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Infection control: protecting against Ebola.

With all the news and information about the risk of the Ebola virus disease (EVD) reaching New Zealand, infection prevention and control (IPC) nurses throughout the country are busy answering questions, refreshing staff about the correct use of personal protective equipment (PPE) and helping put in place the many protocols that will be needed, should a case present at any New Zealand facility.

It is important to remind staff that risk stratification should take place before any of these protocols are activated. The risk factors are:

* A person with a clinical illness compatible with EVD and within 21 days before onset of illness, either:

* A history of travel to the affected areas or

* Direct contact with a probable or confirmed case or

* Exposure to EVD-infected blood or other body fluids or tissues or

* Direct handling of bats, rodents or primates, from Ebola-affected countries or

* Preparation or consumption of "bush meat" from Ebola-affected countries. (1)

The key point regarding EVD is that, while Ebola is a dangerous virus that can be life-threatening, its spread can be contained. Nigeria was recently declared Ebola-free after 19 cases of EBV were transmitted from one person who entered the country with EBV from Liberia. At the time of writing, it has been 42 days since the last case. (2)

The risk to New Zealand is still low, but we should be prepared, as we should for any potentially transmissible disease. The basis for IPC is to use standard precautions at all times (and in some situations, transmission-based precautions as well) where a health-care worker (HCW) may come into contact with blood or body fluids. Sometimes, this means you will need to wear a gown, gloves and mask in situations where the patient/client is not yet in formal isolation. It is also timely to remind all HCWs it is very important to avoid hand-to-face contact at all times, as this is when inadvertent transmission can occur. Following the 5 Moments for Hand Hygiene is a key strategy in this. (3) Alcohol-based hand rub (ABHR) will kill EBV and is effective, as long as the hands are not visibly soiled.

The key to preventing the spread of any infection is to identify it, contain it and then stop it from moving elsewhere. Clearly, this has failed catastrophically in the African countries currently in the grip of the worst outbreak of EVD the world has ever seen. There are a myriad of reasons why this has happened, but a lack of basic health care, equipment and infrastructure are prime factors.

We know what this disease is and we know how it is spread (see box below). (2) The onset of Ebola symptoms is sudden and includes intense weakness, muscle pain, headache, nausea and sore throat. (1) Unfortunately, there are few treatment options, apart from supportive therapies and basic nursing care, so the mortality rate, especially in the African countries without access to modern healthcare facilities, is very high (currently around half of cases). The recent cases of nurses in the United States (US) contracting the disease from a known patient have created huge alarm, but as more and more information comes to light, it would seem that, perhaps, this hospital was not prepared and did not have good procedures in place, or the right equipment to deal with such a case.

One of the riskiest times in the use of PPE is during its removal. It must be removed in such a way there is no possibility of the HCW touching the surfaces that have been in contact with the patient.

As a response to this, the Centres for Disease Control (CDC) in the US have issued tightened guidance for US HCWs on PPE for Ebola. (4) These enhanced guidelines have three principles and were used in the other US hospitals where known cases of EBV were cared for, and there was no transmission in these hospitals. The three principles are:

* All HCWs undergo rigorous training and are practised and competent with PPE, including putting it on and taking it off in a systemic manner.

* No skin exposure when PPE is worn.

* All workers are supervised by a trained monitor who watches each worker taking PPE on and off. (5)

New Zealand hospitals are gearing up to train front-line staff (mostly emergency department and intensive care unit staff), using these principles. Tertiary-level hospitals in Auckland (including Middlemore), Wellington and Christchurch are preparing to be the receiving hospitals for any probable cases. This does not mean other hospitals should not have their own protocols in place in the event a potential case presents at their hospital. HCWs should contact the IPC nurse at their own facility, if they have any questions.

The CDC are continually updating their information and guidelines, as is the Ministry of Health, so the latest information is always available on their websites.

The key to successfully containing any case of EVD lies in the hands of HCWs who, with the right equipment, education, practice and preparedness, will be well equipped to contain any cases that might reach New Zealand shores, while keeping themselves safe

How is the Ebola virus spread?

* EVD is spread by contact with blood or any other body fluid from a person with symptoms of EVD infection. Infection is spread when infected body fluids come into contact with mucous membranes or breaks in the skin or by sharps injuries.

* EVD is not transmitted through the air, unless there is exposure to body fluid droplets from an infected person (eg coughing, sneezing or spitting).

* EVD is not transmitted from persons who don't have symptoms of infection.


(1) Ministry of Health. (2014) Updated information for health professionals: Ebola virus disease (EVD). diseases-and-conditions/ebola-updates/ebola-information-healthprofessionals. Retrieved 23/10/2014.

(2) World Health Organisation. (2014) Global Alert and Response. Retrieved 23/10/2014.

(3) Health Quality and Safety Commission New Zealand. (2012) The 5 moments for hand health hygiene, php?option=com_content&view=article&id=9&Itemid=109. Retrieved 24/10/2014.

(4) Centres for Disease Control and Prevention. (2014) Guidance on Personal Protective Equipment To Be Used by Healthcare Workers During Management of Patients with Ebola Virus Disease in U.S. Hospitals, Including Procedures for Putting On (Donning) and Removing (Doffing), Retrieved 23/10/2014.

(5) Emory Healthcare. (2014) Emory Healthcare Ebola Preparedness Protocols, Retrieved 23/10/2014.

Report by infection prevention and control nurses' college committee chair Robyn Boyne

Robyn Boyne is an infection prevention and control clinical nurse specialist at Tauranga Hospital.
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Title Annotation:section & college news
Author:Boyne, Robyn
Publication:Kai Tiaki: Nursing New Zealand
Geographic Code:8NEWZ
Date:Nov 1, 2014
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