Protecting health care workers from Ebola: personal protective equipment is critical but is not enough.

Infections among health care workers have played a major role in outbreaks of Ebola virus disease since the virus was discovered in 1976. Available data from past outbreaks show that the deaths of health care workers were the canary in the coal mine signaling that an outbreak of a viral hem­ orrhagic fever had begun. The current Ebola outbreak that is devastating West Africa is unfortunately no different. In addition to an unprecedented number of total infections and deaths (2473 and 1350, respectively, at the time of this writing), this outbreak has surpassed all previous ones with respect to the number of health care workers infected (1). As of 11 August 2014, more than 170 health care workers have been infected and more than 80 have died (2). In general, exposure and infection among health care workers typically occur before recognition of Ebola as the cause of a patient’s illness. The nonspecific and nonpathognomonic presenting symptoms associated with Ebola, in­ cluding fever, fatigue, and diarrhea, mirror the symptoms of more common ailments in sub-Saharan Africa, such as typhoid fever and malaria. The difficulty in the clinical recognition of Ebola combined with a lack of diagnostic capabilities complicates prevention efforts. Limited sup­ plies of personal protective equipment (PPE) that prevents nosocomial transmission, including gloves, gowns, and face masks, in addition to inadequate training in standard pre­ cautions and poor public health care infrastructure, can create an environment that fosters infection of health care workers with Ebola, primarily at the start of an outbreak. However, nosocomial transmission to health care workers can easily be mitigated with vigilance and the in­ stitution of barrier protection. In April 1995, a nosocomial cluster of Ebola was first identified among health care workers who participated in exploratory laparotomy of a laboratory worker with suspected typhoid-associated ab­ dominal perforation (3). Many of the health care workers who participated in the procedure unknowingly contracted Ebola from the patient and then spread the virus to their subsequent contacts (3). In total, 80 of the 315 (25%) persons infected during this 6-month epidemic were health care workers (3). Transmission primarily occurred before Ebola was recognized as the etiologic agent, and this out­ break was successfully terminated with the initiation of barrier protection techniques. If transmission of Ebola is effectively interrupted with barrier protection, why are so many health care workers in the current outbreak being infected, particularly this late in the epidemic? Two contributing factors include an insuffi-