choice of alternate attire, such as scrub uniforms or other short sleeved personal attire, remains undefined. BBE is defined as wearing of short sleeves and no wristwatch, jewelry, or ties during clinical practice.
2. White Coats: Facilities that mandate or strongly recommend use of a white coat for professional appearance should institute one or more of the following measures:
   1. HCP should have two or more white coats available and have access to a convenient and economical means to launder white coats (e.g. on site institution provided laundering at no cost or low cost).
   2. Institutions should provide coat hooks that would allow HCP to remove their white coat prior to contact with patients or a patient's immediate environment.
3. Laundering:
   1. Frequency: Optimally, any apparel worn at the bedside that comes in contact with the patient or patient environment should be laundered after daily use.
   2. Home laundering: If HCPs launder apparel at home, a hot water wash cycle (ideally with bleach) followed by a cycle in the dryer or ironing has been shown to eliminate bacteria.
4. HCP footwear: All footwear should have closed toes, low heels, and non-skid soles.
5. Shared equipment including stethoscopes should be cleaned between patients.
6. No general guidance can be made for prohibiting items like lanyards, identification tags and sleeves, cell phones, pagers, and jewelry, but those items that come into direct contact with the patient or environment should be disinfected, replaced, or eliminated.

If implemented, the authors recommend that all practices be voluntary and accompanied by a well-organized communication and education effort directed at both HCP and patients.

In their review of the medical literature, the authors noted that while patients usually prefer formal attire, including a white coat, these preferences had little impact on patient satisfaction and confidence in HCPs. Patients did not tend to perceive the potential infection risks of white coats or other clothing, however when made aware of these risks, patients seemed willing to change their preferences of HCP attire.

The authors developed the recommendations based on limited evidence, theoretical rationale, practical considerations, a survey of SHEA membership and SHEA Research Network, author expert opinion and consensus, and consideration of potential harm where applicable. The SHEA Research Network is a consortium of more than 200 hospitals collaborating on multi-center research projects.

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WHO: UAE Reports New MERS-CoV Case (HCW)

 

Coronavirus – Credit CDC PHIL

 

 

# 8125

 

 

The World Health Organization has just posted a GAR update  (h/t @MackayIM & @HelenBranswell)  with information on a new MERS case in the UAE – a 33 year-old Health Care Worker who was in contact with an earlier confirmed case (see WHO Coronavirus Update – December 22nd) who has since died.

. 

 

This newest case is described as being hospitalized with bilateral pneumonia, acute renal failure and thrombocytopenia on December 28th, and is currently listed in stable, but critical, condition.

 

One of the ongoing concerns over MERS is the relatively high number of hospital (nosocomial) transmissions we continue to see, despite presumed increases in infection control procedures.  Today’s WHO update once again contains a strong reminder for vigilance among medical staff to prevent transmission.

 

 

Middle East respiratory syndrome coronavirus (MERS-CoV) - update

Disease outbreak news

3 January 2014 - On 31 December 2013, WHO has been informed of an additional laboratory-confirmed case of Middle East Respiratory Syndrome coronavirus (MERS-CoV) in United Arab Emirates.

 

The case is a 33 year-old male healthcare worker in Dubai who was in contact with the confirmed MERS-CoV case reported to WHO on 20 December. He developed symptoms on 27 December, and was hospitalized on 28 December with bilateral pneumonia, acute renal failure and thrombocytopenia. The patient has underlying history of bronchial asthma and chronic kidney disease. The case was laboratory confirmed for MERS-CoV on 29 December 2013. The patient is in critical but stable condition.

 

Globally, from September 2012 to date, WHO has been informed of a total of 177 laboratory-confirmed cases of infection with MERS-CoV, including 74 deaths.

 

Based on the current situation and available information, WHO encourages all Member States to continue their surveillance for severe acute respiratory infections (SARI) and to carefully review any unusual patterns.

 

Health care providers are advised to maintain vigilance. Recent travellers returning from the Middle East who develop SARI should be tested for MERS-CoV as advised in the current surveillance recommendations.

 

Patients diagnosed and reported to date have had respiratory disease as their primary illness. Diarrhoea is commonly reported among the patients and severe complications include renal failure and acute respiratory distress syndrome (ARDS) with shock. It is possible that severely immunocompromised patients can present with atypical signs and symptoms.

 

Health care facilities are reminded of the importance of systematic implementation of infection prevention and control (IPC). Health care facilities that provide care for patients suspected or confirmed with MERS-CoV infection should take appropriate measures to decrease the risk of transmission of the virus to other patients, health care workers and visitors.

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Philippines DFA: Filipino Nurse Died Of MERS in Saudi Arabia

 

 

# 7779

 

The story is all over the Filipino press this morning (see here, here & here), all stemming from a press briefing provided today (Sept 17th) by Department of Foreign Affairs (DFA) spokesperson Raul Hernandez, where he announced the death of a Filipino nurse – working in Saudi Arabia – from the MERS coronavirus. 

 

Hernandez also cites another Filipino as being hospitalized with the virus (reportedly acquired in the hospital while receiving dialysis), although a quick check of the DFA website turns up no printed announcement.

 

Trying to match these cases to the barebones reports we get from the Saudi MOH can be risky, but this may well be FluTrackers case #114 - Age 41, health care worker, Riyadh - Saudi Arabia Death reported on September 5th.  As the age of the second Filipino is not provided, I’m unable to hazard a guess as to whether she has been previously reported.

 

Although it may not be connected, you may recall that last week  Prince Sultan Military Medical City in Riyadh issued strenuous denials that a `Saudi nurse’  had died of MERS in their facility (see KUNA: Saudi Hospital Issues MERS Denial).  Since the name of the hospital where these cases occurred is not provided, we’ll have to wait to see if they are one and the same.

 

Here is the coverage of this story from GMA News.

 

DFA confirms first Pinay coronavirus death in Saudi

By MICHAELA DEL CALLAR September 17, 2013 5:48pm

A 41-year-old female Filipino nurse died of MERS coronavirus in Saudi Arabia last month, the Department of Foreign Affairs (DFA) said on Tuesday.

The Filipino, whose identity was not disclosed, is the first reported fatality from the Philippines. She died at a hospital in Riyadh last August 29.

A medical report obtained by the Philippine Embassy says the deceased “tested positive for the coronavirus before her death,” Foreign Affairs spokesman Raul Hernandez told a press briefing.

The hospital’s VIP ward supervisor said prior to her death, the Filipina went to the United States for a vacation on July 13. She returned to Riyadh on July 19 and reported for work on July 21.

In mid-August, she complained of fever and coughing and developed respiratory distress. She was put on a ventilator on Aug. 22.

Two days later, she was diagnosed with severe pneumonia and had to be transferred to the hospital’s Intensive Care Unit.

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New York State’s New HCW Flu Vaccination Policy

Photo Credit – CDC PHIL

 

 

# 7620

 

Four years ago (2009), with the specter of the H1N1 pandemic looming, the state of New York attempted to mandate that all health care workers (HCWs) receive a yearly flu shot.

 

But due to a shortage of pandemic H1N1 vaccine that fall, and vigorous protests (and threats of legal action) by employees, in October of 2009 we saw New York Rescind Mandatory Flu Shots For HCWs.

 

Since that time, the debate over mandatory flu vaccinations for HCWs has raged. While the CDC only recommends the flu shot, many professional medical organizations have adopted policies calling for mandatory vaccination of health care workers.

 

APIC Calls For Mandatory Flu Vaccination For HCWs

AAP: Recommends Mandatory Flu Vaccinations For HCWs

SHEA: Mandatory Vaccination Of Health Care Workers

IDSA Urges Mandatory Flu Vaccinations For Healthcare Workers

 

While many infection control experts see this as a long overdue step in patient and co-worker protection, some HCWs see this as an infringement of their rights to decide what will be injected into their bodies (see HCWs: Refusing To Bare Arms & HCWs: Developing a Different Kind Of Resistance).

 

In July of this year, the CDC reported – after seeing increases in the update of flu vaccines by HCWs over the past few years – that last year (2012-13) saw little improvement over the previous year (see CDC: Uptake Of Flu Vaccine By HCWs).

 

• Available as PDF  [627 KB, 15 pages]

 

In recent years a growing number of medical facilities have implemented mandatory flu vaccination as a condition of employment, including Seattle’s Virginia Mason Medical Center and BJC Healthcare of St. Louis, Missouri  (see here and here).

 

Some states have begun to consider laws requiring HCW immunization, including last October when Rhode Island Adopts New Flu Vaccination Requirements For HCPs.

 

Earlier this month, New York state quietly passed a regulation that would require – once flu season begins – for all health care workers either to be vaccinated against influenza, or `wear a surgical or procedure mask while in areas where patients or residents may be present’.

 

Essentially, this approach allows HCWs with medical or ethical objections to flu vaccination to opt out and elect to wear a surgical facemask during flu season when in close contact with patients.

The entire regulation may be read at this link.

 

Critics point out that we really don’t know just how effective masks are in preventing the transmission of influenza to patients. The assumption is, by helping to contain respiratory secretions, they would help reduce transmission. 

 

But by how much?  No one knows.

 

Of course, flu vaccines aren’t close to being 100% effective either.

 

Most years (see CIDRAP: The Need For `Game Changing’ Flu Vaccines), protection from the flu shot runs under 60% for healthy adults, and probably even less for those over 65 or with weakened immune systems.

 

While admittedly imperfect solutions - given the increased risk to patients of serious illness or death from influenza - reasonable measures that can reduce the spread of the flu in the healthcare environment are increasingly being considered. 

 

Love the idea or hate it – short of an overturn in the courts – the requirement for annual flu vaccinations in HCWs appears to be gaining traction across the country.