Ebola outbreak underscores weakness in worker safety
OSHA moves forward on infectious disease standard
The recent Ebola infection of two Dallas nurses raises troubling questions about how prepared hospitals are to protect their employees from infectious diseases and whether the health care industry needs a higher level of worker safety.
Indeed, the Ebola outbreak provided a compelling backdrop to recent regulatory action by the Occupational Safety and Health Administration, which has posted a draft infectious disease standard that would make infection control measures mandatory. (See related story, p. 137.)
When the two nurses became ill in mid-October, national attention soon turned to their personal protective equipment. Media images showed workers cleaning the apartments of the Dallas patients wearing hazmat suits with elastomeric respirators. Health care workers in West Africa also wear hazmat suits.
Yet nurses caring for Thomas Eric Duncan wore surgical masks or N95s while Ebola was suspected but not confirmed. Their necks and foreheads were exposed, and they didn’t wear booties or leg coverings. The hospital noted that it was following the Centers for Disease Control guidelines for contact and droplet precautions.
Nurses protested after CDC director Thomas Frieden, MD, MPH, said the transmission was likely caused by a "breach in protocol" in removing the protective equipment. He later apologized, saying he did not intend to blame the workers, expressing regret that the CDC did not send in an infection control team more swiftly to provide assistance.
A week later, CDC announced new infection control recommendations that called for N95 or powered air-purifying respirators (PAPRs), face shields and hoods that fully cover the neck, boot or shoe covering, and trained observers monitoring the donning and doffing of PPE. The "increased margin of safety" was necessary because American health care involves intensive nursing care and procedures, Frieden told reporters.
"Even a single health care worker infection is one too many," he said. "We may never know exactly how that happened, but the bottom line is that the guidelines didn't work for that hospital. Dallas showed that taking care of Ebola is hard."
But occupational health and safety experts also noted another lesson: Hospitals need to raise the bar on worker safety.
"This is a small microcosm of a larger issue of how do we protect our health care workers,’ says Andrew Vaughn, MD, MPH, medical director of Occupational Health and Safety at Mayo Clinic Rochester (MN). "That is something that clearly needs additional attention."
The silver lining of the Ebola outbreak has been a new awareness about risks to health care workers and the responsibility that their employers have to keep them safe, Vaughn says.
CA has law in place
Regardless of how strict they are, CDC guidelines are voluntary except in California, where the Aerosol Transmissible Disease Standard requires employers to follow the infection control guidelines. But a national OSHA standard under development would make those guidelines enforceable at all hospitals and health care facilities.
OSHA is investigating the Dallas transmission, alongside the CDC, a spokesperson said. But beyond an information page on its website, OSHA has said little publicly about Ebola and nothing about the infection of the nurses. However, the Ebola outbreak began just as OSHA convened its small business review for a draft infectious disease standard.
On October 9, the day after Thomas Eric Duncan died of Ebola at Texas Health Presbyterian Hospital in Dallas -- and three days before the first nurse tested positive -- OSHA released background documents detailing its proposed approach to an infectious disease standard.
Written worker IC plan
The proposed standard would be patterned after the Bloodborne Pathogen Standard and California’s Aerosol Transmissible Diseases Standard, requiring a written Worker Infection Control Plan, identification of at-risk job classifications, infectious agent hazard evaluations, worker protections, training and exposure investigation.
OSHA’s draft infectious disease standard provides for "medical removal protection benefits," including full pay and protected job status.
"Hopefully, this Ebola outbreak and the issues around this will provide the push for OSHA to continue to move on [the standard]," says Mark Catlin, health and safety director for the Service Employees International Union (SEIU). "It certainly provides evidence that there’s a need -- that the health care sector wasn’t prepared to deal with this high level of dangerous disease."
Echoes of SARS
Ebola also has revived a concept that emerged after Severe Acute Respiratory Syndrome (SARS), which infected some 170 health care workers during the 2003 outbreak in Toronto. The precautionary principle holds that "reasonable steps to reduce risk should not await scientific certainty," the SARS commission concluded.
Even before CDC upgraded its recommendations, some hospitals were looking at special containment units in Atlanta and Nebraska as models. Emory University Hospital treated four Ebola patients with no transmission to health care workers. Those caring for the patients wore Tyvek full-body suits and powered air-purifying respirators.
Confidence over anxiety
"Although not strictly required, this approach was practical and allowed our HCWs to confidently focus on safely caring for and transporting these patients without needless anxiety and distraction," Emory physicians explained in the Annals of Internal Medicine.1
Conversely, Texas Health Presbyterian Hospital used hospital gowns and face masks giving nurses an option of surgical masks or N95s. Nina Pham, the first infected nurse, "was using full protective measures under the CDC protocols, so we don’t yet know precisely how or when she was infected," Daniel Varga, MD, chief clinical officer and senior executive vice president for Texas Health Resources, told a Congressional subcommittee in mid-October.
National Nurses United, which does not represent nurses in Texas, nonetheless became their public voice and complained that nurses had skin exposed in their protective garb and used medical tape to try to cover their necks.
"Were protocols breached? The nurses say there were no protocols. There were no mandates for nurses to attend training," union co-president Deborah Burger said in a press briefing.
More than 10 years after SARS, too many hospitals still don’t have adequate isolation rooms in the emergency department or ready access to fit-tested N95s, says Gabor Lantos, MD, PEng, MBA, president of Occupational Health Management Services in Toronto and a consultant to hospitals. "Ask nurses if they feel they’re adequately protected or not," he says. "They know the systems aren’t in place."
The situation harkened to other outbreaks that have sickened and killed health care workers, including tuberculosis, MERS and flu pandemics. The lesson learned: Use available resources and technology to identify the illness quickly and to protect health care workers, says health care historian Deborah A. Sampson, PhD, APRN, who is also an occupational health nurse practitioner in New Hampshire.
"If you don’t prepare and you don’t intervene for a communicable disease, you can have significant issues," she says.
Droplet vs. airborne
The Ebola outbreak also has brought another controversy to light: The tension between infection control and industrial hygiene on the issue of disease transmission.
Even as the CDC upgraded the recommended Ebola protective gear, Frieden repeated that Ebola is not airborne. Yet experts in respiratory protection argue that the paradigm of droplet versus airborne transmission is outmoded.
Particles of various sizes are present near an infected patient and can be inhaled by caregivers, argued Lisa Brosseau, ScD, professor, and her colleague Rachael Jones, PhD, assistant professor, in the School of Public Health at the University of Illinois at Chicago, in a commentary written about a month before the U.S. nurses contracted Ebola..2
They urged the use of PAPRs in the treatment of Ebola patients. Coughing, vomiting, and diarrhea produce aerosols, creating a risk of inhalation, Brosseau notes. CDC’s original guidance speaks only of extra protection during "aerosol-generating procedures," and even the updated guidance recommends PAPRs or N95s because of the potential for "an unexpected aerosol-generating procedure."
`Shock and anger’
"I have to say I was shocked and sad and very angry about the infection of two health care workers in Dallas," she says. It was a failure that "can be placed directly at the doorstep of CDC."
"We’re watching the flaw in the infection control system that many of us have seen for years coming to the surface," agrees Catlin.
CDC needs to work more closely with occupation health experts at the National Institute for Occupational Safety and Health (a division of CDC) and OSHA, Brosseau and Catlin say.
Meanwhile, National Nurses United kept the heat on with a petition drive and press briefings calling for better protections.
"When the CDC is transporting Ebola patients they all have hazmat suits on. Our nurses want the optimal protection, period," NNU executive director RoseAnn DeMoro said in a national conference call before CDC announced the new precautions. "And we’re not going to stop until it’s done."
- Isakov A, Jamison A, Miles W, et al. Safe management of patients with serious communicable diseases: Recent experience with Ebola virus. Ann Intern Med 2014; doi:10.7326/M14-2084. Available at
http://bit.ly/1E5EI58
- Brosseau LM and Jones R. Commentary: Health workers need optimal respiratory protection for Ebola. Center for Infectious Disease Research and Policy, University of Minnesota. September 17, 2014. Available at. http://bit.ly/1pjWQQJ
