CDC unveils new PPE guidance for Ebola

The US Centers for Disease Control and Prevention (CDC) this evening unveiled new personal protective equipment (PPE) recommendations for health workers who will be caring for Ebola patients, with the main change being no exposed skin. The guidance allows for two choices of respiratory protection.

The new recommendations replace its initial guidance released on Aug 1 and come in the wake of two infections in nurses who cared for Thomas Eric Duncan, the nation's first Ebola patient. At a media telebriefing, CDC Director Tom Frieden, MD, MPH, said the new PPE recommendations are designed to increase the margin of safety for frontline health workers and reflect an expert consensus.

"The bottom line is that the recommendations didn't work for that hospital," he said of the initial recommendations. Although teams are investigating the events that led to the two nurses' infections in Dallas, Frieden added, the specific problems that led to the exposures may never be known.

Two other key elements of the new guidance are training and demonstrated competency in donning and doffing PPE and having every step of that process supervised by a trained observer to ensure that all steps are properly completed, Frieden said.

Earlier CDC recommendations for Ebola PPE are based on World Health Organization (WHO) recommendations, which have worked well in African settings, Frieden said. However, some procedures that might be performed for Ebola patients in American hospitals—such as intubation—may increase the risk a health worker's exposure to the virus, he added.

 The CDC said two main equipment changes are the addition of coveralls and single-use disposable hoods. It no longer recommends goggles, because they may not provide full skin coverage, aren't disposable, can fog up, and often are manipulated with health workers' gloved hands.

For respiratory protection, the guidance recommends either an N-95 respiratory or powered air-purifying respirator (PAPR). Frieden said either option is acceptable, and that two of the high-containment treatment units that have treated Ebola patients take different approaches between those two options. The guidance offers different options for configuring PPE, based on a hospital's availability, preference, and staff comfort, he said.

The new guidance also spells out step-by-step PPE removal instructions, which includes disinfecting visibly contaminated equipment using approved wipes. It says gloved hands should be disinfected with registered wipes or an alcohol-based rub between steps of removing PPE.

WHO declares Nigeria free of Ebola

In other Ebola news, the World Health Organization (WHO) today declared Nigeria free of Ebola transmission and said the country's lessons learned in battling the virus are useful to other nations both in and outside of Africa.

The declaration comes just 3 days after the WHO made a similar statement for Senegal, which had just one travel-linked case in its capital, Dakar. A country is declared free of the virus when it goes two incubation periods—42 days—without reporting any new Ebola infections.

Nigeria's initial case was also travel linked, in a man from Liberia who flew to Lagos while sick. He told medical responders that he thought he had malaria, but investigations found he had helped care for his sister, who died from Ebola, and that the man had attended the traditional funeral.

The WHO said all 19 cases detected in Nigeria were linked to the initial case. Many subsequent infections were in health workers who were exposed to the man before his Ebola exposure was known. Seven deaths were reported, for a case-fatality rate of 40%, much lower than the 70% seen in West Africa's main outbreak region.

As the first travel linked case of the outbreak, Ebola's detection in Nigeria prompted deep concerns in the global health community, since Nigeria is Africa's most populous country. Its capital, Lagos, is Africa's largest city, a crowded urban area home to 21 million people. The detection of Nigeria's first case prompted the CDC in early August to activate its emergency operations center to its highest level.

In a statement today, WHO Director-General Margaret Chan, MD, MPH, said if a country like Nigeria, with its security problems amid other health challenges such as Guinea worm disease and attempts to interrupt polio transmission, can curb the spread of Ebola, others can, too. "Any country in the world experiencing an imported case can hold onward transmission to just a handful of cases."

Keys to the country's success were quick national and state government financing for outbreak response and speedy response of international partners such as the WHO and CDC, who played a vital role in contact tracing, one of the most important tools in battling Ebola. The WHO said the public health infrastructure and technology tools, such as GPS tracking, for battling other diseases such as polio were useful for responding to Ebola.

Texas and Ohio updates

Texas health officials announced today that 43 people who had possible contact with the state's first Ebola patient, a traveler from Liberia who died from his infection on Oct 8, have finished their 21-day monitoring period. They have no symptoms and aren't at risk for developing the disease, according to a statement today from the Texas Department of State Health Services (TDSHS).

The group who just finished monitoring is a mix of health workers, household contacts, and community members whose last possible contact with Duncan was on Sep 28.

The TDSHS said about 120 more people continue to be monitored for symptoms. Also, an additional group of people who were on one of two Frontier Airlines flights and may have had contact with the second of Duncan's hospital nurses who were infected by Ebola are being monitored. Those people sat within 3 feet of Amber Joy Vinson and have been asked to stay home and monitor for symptoms, because they could be at higher risk.

In other Texas Ebola developments, a Carnival cruise ship returned to Galveston yesterday carrying a hospital lab worker who was isolated on the ship in the wake of earlier confusion regarding travel issues among Duncan's possible contacts. The woman on the cruise worked in the lab at Texas Health Presbyterian Hospital in Dallas where Duncan was treated, Reuters reported yesterday. She didn't have contact with Duncan but may have had contact with his lab samples.

A US Coast Guard contingent met the ship before it reached its port and transported a blood sample from the woman for tests, which were negative for Ebola, according to Reuters.

Over the weekend, the TDSHS issued statements tightening restrictions for three groups of people on Ebola contact lists: lab workers, hospital workers who helped care for sick colleagues, and air passengers who sat within 3 feet of Vinson. It said those contacts should be monitored twice a day for 21 days and avoid commercial transportation during that time.

Meanwhile, Ohio is monitoring 142 people, including 3 who are quarantined, according to an update today from the Ohio Department of Health (ODH). They all had contact with Vinson. The contacts are from 16 different Ohio counties, but more than half (86) are from Summit and Cuyahoga counties.

On Oct 18 the ODH tightened its travel restrictions for several of the contacts. Those who require active monitoring by the public health department are barred from leaving the county's jurisdiction, and those who are self-monitoring have been ordered not to leave the United States.

Other developments

  • An Associated Press (AP) account based on a draft WHO report that it obtained says the group admits that it boggled its initial response to West Africa's Ebola outbreak, due to lack of data and incompetence. The report described in the Oct 17 AP story includes a timeline of events and also covers bureaucratic missteps, such as the WHO's Guinea office not helping an Ebola response team get visas and hampering the flow of aid money into the country. The WHO initially told the AP that the report would be publicly released, but the agency later said it would probably not be released, and no WHO official would comment on the report. The WHO, in an Oct 18 statement, said the document is the first draft of an internal document detailing the chronology of the outbreak for later review. It said the report hasn't been fact-checked and is part of ongoing analysis. It said it wouldn't respond to questions about the document until it is completed and a detailed review will come, after the urgent response time has passed.

  • A Spanish nursing assistant who contracted Ebola when caring for infected Spanish missionaries has recovered after close to 2 weeks of treatment and has no sign of the virus in her blood, Fox News reported today. Teresa Romero, 44, is believed to be the first person in the current epidemic to have caught the virus outside West Africa. She remains in isolation at Carlos III Hospital in Madrid and must be tested again to make sure she is free of the virus, the story said. The story said she was treated with blood plasma from other Ebola survivors, but authorities, at her request, have not said anything more about her treatment. None of the 15 people who had contact with her after her symptoms started have experienced Ebola symptoms.

  • The European Union has vowed to increase efforts to raise 1 billion euros ($1.27 billion) to help fight Ebola in West Africa and has rejected the idea of barring flights to Europe from that region, the AP reported today. British Prime Minister David Cameron wants a 2-day summit of the 28 EU leaders ending Oct 24 to reach the $1.27 billion aid threshold, the story said. So far, the EU and its members have raised 500 million euros ($640 million), with Britain contributing 160 million euros. If the EU barred flights from the affected countries, said French Foreign Minister Laurent Fabius, "Instead of going to Brussels or to France, (West African) passengers would go to Dubai or elsewhere and come in from there. We would no longer be able to check anything."

  • The CDC over the past few days issued two new guidance documents, one for hospitals on caring for suspected and confirmed Ebola case-patients and the other offering advice on how healthcare workers in West Africa can avoid heat illness burden while wearing PPE in Ebola treatment settings.

News editor Robert Roos contributed to this report.

See also:

Oct 20 CDC fact sheet on PPE for Ebola

Oct 20 WHO statement

Oct 20 TDSHS statement

Oct 19 Reuters story

Oct 20 ODH contact monitoring report

Oct 18 ODH statement on quarantine protocols

Oct 17 AP story

Oct 18 WHO statement

Oct 20 Fox News story

Oct 20 AP story

Oct 20 CDC guidance on caring for suspected and confirmed Ebola patients

Oct 17 CDC guidance on heat burden and Ebola PPE

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