The 2014 Dallas, Texas, Ebola Incident: Global Implications to All-Hazards Preparedness and Health Care Worker Protection

By Eddy, Christopher; Sase, Eriko | Journal of Environmental Health, September 2015 | Go to article overview

The 2014 Dallas, Texas, Ebola Incident: Global Implications to All-Hazards Preparedness and Health Care Worker Protection


Eddy, Christopher, Sase, Eriko, Journal of Environmental Health


Ebola and Risk

The Ebola virus is a zoonotic, nosocomial, and priority bioterrorism agent that is categorized under the rubric "viral hemorrhagic fevers (Centers for Disease Control and Prevention [CDC], 2013, 2015; Institute of Medicine, 2009)." In this article, we examine the personal protective equipment (PPE) utilized in U.S. hospitals during viral hemorrhagic fever (VHF) outbreaks by reviewing applicable, relevant, and appropriate guidance, published scientific literature, and other available information sources.

We examined a series of well-documented nosocomial VHF outbreaks, including the 2014 U.S. Ebola incident in Dallas, Texas, and a single nurse assistant in Madrid, Spain. They share common epidemiological attributes and indicate that a rapidly evolved Ebola patient viral load (which approximates 5-8 days of first symptom) causes a very short period between diagnostic recognition to response and opportunity for PPE escalation (Locsin, Barnard, Matua, & Bongomin, 2003; Towner et al., 2004). Infective dose is in the virus particle range (<10 virions); late stage infections render the patient increasingly contagious (Burd, 2015; Henderson, Inglesby, & O'Toole, 2002). Patient signs, including the loss of up to 8 L of highly viremic vomit and diarrhea daily (CDC, 2015; Kreuels et al., 2014), may present challenges to traditional hospital emergency room PPE procedures and practices. Terminal stage patients with VHF may present a severe risk to health care workers exposed to blood and other bodily fluids, both by direct and cutaneous contact (Mardani, Keshtkar-Jahromi, Ataie, & Adibi, 2009). Further, scientific consensus on the viability of Ebola transmission by aerosol/respiratory pathways remains equivocal (Brosseau & Jones, 2014; Osterholm et al., 2015). Hospitals are required to assess workplace hazards and control risk by the hazard vulnerability analysis assessment process (Pandemic and All-Hazards Preparedness Reauthorization Act [PAHPRA], 2013), including the selection of worker PPE based upon those evaluated hazards.

Nosocomial VHF

Historically, VHFs have caught health care facilities off guard. From seven documented outbreaks of nosocomial VHF (Ebola nonendemic countries), 27 secondary or tertiary nosocomial infections occurred. The outbreaks are significant to the Ebola 2013-2014 epidemic globally and to the 2014 Dallas, Texas, Ebola incident specifically due to instances of misdiagnosis, patient morbidity, and the secondary infection of health care workers wearing various levels of PPE. The outbreaks involved dengue, Crimean-Congo hemorrhagic fever (CCHF), or Ebola, all of which are designated as Category A bioweapons agents (CDC, 2013; Henderson et al., 2002). The pathogens were determined to be primarily vectored by tick bites or direct human contact or needle stick accidents in Russia, Turkey, Iran, Germany, Pakistan, and Afghanistan. An American soldier was misdiagnosed with foodborne illness and later tested positive for CCHF (bitten by a tick in Afghanistan), and after infecting two military medical workers who did not wear respirators during aerosol-generating processes (bronchoscopies), he died (Conger et al., 2015). A Madrid nurse assistant wearing standard precaution PPE became infected with Ebola from an unconfirmed transmission pathway, while involved in the disposal of liquid Ebola waste "absorptive material (Parra, Salmeron, & Velasco, 2014)."

Transmission Pathways

Although the Centers for Disease Control and Prevention (CDC) advise that Ebola cannot be transmitted by airborne pathways, the routes of transmission are unclear (Brosseau & Jones, 2014). Ebola has long been known to be transmissible by aerosol (Henderson et al., 2002; U.S. Army Medical Research Institute of Infectious Diseases, 2011). Recent research by Osterholm and co-authors suggests that Ebola is potentially transmissible as a "respiratory pathogen with primary respiratory spread (Osterholm et al. …

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