Credit CDC
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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.
[PDF - 4.7 MB]
