A Handy Guide to Freaking Out About Healthcare Workers and Ebola

(Click on the comic to see it larger) EbolaOccupationalHealth

If you spend any amount of time talking to people who work in U.S. hospitals, then you know some people who are totally over discussing Ebola. My friend Amanda, an EMT, recently announced, “I just discovered a new disease. It’s called E.I.F. (Ebola Information Fatigue). Symptoms appear during, or after, Ebola information and planning events and include mental overload, extreme tiredness, headache, and an urge to bash one’s head against a table upon hearing the phrase ‘but this will change.'” And it sure doesn’t help that the public conversation about Ebola for the past few weeks is all about doctors and nurses and whether or not their selfish desire to go bowling or biking is going to kill us all.

The misplaced priorities are pretty frustrating. Ebola matters–I’d like to think this goes without saying, given that more than 4,000 people have died in this outbreak, and it’s been predicted to get much, much worse. This is an urgent crisis in Guinea, Liberia, and Sierra Leone. But stateside the public conversation is all about us, with all of the urgency that should be applied to the epidemic in Western Africa instead being applied to freaking out about the handful of American healthcare workers who have been exposed.

Ebola is legitimately scary because of its high mortality rate–that is, a scarily high proportion of people who are infected die from the disease–but not because it’s especially infectious. As usual, however, the people hyping its scariness are doing so for reasons unrelated to epidemiology. Ebola has become a political issue because of the widespread concern that decades of budget cuts to the CDC and NIH have strained our health care system past the point where we can cope with a major epidemic. Nah, just kidding, it’s racism again.

So to help you wade through the mire of misinformation, and generally organize your response to the specter of Ebola on U.S. soil,  here, as promised, is a handy guide, which will help you to spend your freakout time in the most efficient way possible.

Question 1: Are you a healthcare worker?

Question 2: There is no question 2.

EbolaDogJokeIf you answered no to Question 1, stop freaking out about Ebola and go worry about any of the other completely horrible world events in the news. Seriously, consider yourself in the clear. It’s just not that easy to get Ebola. This is not the fictional virus in 12 Monkeys that was released just by unstoppering a test tube. To get Ebola you have to have contact with the fluids of a person who is already ill. People who have been exposed can take steps to isolate themselves before they become infectious as long as they watch out for symptoms. This last issue is why it really doesn’t matter that the infected doctor in New York went bowling the night before he got sick, and why I consider it plain that the governor of Maine’s attempts to isolate a nurse who wasn’t even infected was pure political theater.

If you’re worried about catching Ebola from randos on the subway, rest assured that regular folk can protect themselves from exposure by doing things you already have reasons to do: washing hands, using condoms, minimizing contact with other people’s vomit, etc. In a country with good sanitation and a (mostly) functional public health infrastructure, the risk to the general public is, to use a scientific term, bupkis. All known cases of Ebola have been people who cared for the sick or the dead.

But that, of course, is exactly what health care workers do. For them it’s a different question. In the countries where Ebola has been widely transmitted, over 200 health care workers have died. That’s just another number, but let the meaning of that sink in for a minute. People have continued to show up to work in drastically under-resourced settings to care for the sick and the dying, knowing their own lives were on the line.

In the U.S., obviously the situation is different–a handful of cases rather than thousands, comparatively abundant resources for infection control, and legal protections intended to prevent workers from catching their patients’ germs. There are protocols.

Here’s the catch. It turns out that the question of how Ebola is transmitted is a matter of some controversy, and by extension it is not clear whether the protocols which exist to protect health care workers are adequate. The epidemiologic evidence shows that dead horse I’ve been beating, that you can’t get Ebola unless you’re in close contact with an infected person. But other than proximity, there is not much evidence as to how the people who did get the virus got infected. For a comprehensive treatment of the topic by scientists who study occupational exposures and the transmission of pathogens, go read this commentary by Drs. Brosseau and Jones. For those less comfortable with technical language, I’ll provide a far less expert summary.

Ebola is assumed to be transmitted by droplets, meaning that when fluids are expelled from a sick person’s body into the air they are too heavy to stay there and quickly fall down to a surface below. That’s how colds are transmitted–different fluids, but the same principle. Unless someone sneezes directly into your mouth or eyes, most people catch droplet-transmitted infections by touching a surface onto which germ-laden droplets fell, and then touching their own eyes, nose, or mouth with their contaminated hand. The most powerful prevention for a droplet-transmitted pathogen is simple handwashing.

Airborne pathogens such as TB, in contrast, are found in small particles that stay in the air for long periods of time and travel greater distances, allowing people to breathe in the germs and become infected.  And because these particles are small, they can still slip in the space between your face and a mask, or even between your face and a respirator if the respirator doesn’t fit right or doesn’t filter out small enough particles.

I was always taught that there was a clear line between droplet transmission and airborne transmission, but the truth turns out to be more complex. As the commentary I linked to above makes clear, the concept of this binary distinction dates back to a time when no one had the ability to measure very small particles in the air. In reality there is more of a continuum. The closer you are to a sick person, the easier it is to breathe in larger droplets.

So it wouldn’t be accurate to say that a droplet-transmitted disease is never airborne. It is already well known that medical procedures can produce smaller droplets than occur naturally, aerosolizing the particles and allowing germs that would normally fall out of the air to stay airborne. Drs. Brosseau and Jones suggest that even vomiting or flushing a toilet can aerosolize infectious particles. These particles don’t stay in the air indefinitely like those of a true airborne disease, but people working close by can still breathe them in and get infected.

So why is this issue relevant to health care personnel in the U.S.? I’ve just got through explaining how Ebola in the U.S. is basically not a thing. What unnerves me, as a person staring down a lot of years working in a hospital, is that if Ebola is not that easy to get, what does it say about infection control in hospitals when healthcare workers get infected?

The two healthcare workers in Texas who contracted Ebola from the first U.S. patient back in September were exposed for one of two reasons. Either the protocols in place to prevent infection weren’t followed correctly, or the protocols were inadequate. It’s often hard to say which it is.  As this article in Science makes so vivid, there is not always an event that can be pinpointed to explain someone’s exposure.

The CDC has now changed its guidelines for working with patients with Ebola, but at the time that the first U.S. case was admitted, the official recommendation was droplet precautions. Someone scrupulously following the rules could still have been exposed. More concerning still is the case of the doctor in New York, who is one of a handful of people to become exposed during their time working with Doctors Without Borders, the organization whose protections for healthcare workers has become a model throughout the world.

When HIV first came to the U.S.,establishing universal precautions was an uphill battle. It succeeded in part because of the widespread fear of AIDS, and because health care workers who had contracted HIV from their patients told their stories and moved people to change the culture. The health care workers infected with Ebola remind us of the limits of these hard-won standard precautions. When greater protection means having to work in uncomfortable equipment, how worried would you have to be about getting sick to agitate for a new standard? Engineers, please get on this.

What does all this mean about all the other infections U.S. hospitals do see on a regular basis? If a nurse can get Ebola from her patient, she can get influenza from her patient. Which, incidentally, means her other patients can get influenza from her. For context, the U.S. recently had 770,000 hospital-acquired infections in a single year. That’s what I’m freaking out about today.

As a nation we have wasted a lot of our precious time worrying about whether a few health care workers pose a threat to the general public. Maybe we should be more worried about what it means for our health care when we force the people who care for us to risk their own health by doing their jobs.

 I’d like to thank my father-in-law Frank Mirer for steering me straight on some of the occupational health issues in this post.

I made that comic on Pixton.


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