We’ve all seen the vivid footage on the news these past few weeks: Two hospital workers donned in full body hazmat suits and respirators helping the Americans who fell victim to the Ebola virus out of an ambulance and into air-tight rooms. To many, it seems like the best way to prevent infections to staff and other patients, given that the West African outbreak is the worst the planet has ever seen, with almost 2,000 people infected and over a 1,000 dead. But are all these extraordinary precautions in U.S. hospitals really warranted?
This week, in an editorial in the Annals of Internal Medicine, Neil Fishman, MD, associate chief medical officer in the University of Pennsylvania Health System, and researchers from Harvard and the University of Iowa help clear the air by sticking to the science.
Here’s what the Centers for Disease Control and Prevention (CDC) recommends: Patients with suspected or confirmed Ebola should be placed in a single room with staff required to wear gowns, gloves, surgical mask and goggles. If an aerosol-generating procedure (like intubation or bronchoscopy) is called for, the agency then recommends wearing a more protective mask and placing the patient in a negative-pressure room.
But many hospitals are planning to put ALL patients in these rooms and have staff wear hazmat suits and full respirators.
“There’s a temptation to maximize the precautions that go above and beyond what the CDC recommends—it’s understandable given this horrible outbreak,” Fishman says. “But the truth of the matter is that these precautions are not backed by scientific evidence, rather, most likely, by mass hysteria and media hype.”
The CDC guidance, the authors point out, is backed by evidence-based science. There have been over 20 outbreaks in the last 40 years—enough to gather up sufficient experience in the control and prevention of the disease. We also have many studies that inform us about transmission rates and risk factors.
For the record, Ebola is transmitted by direct contact with patients’ bodily fluids, especially blood. There are other risk factors, such as fruit bats or eating fruit that has been nibbled on by the critters, but you don’t find fruit bats in hospitals in the U.S.
Transmission requires direct contact and, in reality, is inefficient. A study from the Journal of Infectious Diseases that looked at 173 households with 27 patients with Ebola found that the transmission rate was only 16 percent, and this was despite not using any precautions routinely used in hospitals. The virus is tougher to catch than one might think, in other words.
Another study, published in the same journal, looked at contamination of the care environment. Investigators took 54 clinical specimens from 26 people confirmed to have Ebola. The researchers were able to isolate Ebola from 16 of the 54 samples, including saliva, semen, and blood. They then took 33 environmental sample—including swabs of the stethoscope, bed frame, food bows, and the skin of three different patient attendants. None were positive.
“These studies back up the appropriateness of the CDC’s recommendations,” Fishman says. “And exceeding them may actually increase risk.”
Introducing new and unfamiliar forms of personal protective equipment could lead to self-contamination when removing new gear, the authors write. What’s more, requiring hazmat suits and respirators will likely decrease the frequency of provider-patient contacts, inhibits providers’ capacity to examine patients, and curtail the use of diagnostic tests.
“Using extra gear inflates both patients’ and caregivers’ anxiety levels, increase costs and waste valuable resources,” they conclude. “More insidiously, requiring precautions in excess of CDC’s recommendations fans a culture of mistrust and cynicism about our public health agency.”
Another piece on the Ebola virus, a Viewpoint published in the Lancet this week, made headlines. Co-authored by Ezekiel Emanuel, MD, PhD, vice provost for global initiatives and chairman of the department of Medical Ethics and Health Policy, this one tackled the experimental drug known as ZMapp the two Americans received--who, thankfully, as reported last night, have beaten the disease.
But the experimental treatment raises important ethical questions about distribution. Researchers and health authorities need to ensure that drugs are distributed fairly, and not just to a select group, and in the context of randomized clinical trials, so that researchers can learn whether they work, the authors wrote.
It's less about a vaccine, Emanuel and his co-author from King's College of London stressed, and more about containing the virus in order to end the outbreak.
"Now that the global response to the Ebola outbreak is picking up, the international community needs more focus on strengthening of health systems and infrastructure and less on experimental treatments," Emanuel said in a journal release. "Adoption of infection containment measures with a view to strengthening health systems and infrastructure is the most effective way to curb this epidemic and prevent future ones, and the international community now needs to show that it can meet the challenge of this public health emergency, while learning the lessons for future Ebola and other epidemics."
(Photo credit: Screen shot of CNN coverage August 2014)