Life as an Extreme Sport

No, American Doctors, You Don’t Need Tyvek In Case of Ebola

One of the more interesting aspects of the constant media coverage of the latest Ebola outbreak has been watching how developed nations like the United States, Britain, and Canada assume that the entire world is Just Like Them. The Seattle Times had a charming example of this yesterday, with American doctors questioning the CDC guidelines for how to care for an Ebola patient in America. An example of the ignorance on display comes from Tulsa, Oklahoma emergency physician Justin Fairless, who says that health care workers in West African nations

are wearing the highest level of protection, but the CDC recommendation lets us go down to the lowest level of protection.

Now, the CDC has repeatedly said that caring for patients in African nations is quite different than caring for patients in America, Canada, other developed nations, but apparently Dr. Fairless and others need a pictorial show-and-tell to understand that not everyone lives and works in a state-of-the-art world.

But first, a bit of description to set the stage for the pictures you are about to see. (Note: There are no sick or dead bodies in the following photographs.) This is from a Pulitzer Center on Crisis Reporting report on maternal/fetal care in Guinea, published in February of 2014, before the international community was aware of the Ebola outbreak:

“The biggest problems at Donka are no electricity, no water, no equipment, no sanitation and very high rates of infection,” said Bintu Cisse, adjunct midwife supervisor, who has worked at Donka National Hospital for 20 years … External support provides some operational assistance, but Donka lacks basic facilities due to the inefficiency of Guinea’s under-performing infrastructure … Inside the maternity ward operating room, Cisse pointed out that the equipment did not work and doctors used suspended basins of water and a mixture of chlorine to sanitize. The main light sources were open windows””outside garbage was burning.

Cisse is describing the largest medical center in Guniea, Donka Hospital, which is also the university teaching hospital for the country.

This is what their isolation unit looks like:

Donka Hospital Isolation Tents. Cellou Binani/AFP/Getty Images.
Donka Hospital Isolation Tents. Cellou Binani/AFP/Getty Images.

Those are tents. Here’s what those tents look like on the inside:
DonkaIsolationWard-Open

When patients are inside, they are lined up on cots, one after another. There is nothing separating the patients from anyone, or anything. There is no airflow system—isolation wards in regions where Ebola is active tend to work by setting up large barriers to prevent people from getting close enough to worry about contagion; this could be large plastic sheeting, it could be fences that indicate the line at which people should not pass.

This is what an isolation unit looks like at your average, developed world, fully-equipped hospital:

Isolation room at Wellington Hospital, New Zealand.
Isolation room at Wellington Hospital, New Zealand.

So, as you can see, Dr. Fairless, and others, things are just a little bit different in countries where the GDP is more than USD 6 billion a year.

A MSF worker suits up to care for Ebola patients.
A MSF worker suits up to care for Ebola patients.
The major difference in treatment, aside from already-discussed issues, is who is in isolation. More specifically, in places like Guinea, Liberia, and Sierra Leone, while patients are isolated from other people in order to curtail infection, the health care workers are the ones “in isolation”—they’re the ones who are kitted up in bunny suits, in full Tyvek, layers of gloves, and the whole nine yards. Because: see above. The effort here is to keep the HCW in a protective environment to limit transmission to the worker, because it’s impossible to keep the patients inside a protective environment, due to the economy, the lack of infrastructure, the lack of ability because there’s no technology, there’s no power.

Isolation units in America and other developed countries, on the other hand, function to keep the patient inside isolation; patients are isolated from others to curtail infection, and that includes being “in isolation”: that is, the protective bubble that bunny suits and Tyvek create for HCWs in Guinea, etc, is extended around the patient in the form of negative air pressure rooms and glass walls.

In that sort of environment, the basics of gloves, gown, and mask are more than sufficient to care for a patient with Ebola—or any other highly infective agent. Which is why that’s what the CDC recommendations are; because technology and care levels are different, and the basic approach to isolating and isolation can change.

It’s also worth remembering that bunny suits and Tyvek weren’t always around when people were fighting Ebola. Here’s what Peter Piot was wearing in 1976, when Ebola was first recognized:

Peter Piot wearing protective gear in Yambuku, 1976.
Peter Piot wearing protective gear in Yambuku, 1976.

That’s how the outbreak was stopped in 1976. In conditions that in many ways were worse than in the pictures shown above.

The doctors and other health care workers in that Seattle Times piece should be ashamed of themselves, demanding bunny suits and Tyvek and full protective gear when not only is it unnecessary, it’s a waste of money. But more than that, and even more than the myopic view of the world that appears to assume everywhere is just like their tidy and neat and well-staffed and well-maintained medical center, it illustrates the continued “me me me” reaction people in the developed world have around Ebola.

…after all, you don’t hear anyone suggesting that full isolation suites be sent to Guinea, or Sierra Leone, or Liberia, so that those countries can revert to the simpler CDC recommendations, do you?

10 comments

  1. WHAT IF: This is a 6th variant (a new version of the virus) and is air born. This is being discussed across the globe. It has been stated it is air born in animals by facilities in Canada. WHAT IF…lets be safe, not sorry!!!

    1. This is not a new variant, the disease it not airborne, and safety is utilizing standard precautions and proper PPE. Which, in the case of America and other Developed Nations, and as seen in the last month, is simple glove and gown protection.

  2. It seems you are more interested in pointing out the difference between poor and wealthy people in this write up.
    The picture of Dr. Piot appears to show the equivalent tech 1976 had to offer. If they had tyvek I am sure they would have used it. I bet tyvek is cheaper now than a rubberized gown is. We can buy Tyvek suits at Home Depot for under $10. Far superior face protection and filtration is available for the comfort of workers. Why not use it, since comfort can increase a workers duration which will increase the number of patients they can treat. Forget about the fatigue of equipment which always needs adjusted creating risk to the worker. This is a high intensity exposure, risk is extremely high. Dr Piot worked at great risk and that is a testament to this persons empathy for others. Please don’t underestimate how minor slip ups can cause great harm.
    I work in a technical environment supervising a crew who work regularly with extreme toxins/chemicals. We work 12 hour shifts in gear that is hot, doing maintenance that can be grueling. It’s the PPE (Personal Protective Equipment) which is generally overkill that keeps them safe, particularly when mistakes are made. I would guess Doctors and Nurses helping Ebola victims could relate except we don’t fix people. The bottom line for PPE is it keeps the person safe and truly is not that expensive when you think of how it protects from further spread as we are seeing in Africa and now into the US.
    It’s rather cheap so why not be safer for everyone’s sake.

    1. Because the presumption that PPE makes people safer is, in a word, wrong. As a matter of fact, quite the opposite: repeated studies show us that people who use PPE who are not frequently using it and accustomed to it make more mistakes than those following basic barrier practice protocols.

      Comfort for aid workers isn’t an issue in American hospitals, unless, of course, you think it’s common for American hospitals to not have basic HVAC equipment.

      The difference in society—and yes, extreme poverty vs. one of the wealthiest nations on Earth—is extremely important when discussing Ebola. Pretending otherwise is ignorant; it’s up to you if it’s willful or not.

      1. Ebola is a BSL-4 biosafety hazard and a class A biowarfare agent. That is science, not speculation.

        People who are using <BSL-4 appropriate (ie, substandard) protective gear should not consider themselves safe with respect to the ebola virus.

        They maybe lucky, but they are rolling the dice.

        The reality is that the WHO recommends sub-standard PPE so they don't scare or offens local populations who need to fight this disease under duress and in backcountry settings.

        In other words, the WHO and (nov revised) "safety guidelines" are pure political propoganda on the front line of this disease.

        Frankly, common Tyvek and similar (eg, 1441 type) fabrics may not really be appropriate without additional precautions. They are micro-porus its possible to wet them through under field-conditions.

        The appropriate fabric is actually something else.
        So, its safe to say this essay (however meaningful) is adjectly wrong both in its fundamental assumtions ("tyvek is overkill") and its conclusions as a result (Tyvek is actually not enough–you need something better).

        (Pleas see du Pont's website if you doubt this).

        1. Rather than look at du Pont—a company that has a vested interest in selling supplies—I think I’ll go with actual BSL-3 & -4 researchers. For example, Stephen Goldstein points out in The Atlantic that

          In reality, the gold standard for clinical Ebola PPE, recommended by Doctors Without Borders and now the CDC, is something less than that. This entails full skin coverage with an impermeable gown or suit, use of a respirator to protect the worker during procedures like intubation, double gloves, and show covers. This all sounds a lot like what we wear to work with SARS or MERS, two viruses that require BSL-3 containment and procedures.

          The specialized facilities we have to treat diseases like Ebola do reflect this. None of the hospitals that have safely treated Ebola patients, Emory, University of Nebraska, the NIH, or Bellevue have BSL-4 medical suites. What they have are contained-isolation rooms and the rigorous and careful use of BSL-3-like PPE by highly trained staff.

          How Ebola is handled in laboratory research environments is a complete different thing than real-world scenarios. Please do your best to avoid propaganda by those who want to sell things, and instead rely on science.

  3. As someone who received a unit of counterterrorism training specifically related to Ebola (Pre-9/11 I might add), I can tell you that you are wrong. Tyvek C should be minimum. The “Extra Margin” is worth it. Frankly I wouldn’t go into an Ebola ward without a positive pressure suit. Just ask the Nurse in Dallas and her boyfriend. The CDC was wrong to contradict the original FEMA guidelines. The “New Research” the media is parroting is information my dumb, uneducated, first-responder mind has known for 15 years now. A Tyvek C suit costs around 8-10 dollars. Add booties, a proper respirator filter, proper gloves and you still come in well under $40.00 for PPE.

  4. Do you believe your viewpoint still holds merit after 2 nurses in Dallas were infected, and the CDC now updated their guidlines to be more stringent?

    1. Actually, the CDC nurses were infected because they weren’t following the protocols suggested by the CDC. The new CDC protocols still are not the same as the ones used in Africa, so yes, my “viewpoint still holds merit,” in that it’s still correct.

      Basic barrier control is all that’s needed to control an Ebola outbreak. It’s a pretty sad day when that’s difficult to achieve in America. (Then again, basic barrier control also involves other simple things we’ve been unable to get the majority of the medical community to consistently do,… like wash their hands.)

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