School of Public Health and Community Medicine

Experts warn Ebola health worker guidelines may be putting lives at risk

Army technician sets up an assay Ebola within containment laboratory. Photo by Dr. Randal J. Schoepp. Flickr Creative Commons. Attribution license

Sydney, 9 September 2014 – Public health experts have raised concerns about guidelines that suggest health workers need only wear surgical masks rather than higher-level protective equipment, such as respirators, when treating Ebola patients.

The West African region is experiencing an unprecedented epidemic of Ebola virus. Ebola causes a highly lethal viral haemorrhagic fever, and up to a 90% death rate. The West-African region has among the highest rates of poverty and the poorest health systems, making the epidemic difficult to control. The World Health Organization (WHO) has said the epidemic is outpacing attempts to control it, and declared a global public health emergency on 8th August 2014.

UNSW Australia Professor of Infectious Diseases Epidemiology Raina MacIntyre is the lead author of a guest editorial that questions the health worker protection guidelines issued by the World Health Orgainization (WHO), the US Centers for Disease Control and Prevention (CDC) and countries including Australia. It is published today in the online issue of the International Journal of Nursing Studies (IJNS).

The CDC, the WHO and many countries including Australia recommend surgical masks for health care workers (HCWs) treating Ebola, based on evidence that Ebola is largely transmitted through direct contact with blood and bodily fluids. The guidelines only consider this theoretical principal of transmission based on limited experimental studies and epidemiologic data.  In a bizzare contradiction, the same organisations recommend higher levels of protection (including respirators, which filter smaller particles than masks, and also create a seal around the face) for scientists working with Ebola in laboratories. Yet scientists work in a cleaner, more controlled environment than nurses and doctors. “The hospital is an unpredictable, highly contaminated setting which poses higher risk of Ebola transmission. It makes no sense to play Russian roulette with the lives of our health workers,” Professor MacIntyre says.  Professor MacIntyre argues that the research evidence about the transmission of Ebola is limited and uncertain, and the guidelines may be putting the lives of health workers at risk.

“Guidelines that recommend masks do so solely on the basis of Ebola being transmitted theoretically by direct contact only,” she says. “They fail to consider the complexity of infection transmission in the clinical setting, and the documented spread of Ebola by other modes. They also fail to consider the high death rate of Ebola, the lack of available proven treatments or vaccines, and the human price we may pay by getting it wrong. A more comprehensive risk-analysis approach is needed.”

Protective equipment used by health workers treating Ebola patients is controversial. The IJNS guest editorial challenges a letter published in The Lancet in August, which argued that in some cases “goggles and masks might not even be necessary to speak with conscious patients, as long as a distance of 1-2 metres is maintained”.

This comes as Medecins Sans Fronteires (MSF) has said the global response to the Ebola outbreak has been “lethally inadequate” and called for urgent military intervention as health systems have crumbled. Hundreds of frontline health workers have already contracted Ebola or died, many while wearing masks. MSF, who is the main outside responder to the outbreak, also recommends the highest level of PPE for health workers, and so far no MSF worker has contracted Ebola. In contrast, a WHO worker contracted Ebola despite reportedly not having direct contact with an Ebola patient.

Professor MacIntyre’s concerns are shared by co-authors Professor Patricia Davidson, Dean of Nursing at John Hopkins University in the US and Professor Guy Richards, an intensive care specialist from the University of Witwatersrand, Johannesburg, South Africa who managed an Ebola outbreak and whose work was cited in support of the WHO/CDC guidelines. All three argue the guidelines that recommend surgical masks for Ebola should be urgently reviewed.

“Whilst theoretical and experiment data support that Ebola is predominantly spread by direct contact, the reality in the hospital setting is much more complex,” says Professor Richards. “There is a lot of uncertainty around the mode of transmission of Ebola in hospitals … I am surprised that my paper on the South African outbreak has been cited in support of these guidelines ... I think the full PPE [personal protective equipment] is warranted for health workers treating Ebola.”

An excerpt on Ebola PPE from MacIntyre’s keynote address at the UNSW Symposium on Public Health Aspects of Infectious Diseases on September 4, 2014, is available at

https://www.youtube.com/watch?v=ahBzAn4w-9M&feature=youtu.be

The full talk on PPE is available here: https://www.youtube.com/watch?v=If8B7lpHBP0

Editorial: http://www.sciencedirect.com/science/article/pii/S002074891400234X#

Contact Name : 
Prof Raina MacIntyre
Phone : 
+61 2 9385 3811