Keeping superbugs at bay
The Ebola crisis and the escalating fight against untreatable bacterial and viral diseases show no signs of abating and point towards a new level of risk for paramedics and other emergency responders.
The recent outbreaks of Ebola virus in West Africa and the public fear surrounding the possibility of global transmission has put the risks from highly communicable and non-treatable diseases firmly in the spotlight. Keeping ahead of deadly bacterial and viral pathogens is an uphill struggle and emergency services need to be prepared for the worst.
However, without deriding the natural anxiety in the UK over Ebola, the level of public fear is perhaps a little unwarranted given that should this particular disease be detected in the UK it will probably be relatively easy to contain. Unlike some other untreatable diseases, Ebola is not especially contagious and, although highly virulent, its symptoms manifest themselves quickly which allows for the rapid isolation of those infected.
Nonetheless, in an age of two billion air passengers every year and increasingly porous national borders the risk of deadly and difficult to control diseases arriving on these shores is very real and growing. And it is a threat that sits alongside the problem of more familiar homegrown diseases that are fast becoming resistant to modern antibiotics. According to a recent BBC report (1) it is estimated that drug-resistant strains of bacteria are already responsible for 5,000 deaths a year in the UK and 25,000 deaths a year in Europe.
WHAT IS BIO-HAZARD?
A biological hazard -'bio-hazard' - is any biological micro-organism or agent that poses a threat to humans, animals or the environment. In the vast majority of cases, micro-organisms are either beneficial or completely harmless to man. However, a small proportion are highly dangerous, sometimes deadly, and with their tenacity, ease of transmission, ease of replication, tendency to mutate, complete invisibility and unremittingly invasive behaviour, can present a unique challenge when it comes to their suppression and eradication. According to the
World Health Organisation dangerous pathogens such as bacteria, viruses and parasites are responsible for over 16% of the annual deaths worldwide (2).
Bio-hazards can present themselves in numerous ways and their very omnipresence can make them very difficult to manage and control. Bio-hazards may be bacterial, viral, parasitic or fungal and any source materials, such as contaminated body fluids, tainted packaging and dirty work surfaces are potential bio-risks. Causal origins of biological hazards range from decaying foodstuffs and faecal bacteria to highly virulent medical wastes and germ warfare agents. All of these bio-hazards and many others relate to the presence of infectious biological agents and biologically-derived toxins or contaminated materials including organic dusts and mould spores.
Bio-hazards also have widely varying transfer mechanisms. Some infectious diseases, influenza for example, can be contracted directly by touch or by inhaling respiratory droplets while others, such as tuberculosis, are mainly spread by airborne transmission. Malaria, on the other hand is transmitted by mosquitoes whilst Ebola and AIDS generally require the direct transfer of infected body fluids.
THE NEED FOR PROTECTIVE PROCEDURES AND BARRIERS
In practice, things are never so clear cut. Ebola, for example, can survive and remain infectious for 48 or more hours outside the human body (3) so it can be contracted simply by contact with a contaminated surface. And this means that stretchers, ambulances, medical equipment and PPE need to be rigorously decontaminated in the event of any possible exposure. Keeping these areas clean to the standard necessary to contain highly virulent pathogens such as Ebola is a challenge in itself and requires money, education and commitment. Such measures would no doubt put the emergency services under considerable strain should Ebola or a similar disease gain a foothold in the UK.
As can be seen from the recent Ebola outbreaks, exposure to biological contaminants can have very serious and rapidly escalating health consequences which means there is little room for complacency or delay when it comes to putting the correct protective procedures in place. The vast number of potentially dangerous micro-organisms and the huge range of possible biological risk conditions means that the selection of personal protection equipment (PPE) for personnel faced with live threatening pathogens can be a very complex exercise indeed.
Cases of paramedics and first responders contracting infectious diseases from patients and then passing them on, are not unknown.(4)
In addition to effective protection against naturally spreading infections and diseases, there is a need for personal protection in emergency response scenarios whenever biological agents are being manufactured, handled, distributed, studied, administered, neutered, removed or disposed of. The types of sites where these activities can occur include hospital facilities, defence and military establishments, medical and biological research laboratories and biotechnology production facilities. Bio-hazard precautions are also necessary in a wide range of crisis scenarios from flood management operations to trauma scene cleaning to bio-terrorism responses.
In all cases of biological hazard exposure a dedicated risk assessment must be carried out on all PPE ideally with reference to the performance classes described included in European Standard EN 14126 (5). Biological agents are classified into four categories (6) and, due to the extremely wide compass of risk involved with infective agents, it is absolutely essential that expert guidance is sought when selecting appropriate PPE for the different levels of hazard.
And safety for emergency responders isn't just about having the right protective gear. The correct training is every bit as important. It is a fact that many cases of biological hazard exposure have been due to lapses of attention or procedure; things that can easily happen in the stressful conditions of an emergency response situation. Armand Sprecher, the medical adviser to Doctors Without Borders for haemorrhagic fevers, affirmed this in a recent interview for NPR in the United States (7): "Where we see health care worker infections when the
PPE is in place, [the worker] did something to override the PPE: they didn't wear it appropriately or contaminated their hands in the process of getting [the suit] off."
In many people's view it is only a matter of time before a major national or international medical emergency occurs involving an incurable or very difficult to treat disease. The risks are hard to quantify; the difference between an isolated case and a global pandemic might be a single infected traveller stepping undetected off a plane. But if and when such a disaster strikes it will be the emergency services that put themselves on the line to protect, serve and support the public. We need to be preparing now to ensure this is a battle we do not lose.
(1) see http://www.bbc.co.uk/news/health-28098838
(2) World Health Organisation: The Global Burden of Disease: 2004 Update
(3) Public Health Agency of Canada; Ebola Virus - Pathogen Safety Data Sheet
(4) Putting their lives on the line: Meningitis in first responders; B. McKenna, Wired 11.18.10
(5) 'Performance Requirements and Test Methods for Protective Clothing Against Infective Agents'
(6) Refs: United States Centers for Disease Control and Prevention (CDC) and EU Directive 2000/54/EC
(7) This Suit Keeps Ebola Out - So How Can A Health Worker Catch It?; M. Silver; NPR; July 24, 2014