WHO updates Ebola PPE guidance for health providers

Based on an expedited review, the World Health Organization (WHO) today updated it guidance for personal protective equipment (PPE) for use in treating suspected and confirmed Ebola infections, which prioritizes protecting mucosal areas and hand hygiene.

The guidance updates the WHO's recommendations from August and comes from a group of 13 international experts convened in early October, including participants from the US Centers for Disease Control and Prevention (CDC), Doctors without Borders (MSF), and the Infection Control Africa Network, the WHO said today.

In West Africa, the Ebola virus has taken a heavy toll on health workers, which has spurred a close look at PPE practices. So far 523 have been infected in the outbreak region.

Ebola infections in health workers have also occurred in developed countries such as the United States and Spain and have also steered a closer look at PPE equipment and practices. On Oct 20 the CDC updated its PPE guidance, which called for no exposed skin and the addition of coveralls and single-use disposable hoods.

More mucosal protection, hand precautions

Edward Kelly, PhD, the WHO's director for service delivery and safety, said in a statement that the guidelines clarify PPE options for protecting health workers and patients. "Paramount to the guidelines' effectiveness is the inclusion of mandatory training on the putting on, taking off, and decontaminating of PPE, followed by mentoring for all users before engaging in any clinical care," he added.

The experts agreed that the most important factor was protecting the mucosa (eyes, nose, and mouth) from droplets and fluids that contain the Ebola virus. Contamination of the mucous membranes is probably the most important mode of filovirus transmission, they said, and devices that protect that area should probably be doffed as late as possible to avoid contamination.

The team found no scientific evidence comparing the effectiveness of face shields and goggles and said either could be used, based on preference and availability. However, they said the two should not be worn together.

For respiratory protection, the team recommends waterproof masks that don't collapse against the mouth, such as a "duckbill" design, for regular treatment and fluid-resistant (surgical) particulate respirators for use during aerosol-generating procedures. This differs from CDC guidance, which calls for N95 respirators or powered air-purifying respirators for all patient care.

Hand hygiene is a key consideration, because hands can transmit the virus to other parts of the body and to other patients, the team said. All health workers should wear double gloves, preferable nitrile ones that resist chemicals, when caring for patients with Ebola and other filovirus infections. Other essential elements for protecting health workers include face cover, protective footwear, gowns or coveralls, and head covering that protects the neck, according to the guidance.

The agency recommends against taping gloves to gowns or coveralls because that might interfere with PPE removal.

Marie-Paule Kieny, PhD, the WHO's assistant director-general of health systems and innovations, said in the statement that PPE is only effective when applied alongside other controls and that its benefits depend on sticking to established protocols.

The guidance suggests PPE choices should balance the best possible protection with allowing health workers to provide the best care with maximum ease, dexterity, comfort, and minimal heat stress. The guidance also allows different PPE options because evidence is still being collected about what works best and is sustainable, the WHO said.

Larry Lynam, a former biotechnology and biopharmaceutical executive who has trained in and observed donning and doffing in 15 different countries, said the procedures take a lot of practice to develop the proper skill and dexterity required to be consistent in proper use. He added that he has been worried about earlier cavalier assumptions that health workers were prepared to handle Ebola patients.

Lynam is founder of the Lynam Group, a biotechnology consulting services company based in Coral Springs, Fla.

He said the language and assumptions in the updated WHO recommendations show that health officials have been listening to people with experience. "I applaud the recommendations about increased training and continuous observation of processes," he said.

The recommendations against taping the gloves to other PPE are good, said Lynam, and he added that he hopes nitrile gloves are feasible, because the better protection and dexterity they afford the wearer could increase the margin of safety.

New ETU in Monrovia

In response developments, a new Ebola treatment unit (ETU) opened today in Liberia's capital, Monrovia, bringing the number of such facilities in Monserrado County to four, the WHO said today. The ETU has the capacity to treat up to 200 suspected, probable, or confirmed Ebola patients and was a joint project of several global health partners, including Liberia's health ministry, the WHO, the US Agency for International Development (USAID), and the World Bank.

The new ETU will be managed by Liberia's health ministry and staffed by African Union and Cuban medical teams. It is located at the defense ministry's former compound on the outskirts of Monrovia.

Liberia now has eight ETUs, and construction is under way on others. However, there is still an urgent need to staff them, the WHO said.

Despite the progress, there is still an acute shortage of ETUs and treatment beds. Earlier this week a WHO official said 19 ETUS more are needed, in addition to the ones being built.

Needed supplies

In other developments, a British Navy ship, the RFA Argus, arrived in Freetown, Sierra Leone, yesterday, carrying 80 medics and 80 Marines among the 350 people on board, Agence France-Presse (AFP) reported today. The ship's arrival brings the number of British troops in Sierra Leone to about 900.

The ship also brought 32 pickup trucks and 3 helicopters, along with air crew and engineers to help support medical teams and aid groups, the report said.

In Liberia, MSF teams have started delivering antiviral medication in the western part of Monrovia, the country's capital city, according to a statement today.  Amid the Ebola outbreak and the collapse of the country's health system, getting treatment for malaria—endemic in Liberia—has been difficult or impossible, MSF said.

The deliveries began Oct 25, targeting 300,000 people living in the poorest areas, which are densely populated and have almost no access to medical care, according to the group.

MSF said the treatment is for both children and adults. Because malaria symptoms can mimic the early symptoms of Ebola, treating patients for malaria infections can help keep them out of Ebola treatment centers, where they could have contact with infected patients.

New case, death numbers

In a situational update today, the WHO said that, as of Oct 29, the global number of Ebola infections is 13,567, along with 4,951 deaths. The WHO said the number of cases it reported today is fewer than those it reported in an Oct 29 update, mainly because a number of suspected cases from Guinea were discarded.

For just the three main outbreak countries, the latest totals are 13,540 infections, 4,941 of them fatal. The case totals are thought to dramatically underestimate the true burden of the disease.

Today's update doesn't include new cases from Liberia since Oct 25. However, it includes 103 new cases reported from Sierra Leone from Oct 28 and Oct 29.

Legal seesaw over health worker quarantine

After issuing a temporary order yesterday ordering Maine nurse Kaci Hickox to stay at least 3 feet away from people and avoid public places and public transportation, a state judge today lifted parts of a mandatory quarantine, NBC News reported.

The nurse, quarantined against her will in New Jersey last weekend after returning from West Africa where she cared for Ebola patients with MSF, has been under mandatory quarantine in Maine, which she said is not science-based and violates her civil rights. She defied the quarantine twice, going outside her house to speak with reporters and going for a bike ride with her boyfriend.

In a statement today, Maine's Governor Paul LePage said, "As Governor, I have done everything I can to protect the health and safety of Mainers. The judge has eased restrictions with this ruling and I believe it is unfortunate. However, the State will abide by law."

In a measure that could help soothe controversy over quarantine for health providers returning from the outbreak region, the state of New York and New York City announced a financial incentive program to encourage health professionals to travel to West Africa to help treat Ebola patients.

Similar to a system for military reservists, the program would ensure that health providers have their pay, health care, and employment continue without interruption after they get back.

Other developments

  • Canada has joined Australia in not issuing visas to residents of Ebola-struck West African nations, the Canadian Press reported today. The Canadian government will stop issuing visas to workers, students, and visitors from the region and will not process any applications already in its system, the story said. An immigration spokesman said the policy is similar to but slightly less restrictive than the one Australia announced this week, which was denounced by WHO Director-General Margaret Chan, MD, MPH.

  • The US Department of Defense (DoD) has posted a "request for proposal" to fund research to determine whether the Ebola virus can be transmitted through the air or live outside the body for extended periods, Foreign Policy reported yesterday. "While current science indicates the disease can only be transmitted by contact with contaminated body fluids, it remains unclear if other transmission modes are feasible," the proposal, which was posted Oct 24, reads."Filoviruses are able to infect via the respiratory route and are lethal at very low doses in experimental animal models, however the infectious dose is unknown."

  • Nina Pham, the first Dallas nurse infected with Ebola after caring for Thomas Eric Duncan, will get her dog, Bentley, back tomorrow after he ends his 21-day quarantine, CNN reported today. The King Charles Cavalier spaniel has tested negative for the disease three times and has been quarantined at the formal Naval Air Station since Oct 13 when Pham was hospitalized. In a related development, a Spanish health official yesterday defended the euthanization of a dog owned by a nurse who was infected with Ebola while caring for a sick priest in Madrid. In a ProMED Mail post yesterday, the official from Spain's health ministry said the Spanish nurse had been in contact with her dog for a longer period while having symptoms than the Dallas nurse had with her dog and that the Spain government didn't have the same capacity to keep the dog in quarantine, as US counterparts did. ProMED Mail is the e-mail message board of the International Society for Infectious Diseases.

  • The WHO African regional office needs new leadership, and the upcoming election of a new regional director is crucial, editors of The Lancet wrote today in an editorial. Though now is not the time for a detailed review of failures that led to a slow response to the Ebola outbreak, it's clear that officials from the regional office and some of the WHO country offices failed catastrophically in their mandate, possible putting the credibility of the whole WHO at risk, the editors said. The vote for a new regional office leader will take place between Nov 3 and Nov 7 at the regional committee, among candidates from five different countries.

See also:

Oct 31 WHO statement

Oct 31 WHO updated PPE guidance

Oct 31 WHO statement on Monrovia ETU

Oct 30 AFP story

Oct 31 Maine governor's office statement

Oct 30 New York governor's office press release

Oct 31 NBC News story

Oct 30 New York governor's office statement

Oct 31 Canadian Press story on visa ban

Oct 30 Foreign Policy story on DoD proposal

Oct 24 DoD Ebola research proposal

Oct 31 CNN story

Oct 30 ProMED Mail post

Nov 1 Lancet editorial

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