Healthcare Workers in the Firing Line of Ebola Crisis

Liam Davenport

October 20, 2014

Although the vast majority of the 9000 Ebola cases and more than 4500 deaths are concentrated in West Africa, the disease is spreading, with cases in France, Germany, Norway, Spain, the United Kingdom, and the United States. This makes the current outbreak the largest since the virus was discovered, in 1976, with more cases and deaths than in all the other outbreaks combined.

Healthcare professionals (HCPs) in particular have been affected. It is estimated that more than 425 HCPs have been infected, and 235 have died. According to estimates from the World Health Organization (WHO), the fatality rate is 57% among HCPs, whereas it is 47% in the general population.

"Healthcare workers are Ebola's collateral damage," Håkon Bolkan, head of CapaCare, a nonprofit organization established in 2011 to train community health officers in Sierra Leone to perform life-saving surgeries, is quoted as saying in an article published in Science Daily.

The discrepancy in fatality rates "is a natural occurrence, because healthcare workers are the ones who are dealing with patients infected with Ebola," WHO spokesperson Daniel Epstein is quoted as saying in response.

However, that fatalistic notion is only part of the story. A number of factors have contributed to the high case and fatality rates among HCPs. For example, viral loads of the Zaire virus, which is responsible for the current outbreak, are higher than those seen in strains in previous epidemics.

"That means is that there's more virus in the blood, there's more virus in saliva, there's more virus in urine, there's more virus in any vomit or diarrhea," Jeremy Farrar, MD, director of the Wellcome Trust in the United Kingdom, told BBC Newsnight. "When you have more virus in those bodily fluids, it may be easier to transmit. The way it's transmitted has not changed.... But it may become more infectious if you have contact with those bodily fluids."

Transmission of the virus occurs if broken skin or mucous membranes come into contact with the blood, bodily fluids, or secretions of an infected person, or with contaminated clothing, bed linen, or used needles. With an incubation period of up to 21 days, and patients remaining infectious as long as their blood and bodily fluids contain the virus, the risk for transmission to HCPs is high and ongoing.

Infection Control and Prevention

Recognizing the risks faced by HCPs, the WHO has produced detailed guidance on infection prevention and control to be followed when caring for Ebola patients. They recommend isolating suspected or confirmed cases or, when that is not possible, assigning cases to designated areas separate from other patients.

In addition, the WHO guidance says that, along with standard healthcare precautions, HCPs should apply infection control measures to minimize exposure to infected fluids.

This includes gloves, an impermeable gown, boots or closed shoes with overshoes, and, if within 1 meter of a patient, face protection consisting of a face shield or medical mask and goggles. Hand hygiene should be performed at all possible opportunities, along with safe injection and phlebotomy procedures.

A Fallible System

Although strict observation of these protocols will prevent infection, they are not easy to observe. "The protocol appears to have been designed under the unrealistic assumption that everyone who uses protective gear will navigate the complex process of donning, using, and removing it perfectly every time," John Villasenor, professor of electrical engineering and public policy at the University of California, Los Angeles, wrote in an article published in Forbes.

"And it appears not to recognize the probabilities involved as the number of contacts between health workers and Ebola patients continues to grow," he added. "This is because if you do something once that has a very low probability of a very negative consequence, your risks of harm are low. But if you repeat that activity many times, the laws of probability...will eventually catch up with you."

In practical terms, there are a whole host of ways in which the virus can breach the protocol, as reported by BBC online. With temperatures reaching 40 °C (104 ºF) inside the protective equipment, it is recommended that it is changed every 40 minutes. Although it takes five minutes to put it on, it can take an HCP and a designated "buddy" 15 minutes to take it off.

HCPs are sprayed with chlorine during this process to prevent infection, and any drops on the skin are washed away. However, the eyes, mucous membranes, and any areas of broken skin remain vulnerable.

Furthermore, patients can bleed from their eyes, ears, nose, mouth, and rectum, and diarrhea and vomit can be tainted with blood. The huge infection risk this presents highlights the importance placed by the WHO on rigorous environmental cleaning, the decontamination of surfaces and equipment, the management of soiled linen and waste, and the safe handling of dead bodies or human remains.

Lack of Facilities

These problems are exacerbated by the lack of facilities in the worst-affected countries. According to WHO estimates, 100 extra beds are required in Guinea on top of the existing capacity of 160. In Sierra Leone, another 862 beds are needed in addition to the current 346. Figures are even more dramatic in Liberia, where 2310 beds are needed in addition to the existing supply of 620. This is alongside severe shortages of basics, such as body bags and gloves.

"There is no coincidence Ebola has taken hold in three fragile states — Liberia, Sierra Leone, and Guinea — all battling to overcome the effects of interconnected wars," Ellen Johnson Sirleaf, president of Liberia, said in a open letter.

"In Liberia, our civil war ended only 11 years ago. It destroyed our public infrastructure, crushed our economy, and led to an exodus of educated professionals. A country that had some 3000 qualified doctors at the start of the war was dependent by its end on barely three dozen."

Consequently, local HCPs not working for organizations such as WHO and Médecins Sans Frontières have to cope with clinics that lack ancillary personnel, proper sanitation practices, isolation units, and supplies.

This will have a knock-on effect on deaths from other causes. In a recent editorial (N Engl J Med. 2014;371:1545-1546), Dr Farrar and his colleagues state that "the disintegration of the healthcare systems in the affected countries is already having a profound impact on the populations' health beyond Ebola, as clinics close or become overwhelmed or nonfunctional."

"These health system effects will only worsen as the epidemic progresses: West Africa will see much more suffering and many more deaths during childbirth and from malaria, tuberculosis, HIV-AIDS, enteric and respiratory illnesses, diabetes, cancer, cardiovascular disease, and mental health during and after the Ebola epidemic," they add.

To help tackle these issues, nations such as the United Kingdom are not only providing field hospitals for Ebola patients, they are also providing facilities to treat HCPs. Capt David Eagles, from the Royal Fleet Auxiliary, explained that the naval vessel Royal Fleet Auxiliary Argus, for example, will now treat Ebola patients in Sierra Leone.

Speaking on the BBC's Today program, he said: "Our hospital facility is...to provide reassurance to the UK military and civilian personnel operating in Sierra Leone."

"If they have a non-Ebola injury, they will have facilities identical to what they would find in a UK NHS hospital off the shore on UK sovereign territory."

Success Stories

Nevertheless, there have been several success stories in the Ebola crisis. Senegal was declared free of Ebola on October 17, after what was described by the WHO as "a good example of what to do when faced with an imported case of Ebola."

Today, Nigeria was declared to be free of Ebola virus transmission. In what the WHO called a "spectacular success story," Nigerian authorities repurposed its innovative polio eradication campaign, which uses cutting-edge GPS technology to ensure that no child misses out on polio vaccination, to conduct Ebola case-finding and contact-tracing.

Consequently, every single one of the country's 19 confirmed cases was traced back to direct or indirect contact with a single infected air traveler who arrived on July 20 from Liberia. Of the 19 patients, 7 died and 12 survived; that 40% fatality rate is much lower than elsewhere in the region.

As Margaret Chan, director-general of the WHO, said: "If a country like Nigeria, hampered by serious security problems, can do this — that is, make significant progress toward interrupting polio transmission, eradicate guinea-worm disease, and contain Ebola, all at the same time — any country in the world experiencing an imported case can hold onward transmission to just a handful of cases."

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