BRUSSELS – Inside the eight-piece protective suits worn by doctors on the front lines of the Ebola outbreak, the temperature reaches at least 115 degrees Fahrenheit. But one of the most dangerous moments on the job is going through the 12 steps to take off the suit, which can take 30 minutes.
On a fallow field behind a logistics warehouse in Brussels, Doctors Without Borders runs a training camp for medical staff heading to Ebola hot spots in West Africa. After a full day of classroom instruction on everything from preparation of chlorine solutions to how to safely bury the dead, 12 participants gather inside a tent that simulates an emergency treatment center.
They’re here to learn that if they wear glasses, they need anti-fog spray to cope with 90 percent humidity. Not an inch of skin can be exposed, and the protective hood should cover the eyebrows. They should breathe and move slowly to deal with the suffocating heat. They’re advised to bring lots of extra socks because they’ll become soaked in sweat, and wet socks can lead to blisters.
“The first 15 minutes I was just hot,” said Douglas Lyon, a physician and epidemiologist from Portland, Oregon, on his way to Sierra Leone. “After that I was hot and had a wicked headache. Each breath in was a mix of a hint of cool relief and the feeling of suffocation. Each breath out was as warm and hot and humid as the rest of you.”
In the current Ebola outbreak, the worst ever, at least 300 health workers have been infected and about half have died, highlighting the need for protective gear and proper training on wearing and removing it. Doctors Without Borders had never had a case of Ebola infection among its international workers until earlier this month, when the nonprofit aid group said a French staff member had the disease. It’s investigating how that occurred.
One of the riskiest steps is taking off the suit without touching the yellow exterior that may be compromised with infectious blood or other fluids. Participants at the training, sweat pouring down their faces, were visibly frustrated trying to remove pant legs over boots without using their hands. In between stripping off each item – the first of two sets of gloves, apron, goggles, hood, coverall, mask, boots – hands must be washed in chlorinated water, a crucial step that’s easy to neglect.
“When you’re putting it on, it’s all clean, so if you make a mistake, you can readjust things,” said Lyon, whose work with Doctors Without Borders began in 1994 at a Hutu refugee camp in Zaire amid a cholera epidemic. “But taking it off, you can’t make a mistake. Even though you’ve been sprayed with chlorine, there’s always a chance there’s something on you.”
For a novice, the removal process can take 30 minutes. Doctors repeat the steps as many as four or five times a day, as the 115-degree heat and humidity sap their concentration at every stage.
“Believe it or not, many people don’t know how to remove protective clothing in a way that keeps them safe,” said Ian Lipkin, an infectious disease and outbreak response expert at Columbia University in New York.
Failing to get it right obviates the need for wearing protective equipment in the first place, said Lipkin, who was chief scientific consultant for the film “Contagion,” a thriller about the rapid spread of a virus. “You need to make certain these people are well-trained.”
Inadequate instruction – and in some cases a lack of availability of the protective gear – are among reasons that health workers have been infected, according to the World Health Organization.
A shortage of workers means they are overburdened and make mistakes when tired, said the Geneva-based group, which last month issued a “rapid update” of 2008 guidelines for dealing with Ebola patients. The group advises national health authorities and trains local health workers.
Doctors Without Borders, which trains all of its medical-care providers in using the clothing, recently ordered 25,000 sets, figuring that’s a two-month supply for operating one Ebola care center in Liberia and doing community outreach.
The International Medical Corps, another group fighting Ebola, says a treatment facility with 70 patients goes through about 200 sets of protective clothing a day. A 50-bed treatment center costs about $1 million a month to run, the group said.
The protective items cost about $77 a set, and Doctors Without Borders, largely supported by private donations and known as Medecins Sans Frontieres in much of the world, pays the bill. After each use, the clothing is incinerated with other medical waste. Manufacturers include DuPont Co. for full-body suits, Dunlop for boots, Uvex Group for goggles and Kanam Latex Industries for gloves.
Doctors perform blood tests to confirm Ebola cases, and then give supportive care such as antibiotics and intravenous fluids or oral rehydration with solutions that contain electrolytes.
Since the start of the outbreak in December, the virus has infected 5,864 people, killing 2,811, according to a Sept. 22 WHO report. The disease has reached five West African countries, accelerating in cities including Monrovia, Liberia’s capital. Most cases have been in Guinea, Liberia and Sierra Leone.
The outbreak could spread to hundreds of thousands more people, according to an estimate published yesterday by the U.S. Centers for Disease Control and Prevention. There may be 550,000 to 1.4 million cases in Liberia and Sierra Leone by January, using a model that assumes a significant failure of public health efforts and underreporting of cases.
The World Health Organization said Friday that there may be 21,000 cases by November – in Liberia, Sierra Leone and Guinea – if control efforts aren’t quickly increased.
There is no cure for the virus, which is spread through direct contact with bodily fluids from an infected person. The hope is that a patient’s immune system will fight off the aggressive attack. Ebola causes fever, diarrhea, muscle pain and vomiting, and as it progresses can lead to bleeding from the eyes, ears and nose.
Beyond the health crisis, the World Bank warned that economic costs may escalate to “catastrophic” proportions and U.S. President Barack Obama has said that Ebola poses a threat to global security.
As infection numbers spiral upward, doctors will be challenged with overflowing caseloads and increasingly limited time with each patient. And they won’t be able to interact with the sick the way they are accustomed to.
“In my spacesuit, I won’t be able to connect and provide reassurance with a smile, body language or a concerned look,” Lyon said. “I won’t be able to provide a reassuring human touch or even listen to their lungs or heart and what I believe to be my best physician strength – cool clarity of mind. This will be much harder to find.”
