New CDC Guidance for Ebola PPE Calls for No Skin in the Game

October 20, 2014

Physicians, nurses, and other clinicians caring for patients with the deadly Ebola virus should wear personal protective equipment (PPE) that does not expose any skin, the Centers for Disease Control and Prevention (CDC) announced tonight.

That means donning a surgical hood that completely covers the head and neck, and a single-use, full-face shield instead of goggles.

The advice, which appears in a revised set of guidelines for PPE in Ebola care, supersedes an earlier recommendation that allowed for a small degree of skin exposure. The revised guidelines also call for replacing masks with either a N95 respirator or a powered air purifying respirator to offer better protection against close-range aerosol contaminants such as blood or sputum generated by intubation, suctioning, and other high-risk procedures.

In addition, the CDC now is recommending that clinicians rigorously train and demonstrate competency at both donning and doffing PPE. The latter step, if done improperly, puts a clinician at risk for contamination. Also, a trained monitor should oversee each time a clinician puts on and takes off this gear.

The updated guidelines "provide an increased margin of safety," said CDC Director Thomas Frieden, MD, MPH, at a news conference this evening.

The new Ebola guidance comes in the wake of two registered nurses at Texas Health Presbyterian Hospital Dallas contracting the virus from Liberian national Thomas Eric Duncan. He died on October 8 after he became exposed to a woman dying of Ebola in his native country and then traveled to Dallas. Duncan was the first person diagnosed with the virus in the United States.

The CDC has not yet determined how the nurses, Nina Pham and Amber Vinson, became infected, but insufficient PPE is on the list of suspects, as is the way the nurses might have taken off contaminated gear. By all accounts, the two nurses and other clinicians treating Duncan during the first two days of his hospitalization wore CDC-prescribed gowns, gloves, masks, and eye protection that would have exposed parts of their faces and necks. On September 30, the day Duncan's Ebola diagnosis was confirmed, healthcare workers switched to hooded hazmat-style PPE, according to Texas Health Resources, the hospital's parent company.

The CDC has been criticized for promulgating PPE guidelines for Ebola care that put clinicians in jeopardy. The nurses' union National Nurses United has called on US hospitals to equip nurses with hazmat suits whenever they deal with suspected or known Ebola cases.

In today's news conference, Dr Frieden said his agency's previous set of PPE recommendations, based on those of the World Health Organization, "didn't work" for Texas Health Presbyterian. The new guidelines, he said, generally reflect not only the protocols of Doctors Without Borders in its Ebola campaigns in Africa, but also the protocols of Emory University Hospital, Nebraska Medical Center, and the National Institutes of Health (NIH) Clinical Center. They are three of four hospitals with state-of-the-art biocontainment units designed for the likes of Ebola. None of their healthcare workers have yet to contract the virus in the course of caring for infected patients.

Pham was transferred from Texas Health Presbyterian to the NIH Clinical Center, and Vinson was sent to Emory University Hospital.

Vinson is the fourth patient with Ebola to be treated at Emory University Hospital. Today it discharged the third of its first three patients with Ebola. The patient, declared disease-free, has requested anonymity. The other two patients were American missionaries who became exposed to the virus in Liberia. They were discharged in August.

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