Preparedness and Response to Ebola, and Other Healthcare-Related Issues


Tuesday, May 24, 2016, 10:30 AM - 12:30 PM


Managing the Potential Hazards from Electromagnetic Interference (EMI) with Personal Medical Electronic Devices in Workplaces

J. Bowman and G. Calvert, CDC/NIOSH, Cincinnati, OH; G. Girard, Medtronic, PLC, Minneapolis, MN; D. Witters, Food and Drug Administration, Rockville, MD

Situation/Problem: Personal Medical Electronic Devices (PMED) such as implanted pacemakers and body-worn insulin pumps can be susceptible to EMI from the high electric and magnetic fields (EMF) in some workplaces. When employees with PMEDs want to work around EMF sources, the available recommendations on preventing EMI, such as the EMF TLVs®, can be difficult to apply. A clearer method is needed to collect and assess the information needed to make sound decisions on assuring the electromagnetic compatibility (EMC) of a PMED with workplace EMF.

Resolution: NIOSH initiated a collaboration with PMED experts to develop a strategy for managing and mitigating the EMI risks from lower frequency occupational EMF. The proposed strategy calls for industrial hygienists to collaborate with workers who have PMEDs and their physicians to gather key information on the EMC testing by device manufacturers, worker EMF exposures, and the health consequences of device malfunctions. The goal is an informed decision on whether the employee can work safely at the evaluated worksite. Our strategy includes PMED advisory limits on worksite EMF which we derived from acceptable EMC levels in ISO’s PMED standards. When EMF exposures at a worksite exceeds either these advisory limits or a PMED’s EMC levels, the device’s malfunction risks can be mitigated by engineering and behavioral controls of EMF exposures, or by altering the PMED’s settings.

Results: The proposed strategy was initially verified with EMF survey data conducted for employees with PMEDs. One example is an electrician with an implanted pacemaker who had been exposed to magnetic fields over 2,000 μT at his tractor manufacturing plant. Under our proposal, he would not be allowed to continue in that job because its exposures exceed NIOSH’s 70 μT advisory limits. In another example, a steel worker with an implanted Spinal Cord Stimulator operated a galvanizing line exposing him to 280 μT. Since the device manufacturer reported its EMC level was 264 μT, the line operator might be allowed to work in this site with some restrictions.

Lessons learned: Safety decisions on workers with PMEDs are difficult because industrial hygienists and most physicians do not have all the needed expertise. The proposed strategy is based on a new vision of collaboration with PMED workers that can accurately assess their EMI risks and decide the best course for all parties. To improve these procedures, NIOSH will be seeking comments from industrial hygienists and other stakeholders before their publication.



Developing an Effective and Flexible Ebola Preparedness Plan

M. Tortora, CT Children's Medical Center, Middletown, CT

Situation/Problem: The Ebola epidemic in West Africa made the international news when the first case was discovered in the US in Sept. 2014. The transfer of the virus to two healthcare workers in the Dallas Hospital, where the patient reported, created a frenzy of preparedness activity at all US hospitals in the aftermath. Most hospitals were not prepared to detect, accept and treat a patient with this virus. CT Children’s, shortly after the Dallas Hospital incident, needed to get up to speed to effectively screen, accept and treat a patient with Ebola, while keeping all staff safe.

Resolution: A large, multi-disciplined group of individuals met shortly after the Dallas exposure and formed an Ebola Task Force committee. This committee was tasked to quickly prepare the hospital to screen, accept and treat a patient with Ebola. This group took on the form of a sub-committee of the hospital emergency operations committee (HEOP). The committee was tasked with the following activities: development of screening of all individuals entering the hospital, procedures for isolating an individual with positive travel history, training of staff in use of proper PPE and procedures for safely donning and doffing and planning exercises, practicing all aspects of caring for a patient with Ebola. This resulted in the development of the Ebola Preparedness Plan.

Results: The effectiveness of the program was measured by conducting several mock exercises at the main hospital as well as off-site clinics, and testing the overall incident command system during an event where an affected patient enters the hospital. Effective critiquing of the overall operations helped to develop the program successfully, instill confidence in hospital staff that we would be able to care for a patient safely and enhance our hospital emergency operations plan and incident command response.

Lessons learned: Lessons learned are how important it is to have supplies on hand (PPE, cleaning, etc...) due to the equipment shortages during the crisis, how quickly individuals become engaged in the planning and then exit the process as well as how complex it is to put together a response team to safely care for a patient with Ebola virus. This plan can be adjusted for any future emerging infectious disease.



Ebola Virus Disease Waste Management in the Medical Treatment Facility

L. Baetz, Army Public Health Center (Provisional), APG, MD

Situation/Problem: In 2014, Army Public Health Center (Provisional) responded to a query concerning the Army’s waste management plan for the Ebola patient treatment. The two medical waste incinerators at Fort Detrick are the Army’s only permitted medical waste incinerators. According to their permit, they cannot accept waste from off-site sources.

Resolution: The Army's waste plan for the controlled monitoring sites includes handling all waste as routine solid waste which will be disposed of through installation channels. All waste from the treatment of EVD patients, will be collected and stored separately, packaged into approved-category A drums and transported for treatment and disposal by the existing MEDCOM-wide contract for medical waste disposal.

Results: An EVD waste management Standard Operating Procedure has been developed for managing waste and has been distributed to all Army MTFs to develop their MTF site-specific plans.

Lessons learned: The Army needed to develop guidance for handling waste generated in the care for patients under investigation (PUIs) for Ebola virus disease (EVD) or with confirmed cases of EVD.



U.S. Army Medical Research Institute of Infectious Diseases Support in the Ebola Effort

N. Woollen, Army Medical Research and Materiel Command, Ft Detrick, MD

Situation/Problem: U.S. Army Medical Research Institute of Infectious Diseases played a significant role in assisting the Ebola virus outbreak response in West Africa (on-site laboratory support, diagnostic tools, drug and vaccine research, and biomarkers).

Resolution: Collaboration allows USAMRIID to bring their expertise to bear in responding to an international health crisis.

Results: From on-site laboratory support in Liberia, to training of key personnel, to accelerated research efforts on diagnostic, vaccine and treatment approaches. In addition to providing laboratory testing and training support for the outbreak, USAMRIID provided more than 10,000 Ebola laboratory tests to support laboratory capabilities in Liberia and Sierra Leone.

Lessons learned: A well-coordinated multiagency response was needed to provide an effective rapid response.



Acute Symptoms and Exposure to Hydrogen Peroxide, Acetic Acid and Peracetic Acid in Hospital Cleaning Staff

B. Hawley, M. Casey, M. Virji, and J. Cox-Ganser, Respiratory Health Division, CDC/NIOSH, Morgantown, WV

Objective: Peracetic acid (PAA) is widely used as a disinfectant in healthcare and food production settings, however, occupational PAA exposures have been largely overlooked due to: (1) previous sampling and analytical method limitations and (2) the absence of a current OSHA Permissible Exposure Limit (PEL) or NIOSH Recommended Exposure Limit (REL). In the summer of 2015, NIOSH performed an industrial hygiene survey at a hospital where a new cleaning and disinfectant product, consisting of hydrogen peroxide (HP), acetic acid (AA) and PAA. HP and PAA are strong oxidants and their mixture is listed as an asthmagen and sensitizer by the Association of Occupational and Environmental Clinics. However, few exposure assessment studies to date have measured HP and PAA in a healthcare setting.

Methods: In July and September of 2015, a health and environmental assessment survey was conducted at the hospital. We collected 50 full-shift air samples (41 personal and 9 area samples) and analyzed for HP, AA, and PAA content. We also observed hospital staff performing cleaning duties and noted duration and frequency of cleaning product use. Acute irritation and respiratory symptoms were recorded in a post-shift survey (n = 50). Exposure factors associated with airway symptoms were used to develop recommendations to mitigate potential health risks due to cleaning product exposure.

Results: Partial air sampling results from our July survey ranged from 15-94 ppb for HP, 68-155 ppb for AA and 5-21 ppb for PAA; all measurements for HP and AA were below their respective OSHA PEL or NIOSH REL. Mucus membrane irritation symptoms were reported by 64% (n=32/50) of workers and 84% (n=27/32) reported symptom onset while cleaning. Lower airway symptoms such as cough, wheeze, chest tightness, shortness of breath or difficulty breathing were reported in 34% (n=17/50) of workers, of which, 88% (n=15/17) reported symptom onset during cleaning activities and 82% (n=14/17) worked in areas with high cleaning product use.

Conclusions: Hospital workers using a disinfecting product containing HP, AA and PAA reported work onset airway symptoms despite low levels of measured exposures. Because both HP and PAA are strong oxidants, it is plausible that the mixture of HP and PAA likely contributed to the airway symptoms reported by workers despite low levels of exposure.



Effect of Multiple Alcohol-Based Hand Rub Treatments on Tensile Strength and Elongation of Thirteen Brands of Medical Exam Nitrile and Latex Gloves

P. Gao, G. Niezgoda, and R. Shaffer, CDC/NIOSH, Pittsburgh, PA; M. Horvatin and R. Weible, URS Corporation, Aiken, SC

Objective: Current CDC guidance for the disinfection of gloved hands during personal protective equipment doffing following care of a patient with Ebola allows for multiple applications of alcohol-based hand rub (ABHR) on medical exam gloves. The purpose of this study was to evaluate the effect of ABHR treatments on glove integrity based on changes in tensile properties.

Methods: Thirteen brands of medical exam gloves (8 brands of nitrile and 5 brands of latex from 5 manufacturers), and two different ABHRs containing 70% ethanol and 63% isopropanol, respectively, were included in this study. For each brand, 140 gloves were tested. Thicknesses of the new gloves measured in the palm areas ranged from 0.129 to 0.226 mm among 700 latex gloves and 0.057 to 0.143 mm among 1120 nitrile gloves. A pair of gloves were worn by a test operator and outside surfaces of the gloves were treated with either ABHR for 1 to 6 treatments. Ultimate tensile strength and elongation of the gloves without ABHR treatment and after 1 to 6 treatments were measured based on ASTM D412 standard method by using an Instron Universal Testing Machine with a 500N load cell. Ten replicates were performed and analysis of variance was used for statistical comparison.

Results: Compared to gloves without ABHR treatment, mean tensile strength of the 5 brands of latex gloves decreased 4.3% (p > 0.05) after 6 ABHR treatments using ethanol-based hand rub (EBHR) and 18% (p < 0.05) using isopropanol-based hand rub (IBHR). Mean elongation increased 2% (p > 0.05) and decreased 2% (p > 0.05) after 6 treatments using EBHR and IBHR, respectively. For the 8 brands of nitrile gloves after 6 treatments, mean tensile strength decreased 26% (p < 0.05) using EBHR and 36% using IBHR (p < 0.05). Mean elongation increased 1.7% (p > 0.05) using EBHR and 4.8% (p < 0.05) using IBHR after 6 treatments. It appeared that changes in the tensile properties increased with each ABHR application. For instance, mean decreases of the tensile strength for the nitrile gloves after 3 and 4 EBHR treatments were 14% and 18% respectively.

Conclusions: The preliminary results indicate that ABHRs had more effect on tensile strength of the tested nitrile than latex gloves. In general, EBHR resulted in lesser changes in tensile strength compared to IBHR. Nevertheless, after up to 6 treatments all tested gloves still met NFPA 1999 glove requirements for tensile strength ≥ 14 MPa and elongation ≥ 500%, except for two brands of relatively thin gloves (0.059 and 0.087 mm), 15% of the 13 brands tested.​