The Ebola emergency and the choice to use safety devices in operational protocols

Just a few hours ago, Gino Strada, the founder of the NGO Emergency, wrote on Facebook: "We made it, this time, the epidemic is under control. There will be a few more cases, but this outbreak has been defeated, at last". Therefore, we now feel it is appropriate to look back at the epidemic which has shaken our world.

 What is the Ebola Virus Disease (EVD)? Formerly known as Ebola haemorrhagic fever, it is a severe disease, quite often fatal, caused by a virus in the family Filoviridae. There are five species, 4 of which cause the disease in humans. The ebolaviruses are classified as biological agents belonging to risk group 4. Such biological agents, as defined by European legislation, cause severe human disease and are a serious hazard to workers; they may present a high risk of spreading to the community and there is usually no effective prophylaxis or treatment available.
The natural reservoir for Ebola has yet to be confirmed; however, bats are considered to be the most likely candidate species. Occasionally, the infection is transmitted to a secondary host (humans and other animals), who develops the disease. Humans become infected through contact with infected animals (hunting; slaughter; food consumption), which usually means monkeys, or, more rarely, through contact with bats, i.e. normal carriers. Once a person is infected, EVD can spread between people. The incubation period ranges from 2 to 21 days, 8-10 on average.
EVD is highly infective, human-to-human transmission occurs through via direct contact (through broken skin or mucous membranes) with the blood, secretions, organs or other bodily fluids, including saliva droplets, of infected people, be they alive or dead.
The early symptoms of EVD resemble those of influenza (fever and weakness), together with joint pain, muscle pain, headache, loss of appetite and even hiccough. Then gastrointestinal symptoms follow (nausea, vomit and diarrhoea). Haemorrhage occurs in the later stages, sometimes even internal haemorrhage.
The latest outbreak caused over 10,700 victims and 26,000 infections between Guinea, Liberia and Sierra Leone. In recent months, however, the number of new cases has decreased to and reached a new low in the week of 5th April, with only 30 new cases (and in the next few days it rose to 37).

The healthcare setting is considered high-risk when it comes to transmission, even though the risk for healthcare workers is proportionate to the degree of compliance with preventive measure (standard precautions and mode of transmission), be they common or specific for assistance to EVD patients, the kind of treatment offered and the clinical stage of the disease.
Taking this all into account, AIRESPSA (The Italian Association of Managers and Workers for Prevention and Protection in the Healthcare Setting) has organised a series of events on prevention from the Ebola Virus. These meetings promoted sharing the operational procedures of national healthcare centres with the nationwide leading institute, IRCCS Lazzaro Spallanzani, and also with Don Dante Carraro, the Head of Medici con L'Africa Cuamm and Dr Tampellini from Doctors Without Borders, working in Sierra Leone.
This initiative involved those who have actually dealt with the risk of contagion and helped draw from their experience with preventive measures and personal protective equipment. We will now sum these up in order to highlight that protection from Ebola virus contagion actually consists in implementing the standards
ENVIRONMENTAL MEASURES: the ward and the isolation unit should have separate access with a dedicated route leading to the patient's room. The patient's room should be a one-bed en-suite negative-pressure room (whose ventilation system ensures at least 6 air changes per hour), and it should be equipped with a negative-pressure filter zone furnished with sinks and an interphone. Air flowing out of the room should be filtered using HEPA filters
PERSONAL MEASURES: healthcare workers should enter the isolation room wearing personal protective equipment (PPE).
The patient should stay in his/her room, the doors should always be kept closed and no visitors allowed.
Patients in isolation should be cared for by staff who have received the necessary training on isolation, PPE use and compliance with WHO-mandated '5 Moments for Hand Hygiene' guidelines.
Staff who work in this area should undergo specific health monitoring.
MEASURES ON HANDLING SHARPS: they are regulated by the Health Ministry Decree 28/09/90 et seq. Article 2 states: "disposal of sharps, used on any patient, shall be carried out using appropriate precautions to avoid accidental injuries. In particular, needles, scalpel blades and other disposable sharps shall never be removed from syringes or other tools and shall never be recapped. They shall be put in the appropriate container for disposal."
All healthcare workers should take measures to prevent accidental sharps injuries, when using, cleaning and disposing of sharps.
Using only safety devices, prescribing blood tests only when really necessary and keeping sharps handling to the minimum are highly recommended.
MEASURES TO BE TAKEN IN CASE OF AN ACCIDENT: when an accidental sharps injury to the hand occurs, the first pair of gloves shall be disposed of in the patient's room. The worker should then leave the filter zone, dispose of the second pair of gloves, clean his/her hands thoroughly and disinfect his/her wound.
All accidents should immediately be reported to the doctor in charge of monitoring and carrying out the follow-up procedures.
Isolating healthcare workers who are at risk, especially when it comes to highly dangerous viruses such as Ebola, is the key to avoid exposure. Thus, taking all the preventive measures and using correctly personal protective equipment is vital and so is taking the utmost care in dressing, undressing and disposing of disposable devices. Using safety devices is therefore even more important, as they eliminate the risk of accidental sharps injuries and increase safety for healthcare workers.