Better Protective Equipment Needed to Prevent Ebola Infection

A new set of guidelines from the US Centers for Disease Control and Prevention (CDC) for removing personal protective equipment (PPE) highlights the need for improved protective gear to prevent Ebola infection in health care workers.

In a commentary posted online today in the Journal of the American Medical Association, Michael B. Edmond, MD, MPH, MPA; Daniel J. Diekema, MD, MS; and Eli N. Perencevich, MD, MS, stated that the need for a reengineering of PPE is necessary in US hospitals and, more critically, African outbreak zones.

“The use of cumbersome PPE in the extreme heat and difficult working conditions of Ebola treatment centers in Africa places great stress on health care workers and limits the time they can spend providing patient care,” the authors wrote. “A novel approach to PPE that provides an impermeable fluid barrier that is both more comfortable and easier to don and remove would be a substantial step forward. This will require new materials and designs.”

Health care workers accounted for nearly one-fourth of Ebola infections during previous outbreaks, which is attributable to the fact that the infectivity of the virus increases as the illness becomes more severe. Gowns, gloves, and masks, in particular, are associated with a high rate of self-contamination, the authors noted.

A University of Maryland study indicated that health care workers who treat multidrug-resistant bacterial organisms (MDRO) in intensive care unit patients self-contaminated their hands with the same MDRO after wearing gloves and gowns during 5% of care episodes. The contamination was found to increase with environmental burden, which is of significant concern in the later stages of Ebola infection as viral loads, gastrointestinal manifestations, and bleeding episodes increase.

Given that Ebola is found in bodily fluids and on the surface of the skin, the frequency of gloves and gowns becoming contaminated during patient care is unknown, but it remains likely that gowns and gloves become contaminated when the patient is vomiting and has diarrhea. In training health care workers on the use of PPE, it was found that removal of the gear without touching the skin or underclothing with the external surface of the gloves or gown is difficult with current technology.

“The important point is that wearing and removing PPE require a high level of precision,” the authors wrote. “There is no information about the risk for infection after skin contamination, but until further research provides additional data, contamination of even intact skin must be completely avoided. Even if skin breaks are necessary for infection, transfer of virus from intact skin to mucous membranes is likely to occur given the frequency with which many persons typically touch their nose, mouth, and eyes.”

On October 20, 2014, the CDC released revised recommendations for health care workers who directly care for Ebola patients to safely put on and remove PPE.

The guidelines state that all skin must be covered, a safe sequence of donning and removing PPE must be followed, and alcohol-based hand rub should be utilized multiple times while the gear is removed. A trained observer should also be present to minimize protocol breaches.

The updated guidelines for the removal of PPE has subsequently made the process more complicated, which has emphasized the need for improved protective technologies.

The authors wrote that the ideal PPE would be impervious to fluid, cover all skin and underclothing, be easy to put on and remove with minimal risk for self-contamination, provide maximum comfort, and be easy to dispose of while carrying minimal contamination risks for health care workers and environmental service workers.

“Importantly, improvements in PPE will also assist with better control of MDROs, which is especially needed given the lack of therapeutic options for highly resistant gram-negative bacillary infections,” the authors wrote. “Better PPE will improve safety for both health care workers and patients.”